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.
“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, clinician 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:
- Clinicians
- 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.
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:
- A county outside of a Metropolitan Statistical Area (MSA) or
- 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 clinician 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, clinicians typically spend 60 minutes communicating with the patient and providers via telehealth | G0508 |
| Telehealth consultation, critical care, subsequent, clinicians 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.
