Coding Corner: Telehealth Coding Nuances
By Raemarie Jimenez, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, CCS
For The Record
Vol. 29 No. 4 P. 8
The terms telehealth and telemedicine are often used interchangeably. Telemedicine is the use of technology to provide clinical health care from a distance. It helps to eliminate distance barriers and can improve access to medical services that may not be available consistently in rural communities. Telehealth is a broader array of services that includes not only clinical care but also patient education and monitoring. Both terms refer to services that are provided using technology to communicate but do not require the provider and the patient to be face to face in the traditional sense.
There are different types of telehealth services. Synchronous services are live services using two-way audio and visual equipment. This allows the provider and the patient to communicate as they would in an office setting. Asynchronous services are also referred to as "store and forward." This type of delivery involves forwarding information such as a prerecorded video, an X-ray, or a diagnostic test to a provider for review and evaluation. The provider is not interacting with the patient in real time.
Coders do not require special skills to accurately report telehealth services, but, like all things coding, they need to understand the specifics for reporting the services correctly. Each state has specific regulations for telehealth. For example, Florida Medicaid reimburses live video telehealth but does not reimburse for telephone conversations, chart reviews, e-mail messages, and facsimile transmissions. The Center for Connected Health Policy's website features an interactive map that provides each state's regulations.
The requirements for billing and coding differ by payer. If the payer reimburses telehealth services, there is usually a list of approved codes that can be reported. There are modifiers in CPT and HCPCS Level II to identify telemedicine services.
Rather than create new codes specific to telehealth (after all, the care provided is the same), a modifier to identify telehealth services was created. What differs from the traditional service are the locations of the provider and the patient. If the care for telehealth is different than an existing CPT code, a new code should be considered.
Recently, CPT added modifier 95, Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunication system. Modifier 95 may be appended to 79 designated codes (primarily evaluation and management services and medicine codes, plus several Category III codes) to describe a service that involves "real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional," per CPT instructions. If the telemedicine service is not performed in real time, modifier 95 is not appropriate.
The interactive telecommunications equipment must include audio and video; the patient and provider must be able to communicate and interact in real time. Services reported must meet all minimum code requirements. CPT instructs, "The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction."
There is a new star icon in CPT that identifies the codes that modifier 95 can be appended to as well as a new Appendix P, CPT Codes That May Be Used for Synchronous Telemedicine Services.
CMS Telehealth Requirements
The Centers for Medicare & Medicaid Services (CMS) has specific requirements and coverage limitations for telehealth services. Several conditions must be met for Medicare to make payments for telehealth services under the physician fee schedule. First, the service must be on the list of Medicare telehealth services. Examples of telehealth services covered by Medicare include office visits (99201–99215), individual and group kidney disease education services (G0420 and G0421), and telehealth pharmacologic management (G0459). A complete list of telehealth approved codes can be found on the CMS website.
The following requirements must also be met in order to be reimbursed:
• The service must be furnished via an interactive telecommunications system.
• The service must be furnished by a physician or other authorized practitioner.
• The service must be furnished to an eligible telehealth individual.
• The individual receiving the service must be in a telehealth originating site.
The approved originating sites for Medicare are physician offices, hospitals, critical access hospitals (CAHs), rural health clinics, federally qualified health centers, hospital- or CAH-based renal dialysis centers (including satellites), skilled nursing facilities, and community mental health centers. The originating site must be a rural Health Professional Shortage Area located in a rural census tract unless the site was approved under a federal telemedicine demonstration project or in a county outside of a metropolitan statistical area.
Coders working for a professional provider should append modifier GT, via interactive audio and video telecommunication systems, to the approved code. Modifier GQ, via asynchronous telecommunications system, is reserved for federal telemedicine demonstration programs in Alaska and Hawaii. Place of service 02, telehealth, is reported on the claim. The originating site reports code Q3014, telehealth originating site facility fee.
Consider the following scenario: A patient presents to a rural health clinic complaining of a headache. A clinical staff employee at the originating site escorts the patient to a room where the patient can interact with the provider using audiovisual equipment. The provider performs the necessary history, and a clinical staff employee obtains the clinical information, such as vital signs, requested by the provider.
If the clinic has the appropriate equipment and personnel, diagnostic tests ordered by the provider are performed onsite. The provider renders a patient assessment and plan to be discussed with the patient. During this new patient encounter, the provider performs and documents a detailed history, an expanded problem-focused exam, and moderate medical decision making. A coder reviews the medical record to ensure all code requirements are met. In this example, 99202-GT for the professional provider's service and Q3014 for the services of the originating site should be reported.
If the patient's insurance benefits are with a private payer, according to CPT guidelines, the coder should report 99202-95. Whether the coder appends modifier GT or modifier 95 depends on the payer's preference. This can be determined by reviewing the payer's payment policy for telehealth services; many private payers are reimbursing telehealth services.
Here to Stay
Telehealth can improve follow-up care for chronic illnesses and increase access to behavioral health services. Providers can monitor their patients' progress on the current care plan and make changes as necessary to improve the quality of care. This helps prevent unnecessary visits to the emergency department, an important component in the industry's overall effort to decrease health care costs.
As telehealth proves to be efficient and improves patient outcomes, more services are likely to be approved for reimbursement. Also, more consideration will be given to lifting the restrictions on coverage areas. With this in mind, coders must be ready for changes in reporting and prepared to research the differences in payer policies.
— Raemarie Jimenez, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, CCS, is vice president of member and certification development at AAPC.