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.
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:
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.
Payers need to track the effectiveness of telemedicine visits so they can understand the economics of the benefits relative to reimbursement. That’s why in some cases payers require a GT modifier code to indicate a telemedicine visit. But what does the GT modifier really indicate? According to CMS:
“You should submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, via interactive audio and video telecommunications systems” (for example, 99201 GT). “By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth service.”
But CMS limits eligible originating sites to the following:
However most states with private insurance reimbursement mandates do not restrict the location of the patient to these CMS defined originating sites. California, for instance, expressly forbids payers from limiting the location of the patient during telemedicine visits. Since the GT modifier is a very specific CMS code, not all commercial payers require it.
But how do you know when to use it? 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 2015 guideline calls out about 30 different 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 GT modifier 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.