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CPT Codes for Telemedicine

One of the main obstacles to widespread telemedicine adoption for practitioners has been, and remains, complexity around reimbursement. Both commercial payers and CMS alike have been slow to enact formal policies around telemedicine reimbursement. Because of this, it is a common misconception that providers cannot be reimbursed for telemedicine appointments, or that it is possible but only at a reduced rate. Both of which make telemedicine economically un-appealing to physicians.

The reality is that many commercial payers are required by state law to reimburse for telemedicine – often at the same rate as a comparable in-person service. Some payers in states without reimbursement mandates are covering telemedicine anyway. The motivation for payers to cover telemedicine regardless of mandates is the overall cost savings in Emergency Department preventions and more effective management of chronic conditions.

What CPT codes can be used for telemedicine?

Now that we’ve established that some payers do in fact cover telemedicine, the question remains – What CPT codes are appropriate for these types of appointments?

The answer depends on a number of factors. A good rule of thumb is to use the same coding standards that you would use for an in-person appointment. In the healthcare industry however, relying on a good rule of thumb is not always a best practice.

A common example to explain:

Service: Office or other outpatient visit

CPT codes: 99201-99215

Contained in this set of codes are two of the most common CPT codes for outpatient physician offices; 99203 and 99213 (where 0 indicates a new patient and 1 indicates an existing patient), reimbursing at a national average of $73. But how can you achieve the complexity requirements for a level 3 office visit without a physical exam? The documentation for these encounters require two of three of the following components:

  1. Expanded Problem Focused History
  2. Expanded Problem Focused Exam
  3. Low Complexity Medical Decision Making
    OR
  4. 15 minutes spent face to face with the patient if coding based on time

 

For example, if a provider reviews results of a recent lab test for a hypertensive patient and adjusts medication accordingly, this visit meets the complexity requirements for a 99213. However, as is usually the case with telemedicine, it’s not that simple.

GT MODIFIER:

  • The GT modifier is used to indicate a service was rendered via synchronous telecommunication.
  • In 2018, CMS replaced the GT modifier with POS 02. However, this does not mean that the GT modifier is no longer recognized. Some private payers still recognize and prefer the GT modifier. The Rules Engine provides modifier recommendations for each appointment based on past claims data to help providers determine which modifier is most appropriate.

MODIFIER 95:

  • Modifier 95 is a fairly new modifier and used only when billing to private payers to indicate services were rendered via synchronous telecommunication.
  • It is important to note that Medicare and Medicaid do not recognize modifier 95. As with the GT modifier, not all payers recognize modifier 95. The rules engine is a good resource when it comes to selecting a modifier for your claim.

PLACE OF SERVICE 02:

  • According to CMS, POS 02 is defined as “the location where health services and health-related services are provided or received, through a telecommunication system.”
  • CMS has replaced the GT modifier with POS 02. POS 02 can be used when billing CMS claims for synchronous telemedicine visits

But how do you know when to use each code? The only way to find out is to call the payer to find out their policy for telemedicine visits. If you’ve ever called an insurance company you know this is a labor intensive process. Fortunately Chiron Health has built a scalable, automated database that takes into account the variations between payers and the rapidly changing nature of telemedicine reimbursement policies.


Using the Chiron telemedicine insurance rules engine, Chiron clients are confident in which CPT codes will be paid, and when to use a modifier. The rules engine is learning enabled — if a claim is denied for a specific CPT code, the database will take note and that change is pushed out to all Chiron clients.

What codes can you use for Medicare?

CMS publishes a guideline for Telehealth Services for each Calendar Year. The CY 2018 guideline calls out a significant number of services deemed appropriate by CMS for telehealth services and the corresponding range of CPT codes. These services range from a standard office visit to group diabetes self-management training. CMS always requires a place-of-service 02 code for interactive video services as it indicates that the patient was at an eligible originating site, generally limited to a healthcare facility in a rural area.

The good news for an originating site is that they can bill the Originating Site Facility Fee by using the HCPS code Q3014, which generally reimburses at about $24 per appointment. This is a great opportunity for nursing homes or SNFs that could potentially enable hundreds of telemedicine visits per month.

Finally, code 99490 can be used for Medicare beneficiaries with two or more chronic conditions under the Chronic Care Management program (CCM). This program does not require telemedicine at the modality of care, but video visits are ideal as the CCM program requires 20 minutes of clinical staff time every month. Video visits provide an audit trail.

Chiron Health’s expert regulatory team can help any practice navigate the complexities of reimbursement for telemedicine services.

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