Coding and coverage for telehealth and eVisits during the COVID-19 crisis

Resources and guidance to help GI practices navigate new coding rules to ensure maximum reimbursement for telehealth services.

The following guide was developed jointly by AGA, AASLD, ACG and ASGE.

Top Five Things Gastroenterologists Should Know About Telehealth

As of April 30, CMS again expanded access to telemedicine services, increasing payment for telephone evaluation and management (E/M) codes 99441-99443 to the level of office/outpatient E/M codes 99212-99214 ($46-$110). Previous rules expanded telehealth for all Medicare beneficiaries — not just those that have novel coronavirus — for the duration of the COVID-19 PHE, expanded payments for telehealth services to a variety of settings in addition to existing coverage for originating sites including physician offices, skilled nursing facilities and hospitals, allowed reporting for new patients was well as existing patients, and allowed two-way, real-time audio/visual telehealth services to be paid under the Medicare Physician Fee Schedule at the same amount as in-person services.

  • Effective retroactively from March 1, 2020, national level payment for telephone (audio-only) E/M codes 99441-99443 will increase from $15, $31 and $39 respectively to $46, $56 and $110 to match office/outpatient E/M code payments for 99212-99214 (New in Medicare’s April 30 COVID-19 interim final rule with comment period (IRC)). You must report 99441-99443 with modifier 95 and place of service (POS) where the visit would have taken place in person prior to the public health emergency (e.g., 11-Office, 22-Hospital Outpatient, 23-ASC) in order to get the higher rates. Claims without modifier 95 will be paid at the lower rates.
  • E/M level selection for telehealth (real-time audio/visual) can be based on medical decision making or time and CMS has temporarily removed any requirements regarding documentation of medical history and/or physical exam in the medical record during the COVID-19 crisis.
  • Most telehealth services can be provided to both new and established patients, including 99201-99215 and 99441-99443.
  • Clinicians can provide remote patient monitoring services to patients with acute and chronic conditions and can be provided for patients with only one disease. 
  • Physicians can supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.

Hospitals and a range of clinicians, including doctors, nurse practitioners, clinical psychologists, nutrition professionals, and licensed social workers may now provide telehealth. As part of COVID-19 emergency declarations, many governors have relaxed licensure and other state telehealth requirements so please contact your state board of medicine or department of health for up-to-the minute information.

Medicare will allow audio-only telephone E/M visits to be reported as telehealth, but they must be reported with the telephone E/M codes 99441-99443. Only two-way, real-time audio/visual E/M visits can be reported using codes 99201-99215.

In addition to traditional telehealth platforms, during the PHE CMS will allow apps like FaceTime and Skype as acceptable platforms. Telehealth, both audio-only and interactive audio and video, can be provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. Penalties will not be imposed on physicians using telehealth in the event of noncompliance with the regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) during the PHE.

Standard Medicare copays and deductibles still apply to telemedicine visits, but there’s flexibility. During the coronavirus emergency, health providers will be allowed to waive or reduce cost-sharing* for telehealth visits. However, beneficiaries are still liable for cost-sharing for these services in instances where the practitioner does not waive cost-sharing. Practitioners should educate beneficiaries on any applicable cost-sharing.

*The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers or the cost of non-covered services. Source: www.healthcare.gov/glossary/cost-sharing/ 

Below is a listing of common CPT codes and Medicare coverage for telemedicine services.

Telehealth Visits

Medicare telehealth services include office visits and consultations, among other services, provided by an eligible provider using an interactive two-way telecommunications system with real-time audio and video or audio-only telephone. Clinicians can report telehealth visits for both new and established patients on any real-time, non-public communication platform, such as FaceTime and Skype, and sets payment the same as in-person E/M visits during the COVID-19 PHE (see FAQs above).

E/M level selection can be based on medical decision making (MDM) or typical time listed in the CPT code description and CMS has temporarily removed any requirements regarding documentation of medical history and/or physical exam in the medical record during the COVID-19 crisis.

New patient E/M visitsEstablished patient E/M
 MDMTypical time MDMTypical time
99201Straightforward10 min99211NA5 min
99202Straightforward20 min99212Straightforward10 min
99203Low complexity30 min99213Low complexity15 min
99204Moderate complexity45 min99214Moderate complexity25 min
99205High complexity60 min99215High complexity40 min

Select the appropriate code (99201-99215) and use the place of service (POS) that would have been reported had the service been furnished in person (e.g., 11-Office, 22-Hospital Outpatient, 23-Ambulatory Surgery Center). This will allow Medicare to pay for the service at the same rate that would have been paid if the service was furnished in person based on the provider’s location (i.e., facility or non-facility). Providers must also append telehealth modifier 95 to claim lines to identify that the service was furnished via telehealth. Providers who continue to use the general telehealth POS 02 code will be paid at the “facility” rate.

E/M Values and National Payments

Below are a list of codes and their physician work Medicare relative value units (RVUs) and approximate National office-based payment. E/M code levels must be assigned based on current Medicare E/M coding guidelines and rules. 

New patient E/M visitsEstablished patient E/M
 Work RVUNational payment Work RVUNational payment
992010.48$47992110.18$23
992020.93$77992120.48$46
992031.42$109992130.97$76
992042.43$167992141.50$110
992053.17$211992152.11$148

*A list of all available codes for telehealth services can be found on the CMS website.

Telephone Evaluation and Management Service

CPT codes to describe telephone E/M are time-based. Effective March 1, 2020, payment for telephone E/M code 99441-99443 are equivalent to 99212-99214 and can be used for new or established patient during the PHE. Use modifier 95 and place of service (POS) where the visit would have taken place in person prior to the public health emergency (e.g., 11-Office, 22-Hospital Outpatient, 23-ASC). Check if your commercial payers pay for these services before reporting the codes for non-Medicare beneficiaries.

  • CPT Code 99441 – Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion [$46]
  • CPT Code 99442 – 11-20 minutes of medical discussion [$76]
  • CPT Code 99443 – 21-30 minutes of medical discussion [$110]

 

e-Consultations

e-Consultations are interprofessional telephone, internet or EHR provider-to-provider consultations. Code selection is time-based.

  • CPT Code 99446 – Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review [$18]
  • CPT Code 99447 – 11-20 minutes of medical consultative discussion and review [$37]
  • CPT Code 99448 – 21-30 minutes of medical consultative discussion and review [$56]
  • CPT Code 99449 – 31 minutes or more of medical consultative discussion and review [$74]
  • CPT Code 99451 – Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time [$37]
  • CPT Code 99452 – Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes [$37]

Note – For commercial payors, check with your individual payer’s policies directly for more information on coverage for telemedicine services.

CMS designed a CPT code selection grid located at the bottom of the Medicare Telemedicine Health Care Provider Fact Sheet.

For the latest information on federal policy and payment changes related to telehealth in the midst of COVID-19, visit the CMS Current Emergencies site.