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Telemedicine Billing 101

An in-depth guide on billing for telemedicine

As consumer technology becomes a greater part of our everyday lives, health systems are evolving to provide fast, reliable and efficient service to all patients via their personal technology. We refer to this advancement as telemedicine.

With more than half of United States hospitals actively engaged in telemedicine and an estimated seven million new telemedicine patient users in 2018, telemedicine is on the rise. As a result of this growth, the government, via the Centers for Medicare & Medicaid Services (CMS), has advanced several payment reform packages for telemedicine reimbursement to make this platform accessible to all.

This paper was written by ARMCO’s Director of Coding Integrity, RN, CPC to provide an overview of telemedicine—and tackle the specific requirements and telemedicine reimbursement process.

 

 

What is Telemedicine?

Telemedicine is defined as the diagnosis, treatment and care of patients through a remote connection and is a subset of Telehealth. With telemedicine, the physician, advanced practitioner or psychologist is in one location—even another state—while the patient receiving care is in a separate location. According to BCC Research, the telehealth market is predicted to be valued at over $20 billion in 2019.

 

 LocumTenens.com testimonial

“Telehealth programs enable patients to receive timely care from qualified providers, rendering the health care system more effective and inclusive of all the populations we need to serve. It is a game-changer in a time of provider shortages, sicker patient populations and the ever-rising costs of care.”

—Pamela Ograbisz, DNP, FNP-BC, Director of Telehealth, LocumTenens.com

Terminologies of Telemedicine

The American Medical Association and Wellness Council of America states that almost 75 percent of all doctor, urgent care and emergency room (ER) visits “are either unnecessary or could be handled safely and effectively over the phone or video.”

To gain a better understanding of the growing practice of telemedicine, let’s review some terms commonly used in this field.

Originating site

Location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs.

Distant Site

Refers to a Telehealth site where a specialist or provider either consults with the patient’s provider or sees the patient from a different location. Other common names for this term include referral site, physician site, provider site, specialty site, consulting site or hub site.

Distant site practitioners

Practitioners at the distant site who may furnish and receive payment for covered Telehealth services. These include:

  • Physicians
  • Nurse practitioners (NPs)
  • Physician assistants (PAs)
  • Nurse-midwives
  • Clinical nurse specialists (CNSs)
  • Certified registered nurse anesthetists (CRNAs)
  • Psychologists

Asynchronous

The process of storing and forwarding transmission (not live interaction).

Synchronous

The interactive connections between two videos, when the information transmits at the same time for both directions.

Telemedicine Billing

According to the American Telemedicine Association (ATA), more than half of all U.S. hospitals are currently implementing a telemedicine program. While the coding and subsequent billing of telemedicine services are not overly complex, there are a few nuances and quirks involved that, if you understand, will go a long way in ensuring a successful telemedicine rollout.

Want to learn more? We can help connect you with a billing expert.

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 Telemedicine Billing for Medicaid

Medicaid will reimburse telemedicine services depending on the legislation passed in that state. Since Medicaid programs are state-run, they follow state-specific telemedicine regulations. You may refer to this website and filter by state to better understand the Medicaid telemedicine policy per state.

  

Telemedicine Billing for Commercial Insurance

Telemedicine Parity Laws are State laws requiring private payers to reimburse telemedicine services the same way they would for in-person medical services. Aetna, Blue Cross Blue Shield, Humana, Cigna and United Healthcare all cover telemedicine.

You may check the state Telemedicine Parity Laws here.

Telemedicine Billing for Medicare

Medicare pays for telemedicine services under certain circumstances. Primarily, Medicare reimburses for live telemedicine services or virtual visits delivered via synchronous means. Asynchronous (store-and-forward) telemedicine services are reimbursed in Hawaii and Alaska only at this time. Following are the requirements:

  • Synchronous communication: An interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site (except for Alaska and Hawaii wherein asynchronous is permitted).
  • Originating sites: Medicare beneficiaries are eligible if they are presented from an originating site located in:
    1. A county outside of a Metropolitan Statistical Area (MSA) or
    2. A rural Health Professional Shortage Area (HPSA) located in a rural census tract.
  • CPT and HCPCS codes used are included in the approved list of telemedicine codes from Medicare.

When all these requirements are met, Medicare reimburses 80 percent of the physician fee (the other 20 percent is paid by the patient) and will pay a facility fee to the originating site. Medicare reimburses telemedicine services at the same rate as the comparable in-person medical service, based on the current Medicare physician fee schedule. Additionally, the facility serving as the originating site can charge an additional facility fee.

  • Professional services furnished on or after January 1, 2017: To indicate the billed service was furnished as a telehealth service from a distant site, submit claims for telehealth services using Place of Service (POS) 02: Telehealth.
  • As of January 1, 2018: Distant site practitioners billing telehealth services under the Critical Access Hospital (CAH) Optional Payment Method submit institutional claims using the GT modifier. You should bill the Medicare Administrative Contractor (MAC) for covered telehealth services. Medicare reimburses you the appropriate amount under the Medicare Physician Fee Schedule (PFS) for telehealth services.

CY 2019 Medicare Telehealth Services

Service HCPCS/CPT Code
Telehealth consultations, emergency department or initial inpatient G0425-G0427
Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNF's G0406-G0408
Office or other outpatient visits 99201-99215
Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days 99231-99233
Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days 99307-99310
Individual and group kidney disease education services G0420-G0421
Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction furnished in the initial year training period to ensure effective injection training G0108-G0109
Individual and group behavior assessment and intervention 96150-96154
Individual psychotherapy 90832-90838
Telehealth pharmacologic management G0459
Psychiatric diagnostic interview examination 90791-90792
End-stage renal disease (ESRD)-related services included in the monthly capitation payment 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961
End-stage renal disease (ESRD)-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development and counseling of parents 90963
End-stage renal disease (ESRD)-related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development and counseling of parents 90964
End-stage renal disease (ESRD)-related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development and counseling of parents 90965
End-stage renal disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older 90966
End-stage renal disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age 90967
End-stage renal disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 2-11 years of age 90968
End-stage renal disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 12-19 years of age 90969
End-stage renal disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 20 years of age and older 90970
Individual and group medical nutrition therapy G0270, 97802-97804
Neurobehavioral status examination 96116
Smoking cessation services G0436, G0437, 99406, 99407
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services G0396, G0397
Annual alcohol misuse screening, 15 minutes G0442
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes G0443
Annual depression screening, 15 minutes G0444
High-intensity behavioral counseling to prevent sexually transmitted infections; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes G0445
Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes G0446
Face-to-face behavioral counseling for obesity, 15 minutes G0447
Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) 99495
Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) 99496
Advance care planning, 30 minutes 99497
Advance care planning, additional 30 minutes 99498
Psychoanalysis 90845
Family psychotherapy (without the patient present) 90846
Family psychotherapy (conjoint psychotherapy) (with patient present) 90847
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour 99354
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes 99355
Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service) 99356
Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service) 99357
Annual wellness visit, includes a personalized prevention plan of service (PPPS) first visit G0438
Annual wellness visit, includes a personalized prevention plan of service (PPPS) subsequent visit G0439
Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth G0508
Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth G0509
Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making) G0296
Interactive complexity psychiatry services and procedures 90785
Health risk assessment  96160, 96161
Comprehensive assessment of and care planning for patients requiring chronic care management G0506
Psychotherapy for crisis 90839, 90840
Prolonged preventive services G0513, G0514

About ARMCO Healthcare

As an industry leader in Healthcare Revenue Cycle assistance, ARMCO provides its services to over 100 health systems at over 500 location sites eliminating the issues that can affect the financial health of an organization. Headquartered in Atlanta, GA, ARMCO Partners provides high-quality forensic billing, clinical abstracting, NCCI edit resolution/denial management, and ICD-10 medical coding services for your hospital, physician network, and home health/hospice service.

 

 

 

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