Telehealth Billing & Coding guidelines
Telehealth (aka telemedicine) services substitute for an ‘in-person’ encounter. The reporting of these services varies by payer and state regulations. Depending on where the client is located during the telehealth encounter, telehealth services may make up to two distinct services. The different coding and billing requirements for hosting facilities and performing physicians/providers are outlined in the below table.
Regarding some of the terms in the table, explanations are also given below.
Hosting facility: Originating site
Telehealth services include both an originating site and a distant site. The former is the location of the client at the time the service is being furnished through a telecommunications system.
A telehealth facility fee is paid to the originating site. Claims for this fee should be submitted using HCPCS code Q3014:"Telemedicine originating site facility fee."
Regardless of their location, providers qualify as originating sites if they were participating in a Federal telemedicine demonstration project approved by (or getting funding from) the U.S. Department of Health & Human Services as of December 31, 2000.
An originating site’s geographic eligibility is based on the area’s status as of December 31 of the prior calendar year. This eligibility then continues for a full calendar year.
Authorized originating sites include:
- Critical Access Hospitals (CAHs)
- Rural Health Clinics (RHCs)
- Federally Qualified Health Centers(FQHC)
- Physician and practitioner offices
- Skilled Nursing Facilities (SNFs)
- Community Mental Health Centers(CMHCs)
- Renal Dialysis Facilities
- Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
- Homes of beneficiaries with End-Stage Renal Disease (ESRD) getting home dialysis
- Mobile Stroke Units
Performing Physician/Provider: Distant site/remote site
The distant site refers to the site where the physician or other licensed practitioner delivering the telehealth service is located.
Subject to state law, the following distant site practitioners can furnish and get payment for covered telehealth services:
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists
- Registered dietitians or nutrition professionals
- Clinical psychologists (CPs) and clinical social workers (CSWs)
o They cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services
o They cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836 and 90838
Place of service (POS) code
When telehealth services are being provided, healthcare providers must bill the E&M code with POS code 02. Telehealth services not billed with 02 will be denied by the payer, regardless of insurance carrier (Medicare or others). The Centers for Medicare and Medicaid Services (CMS) requires that the POS code for the hosting facility align with its type. So for an outpatient hospital facility, use POS 22; use POS 11 for a private office, and so on. Check with your payers if you plan to bill out for the hosting facility service.
Claims for professional services should be submitted using the appropriate service code and the i) 95 modifier or ii) GQ modifier.
i) 95 modifier: Append this modifier to an appropriate CPT code when billing a commercial insurance company for a real-time interaction between a physician(or other qualified healthcare professional) and a patient located at a distant site from them.
ii) GQ modifier: Providers participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the GQ modifier.
iii) GT modifier: This modifier is to be used only when directed by a payer in lieu of modifier 95. Medicare stopped the use of modifier GT in 2017 when the place of service code 02 (telehealth) was introduced. If a payer rejects a telehealth claim and the 95 modifier is not appropriate, ask about the GT modifier.
Tips for telehealth services billing and payment
- Submit claims using the appropriate CPT or HCPCS code
- For telehealth services performed through asynchronous telecommunications system, add the telehealth GQ modifier with the professional service CPT or HCPCS code
- Submit telehealth services claims using Place of Service (POS) code 02-Telehealth
- Bill covered telehealth services to your Medicare Administrative Contractor (MAC)
Telehealth originating sites billing and payment
HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your Medicare Administrative Contractor (MAC)for the separately billable Part B originating site facility fee.
Considering the current COVID-19 outbreak, Medicare has announced new updates to existing Telemedicine rules and expanded telehealth under the 1135 waiver. Starting March 6, 2020, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country, including in the patient’s place(s) of residence. These Medicare telehealth visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. Prior to this waiver Medicare could only pay for telehealth on a limited basis.
With regard to virtual check-ins and e-visits, these services can only be reported when the billing practice has an established relationship with the patient. Unlike Medicare telehealth visits which require audio and visual capabilities for real-time communication, virtual check-ins can be conducted with a broader range of communication methods. Medicare coinsurance and deductible would generally apply to e-visit services.
The HHS Office of Inspector General(OIG) is also providing flexibility for healthcare providers (including doctors, nurse practitioners, clinical psychologists and licensed clinical social workers) to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
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