Recent reports indicate that the telehealth trend is growing across America, especially in rural areas. Many states have passed a telehealth parity law, which allows providers to be eligible to receive reimbursements for telehealth at the same level as in-person services. While medical coding outsourcing can ensure appropriate reimbursement for telehealth services, providers need to be aware of the new codes that the Centers for Medicare & Medicaid Services (CMS) added in the CY 2017 proposed Physicians Fee Schedule (PFS) and other changes for the year.
New place of service (POS) code: Starting January 1, telehealth services should be reported using a new place of service (POS) code. POS 02 is the location where health services and health-related services are provided or received through telecommunication technology. CMS permits telemedicine services to be performed on a Medicare beneficiary only in an approved site. Other payers may not have this restriction and may allow a patient to be located in his or her own home or school.
According to CMS, use of the new POS code “would improve payment accuracy and consistency in telehealth claims submissions.”
The POS code would not apply to originating sites billing the facility fee as the patient is physically present at the originating site. Therefore, the originating site should continue to use the POS code that applies to the type of facility where the patient is located.
New modifier 95: A new modifier “95” has been introduced effective January 1, 2017. A new Appendix P in the 2017 CPT manual lists 79 standard CPT codes for which the “95” modifier can be used to specify that the service was provided via a real-time, interactive audio and video telecommunications system, subject to payer approval. The codes listed in Appendix P pertain to:
- Psychiatric, psychotherapy, psychoanalysis, pharmacy management, ESRD
- Ophthalmological remote imaging for detection of retinal disease, cardiovascular monitoring and telemetry
- Genetic or neurobehavioral assessments, medical nutrition
- Office, subsequent hospital, outpatient consult, inpatient consult, subsequent nursing facility, prolonged services
- Behavioral change interventions and transitional care management codes
According to a report in Medical Economics, the requirements for use of Modifier 95 which indicates a telemedicine code are:
- Modifier 95: service generally reported as a face-to-face service that is performed via a real-time interactive audio and video telecommunications system;
- Identified with the new symbol “star”;
- Must meet the key components and/or requirements of the code when performed face-to-face;
- Appendix P listing of codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Includes a minimum use of audio and video;
The American Academy of Pediatrics (AAP) notes that CPT codes with which “95” can be used includes:
- Office or other outpatient evaluation and management (E/M) codes for new patient (99201-99205)
- Established patient visits (99212-99215)
- Various consultation codes such as 99241-99245
- Behavioral health codes, e.g., behavioral change intervention codes 99406-99408
New CPT codes: In 2017, CMS proposed adding the following eight codes to the list of covered telehealth services:
- End-stage renal disease (ESRD) related services for dialysis (90967, 90968, 90969 and 90970)
- Advance care planning services (99497 and 99498)
- Critical care consultations furnished via telehealth using new Medicare G-codes (GTTT1 and GTTT2)
Points to consider when billing telehealth services: The AAP recommends that providers who bill telemedicine services should keep the following considerations in mind:
As each CPT code has required elements such as key components or time for the encounter, documentation should support this. Claims submitted without proper documentation pose audit risks.
- Time can be monitored automatically through an electronic encounter and total time and percentage spent in counseling and/or coordination of care in the patient record should be documented. Only the physician’s face-to-face time with the patient/caregiver applies toward the level of service provided.
- In addition to the required video component for billing telemedicine encounters using the standard CPT code with the 95 modifier, physicians can include assessments performed using home peripherals such as thermometers, stethoscopes, oxygen saturation monitors, spirometers, blood pressure monitors, glucose monitors and otoscopes. Including these assessments will help in meeting the required elements for the CPT code.
- Qualifying services also have to be “synchronous,” or real-time, interactive visits between a patient/family and a clinician. The “asynchronous” category refers to situations where clinical information is supplied and considered at a later time. Examples of asynchronous encounters that will not qualify for the process of using the 95 modifier include email interchanges and radiograph and ultrasound studies.
- Knowing state and carrier rules with regard to reimbursement for telehealth services is crucial as many health insurance policies do not reimburse telemedicine services, including some Medicaid programs under certain conditions.
In its 2016 report, IHS Technology, a technology, media, and telecommunications research expert, predicts that by next year, 7 million people in the United States will use telemedicine, up from under a half million in 2013. The shift to value based reimbursement models has also increased the importance of telemedicine. Healthcare providers who plan to implement a telemedicine program can rely on experienced medical billing outsourcing companies for accurate and timely claim submission in keeping with the new rules. Such medical billing companies have AAPC-certified coders and billing specialists who keep track of coding and regulatory changes which is necessary to take advantage of potential revenue opportunities in 2017 and the years to come.