Telehealth services have become an integral part of modern healthcare, providing patients with convenient access to medical professionals. To ensure accurate reimbursement and compliance with coding guidelines, it's crucial to understand the various CPT codes associated with telehealth visits. In this comprehensive guide, we'll delve into the intricacies of coding for telehealth, audio-only, and virtual-digital visits, covering key scenarios and modifiers.
Telehealth CPT Codes
Telehealth encompasses a range of services, from video visits to audio-only consultations and virtual check-ins. Proper coding is essential to accurately reflect the nature of the visit and secure appropriate reimbursement. Let's explore the specific CPT codes associated with different telehealth scenarios.
Coding for Telehealth Visits
How to Code a New or Established Patient Telehealth Office Visit with Audio-Video Communications Technology
When conducting a telehealth office visit that incorporates both audio and video components, it is essential to utilize the appropriate Evaluation and Management (E/M) CPT codes. Below are the commonly used codes for telehealth visits along with an overview, key components, and information about the Place of Service (POS) and modifiers:
CPT Code 99202-99205
Overview:
These codes represent new patient office visits conducted via telehealth. The selection depends on the complexity of the medical decision-making and the time spent during the encounter.
Key Components:
- History: A comprehensive review of the patient's medical history.
- Examination: Thorough evaluation based on the presenting symptoms or conditions.
- Medical Decision-Making: Determining the appropriate course of action and treatment plan.
- Appropriate Usage: Choose the code that aligns with the complexity of the visit and the medical decision-making involved.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: Use the POS that would have been used if the service had been provided in person (e.g., POS 11 – Office)
Modifiers:
- Commercial: -95 (Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system), GT, GQ, G0 (optional)
- Medicare Advantage: -95
CPT Code 99211-99215
Overview:
These codes cover established patient office visits conducted through telehealth. The choice of code depends on the complexity of the medical decision-making and the time spent during the encounter.
Key Components:
- History: A brief or expanded review of the patient's medical history.
- Examination: Focused evaluation based on the presenting symptoms or conditions.
- Medical Decision-Making: Assessing and deciding on the appropriate course of action.
- Appropriate Usage: Select the code that best reflects the complexity of the visit and the medical decision-making involved.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: Use the POS that would have been used if the service had been provided in person (e.g., POS 11 – Office)
Modifiers:
- Commercial: -95, GT, GQ, G0 (optional)
- Medicare Advantage: -95
CPT Code 99242-99245
Overview:
These codes apply to telehealth consultations for new or established patients that involve comprehensive assessments and decision-making.
Key Components:
- History: Thorough review of the patient's medical history.
- Examination: Detailed evaluation based on the presenting symptoms or conditions.
- Medical Decision-Making: Complex assessment leading to a comprehensive treatment plan.
- Appropriate Usage: Select the code that aligns with the complexity of the visit and the medical decision-making involved.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: Use the POS that would have been used if the service had been provided in person (e.g., POS 11 – Office)
Modifiers:
- Commercial: -95, GT, GQ, G0 (optional)
- Medicare Advantage: -95
CPT Code 99417
Overview:
This code is used for prolonged office or other outpatient Evaluation and Management service(s) when conducted via telehealth.
Key Components:
- Time: Beyond the typical time associated with the primary E/M service.
- Appropriate Usage: Apply when the visit extends significantly beyond the usual time for the primary E/M service.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: Use the POS that would have been used if the service had been provided in person (e.g., POS 11 – Office)
Modifiers:
- Commercial: -95, GT, GQ, G0 (optional)
- Medicare Advantage: -95
CPT Code G2212
Overview:
This code is specific to prolonged office or other outpatient Evaluation and Management service(s) conducted through telehealth.
Key Components:
- Time: Represents additional time spent beyond the typical time for the primary E/M service.
- Appropriate Usage: Apply when the telehealth visit extends significantly beyond the usual time for the primary E/M service.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: Use the POS that would have been used if the service had been provided in person (e.g., POS 11 – Office)
Modifiers:
- Commercial: -95, GT, GQ, G0 (optional)
- Medicare Advantage: -95
By understanding the nuances of each code, healthcare providers can accurately document telehealth encounters, ensuring proper reimbursement and adherence to coding guidelines. Stay informed about any updates or changes in telehealth coding regulations to maintain compliance with industry standards.
Further reading:
Coding for Audio-only Visits
How to code an audio-only visit for a new or established patient
When conducting an audio-only telehealth visit for either new or established patients, specific CPT codes are applied. These codes fall within the range of 99441-99443. Below, you'll find an overview, key components, and appropriate usage for each code, along with information on the Place of Service (POS) and modifiers:
CPT Code 99441
Overview:
This code is designated for telephone evaluation and management services, lasting between 5 to 10 minutes.
Key Components:
- Brief history review.
- Focused examination based on the patient's presenting symptoms.
- Simple medical decision-making.
Appropriate Usage:
Use when the audio-only visit involves a quick assessment and straightforward medical decision-making within the specified time frame.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: POS 02, 10, or use POS used for typical services (e.g., POS 11 – Office) – choose based on applicable regulations.
Modifiers:
- Commercial: -93 or -FQ (depending on payer requirements)
- Medicare Advantage: -95 (depending on payer requirements)
CPT Code 99442
Overview:
This code applies to telephone evaluation and management services lasting between 11 to 20 minutes.
Key Components:
- Expanded history review.
- More detailed examination based on the patient's presenting symptoms.
- Moderate medical decision-making.
Appropriate Usage:
Choose this code when the audio-only visit involves a more comprehensive assessment and moderate medical decision-making within the specified time frame.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: POS 02, 10, or use POS used for typical services (e.g., POS 11 – Office) – choose based on applicable regulations.
Modifiers:
- Commercial: -93 or -FQ (depending on payer requirements)
- Medicare Advantage: -95 (depending on payer requirements)
CPT Code 99443
Overview:
This code is used for telephone evaluation and management services lasting 21 minutes or more.
Key Components:
- Detailed and thorough history review.
- Comprehensive examination based on the patient's presenting symptoms.
- High-level medical decision-making.
Appropriate Usage:
Apply this code when the audio-only visit involves an extensive assessment and high-level medical decision-making that extends beyond 20 minutes.
POS (Place of Service):
- Commercial: POS 02 or 10
- Medicare Advantage: POS 02, 10, or use POS used for typical services (e.g., POS 11 – Office) – choose based on applicable regulations.
Modifiers:
- Commercial: -93 or -FQ (depending on payer requirements)
- Medicare Advantage: -95 (depending on payer requirements)
Audio-Only Scenario Notes
When conducting audio-only telehealth visits, thorough documentation is crucial to ensure accurate coding and proper reimbursement. Here are essential scenario notes to consider for each CPT code (99441-99443):
CPT Code 99441
- Documentation Focus:
- Keep notes concise but comprehensive.
- Clearly document the brief history, focused examination, and simple medical decision-making.
- Emphasize any patient concerns or symptoms discussed during the audio-only visit.
- Time Management:
- Ensure that the visit duration falls within the 5 to 10-minute range specified for this code.
- Document the start and end times of the audio-only encounter.
- Communication Clarity:
- Clearly articulate communication with the patient to establish the need for the audio-only visit.
- Highlight any challenges faced during the audio-only consultation.
CPT Code 99442
- Documentation Focus:
- Provide a more detailed and expanded history in your notes.
- Document a comprehensive examination, detailing findings based on the patient's symptoms.
- Highlight moderate medical decision-making during the audio-only encounter.
- Time Management:
- Ensure that the visit duration falls within the 11 to 20-minute range specified for this code.
- Document the start and end times of the audio-only visit.
- Patient Interaction:
- Emphasize patient engagement during the extended duration, noting any additional concerns or questions addressed.
CPT Code 99443
- Documentation Focus:
- Document a thorough and detailed history, including all relevant patient information.
- Clearly outline a comprehensive examination, detailing findings based on the patient's symptoms.
- Emphasize high-level medical decision-making during the extended audio-only visit.
- Time Management:
- Ensure that the visit duration exceeds 20 minutes to meet the criteria for this code.
- Document the start and end times of the audio-only encounter.
- Complex Cases:
- Provide additional context for complex cases, detailing the challenges addressed during the extended audio-only consultation.
Telephone Evaluation and Management (E/M) services offer a valuable means of communication between healthcare providers and patients, parents, or guardians. These services are distinct in that they should not stem from a related E/M service within the previous seven days nor result in an E/M service or procedure within the next 24 hours or the soonest available appointment.
Importantly, telephone E/M services should not be reported if the time spent on the phone is already accounted for in other reported services. This includes scenarios such as
- the usage of CPT codes 99421-99423 in the previous seven days for the same issue,
- simultaneous use of CPT codes 99339-99340 and 99374-99380 for the same call,
- occurrence within the same month as CPT codes 99487 and 99489,
- when performed during the same service period as CPT codes 99495-99496.
It's essential to note that self-funded plans have the flexibility to develop their own policies and may choose to opt out of certain cost-sharing waivers.
General Considerations for All Codes:
- Patient Consent:
- Confirm and document patient consent for audio-only telehealth visits.
- Include any discussions about the limitations and benefits of audio-only consultations.
- Follow-up Recommendations:
- Clearly outline any follow-up recommendations provided during the audio-only visit.
- Document any referrals or further diagnostic steps suggested to the patient.
- Technical Challenges:
- In case of any technical challenges during the audio-only encounter, document the steps taken to address or overcome them.
- Include any alternative communication methods explored if needed.
Coding for Virtual-Digital Visits
How to code an e-visit (CPT 99421-99423) for an established patient
E-Visits, encompassing online digital evaluation and management services, offer a convenient avenue for healthcare providers to engage with established patients. These services, represented by CPT codes 99421-99423, cater to a diverse range of patient needs. Here's an overview, key components, and appropriate usage for each CPT code:
CPT Code 99421
Overview:
99421 corresponds to online digital evaluation and management services lasting between 5 to 10 minutes. It is ideal for brief assessments and interactions with established patients.
Key Components:
- Quick review of the patient's medical history.
- Focused examination based on the presenting concerns.
- Concise medical decision-making within the specified time frame.
Appropriate Usage:
Use 99421 when providing online digital E-Visits involving straightforward evaluations and decisions lasting between 5 to 10 minutes.
POS (Place of Service):
Utilize POS 11 (Office) for consistency with typical services.
Modifiers:
No specific modifiers are required, but ensure documentation aligns with the prolonged and comprehensive nature of the service.
CPT Code 99422
Overview:
99422 is applicable for online digital evaluation and management services spanning 11 to 20 minutes. It allows for a more in-depth interaction and assessment of established patients' health concerns.
Key Components:
- Expanded review of the patient's medical history.
- Detailed examination addressing specific symptoms or conditions.
- Moderate medical decision-making during the extended time frame.
Appropriate Usage:
Select 99422 for E-Visits involving comprehensive assessments and moderate medical decision-making within a duration of 11 to 20 minutes.
POS (Place of Service):
Use POS 11 (Office) to maintain consistency with typical services.
Modifiers:
No specific modifiers are mandated, but ensure that the documentation supports the extended nature of the service.
CPT Code 99423
Overview:
99423 is designed for online digital evaluation and management services lasting 21 minutes or more. It caters to established patients requiring extensive evaluations and detailed medical decision-making.
Key Components:
- Thorough review of the patient's complete medical history.
- Comprehensive examination addressing complex symptoms or conditions.
- High-level medical decision-making during an extended time frame.
Appropriate Usage:
Apply 99423 when engaging in E-Visits with established patients necessitating an extensive evaluation and high-level medical decision-making beyond 20 minutes.
POS (Place of Service):
Utilize POS 11 (Office) for consistency with typical services.
Modifiers:
No specific modifiers are required, but ensure documentation aligns with the prolonged and comprehensive nature of the service.
Coding Virtual Check-In (HCPCS Codes G2012 and G2010) for Established Patients
Virtual check-ins, facilitated by HCPCS codes G2012 and G2252, serve as concise consultations with a physician or clinician to assess the necessity of an in-person visit. Here's a detailed guide on coding and documentation:
HCPCS Code G2012
Overview:
G2012 represents a brief communication technology-based service lasting between 5 to 10 minutes. This code is employed for virtual check-ins to evaluate if an in-person visit is required.
Key Components:
- Brief interaction through various communication methods (telephone, audio/video, secure text messaging, email, or patient portal).
- Purpose is to determine the necessity of an in-person visit.
Usage Guidelines:
- Virtual check-in cannot be related to a medical visit within the previous seven days.
- Should not lead to a medical visit within the next 24 hours or the soonest available appointment.
Communication Modes:
- Physician or clinician may respond through telephone, audio/video, secure text messaging, email, or the patient portal.
HCPCS Code G2252
Overview:
G2252 is utilized for virtual check-ins similar to G2012, indicating a brief conversation to assess the need for an in-person visit.
Key Components:
- Brief interaction through various communication methods to evaluate the necessity of an in-person visit.
Usage Guidelines:
- Aligns with the guidelines of G2012, ensuring it is not related to a medical visit within the previous seven days.
- Should not lead to a medical visit within the next 24 hours or the soonest available appointment.
Communication Modes:
- Like G2012, responses may be conducted through telephone, audio/video, secure text messaging, email, or the patient portal.
Virtual/Digital Scenario Notes:
Captured Video or Image (G2010):
- In scenarios involving captured video or images (store and forward), use HCPCS code G2010.
- The physician must follow up with the patient within 24 business hours after receiving the visual information.
Cumulative Time Documentation:
- Accurately document cumulative time spent during virtual check-ins, including start and end times for each interaction.
Differentiating Interactions:
- Differentiate between G2012 and G2252 based on the specific HCPCS code used.
- Ensure clear documentation of the communication method employed during the virtual check-in.
Prompt Follow-Up (G2010):
- For G2010, ensure the physician follows up with the patient within 24 business hours after receiving the video or image.
E-Visits: Online Digital Evaluation and Management Services
E-Visits are patient-initiated, non-face-to-face communications with physicians through online patient portals. These encounters occur over a seven-day period and must be permanently stored. Key details for coding and implementation include:
- Time-Based Service:
- Physicians determine the level of service based on cumulative time over seven days.
- Cumulative time includes inquiry review, patient record assessment, clinical staff interaction, management plan development, and subsequent patient communication.
- Communication Modes:
- Occurs through online, telephone, email, or other digitally supported means.
- Online patient portals serve as the primary platform for these interactions.
- Applicable Codes:
- Physicians independently billing Medicare for E/M services can use the following codes:
- 99421: 5-10 minutes of cumulative time over seven days.
- 99422: 11-20 minutes of cumulative time over seven days.
- 99423: 21 or more minutes of cumulative time over seven days.
- Billing Restrictions:
- Avoid billing E-Visits on the same day as office visit E/M services (CPT codes 99202-99205 and 99211-99215) for the same patient.
- Do not bill E-Visits when using the following codes for the same communication:
E-Visits provide a flexible and convenient way for patients to interact with healthcare providers while adhering to specific billing guidelines. The use of online patient portals ensures secure and efficient communication, contributing to the overall effectiveness of remote healthcare delivery.
Further reading:
- How to Schedule Patients Effectively for Clinic Appointments
- Fair Reimbursement for Remote Care: Navigating Healthcare Models
Modifiers Used for Telehealth Coding
Modifiers play a crucial role in conveying specific information about the services provided. Here are some modifiers commonly used in telehealth coding:
- GT Modifier: Used for services delivered via interactive audio and video telecommunications systems.
- GQ Modifier: Applied to asynchronous telecommunications systems, like store-and-forward technologies.
- FQ Modifier: Designates a telehealth service provided under a federal or state-qualified healthcare professional.
Additional Modifiers for E/M Services
- 24 Modifier: Used to indicate that an unrelated E/M service was performed during a postoperative period.
- 93 Modifier: Signifies that a service was performed via synchronous telecommunication.
Conclusion
Navigating the intricacies of telehealth coding requires a thorough understanding of CPT codes and modifiers. By accurately documenting the nature of each visit and applying the appropriate codes and modifiers, healthcare providers can ensure proper reimbursement and compliance with billing guidelines. Stay informed about the latest updates in telehealth coding to deliver efficient and effective virtual healthcare services.
Remember, coding guidelines may evolve, so it's essential to stay updated with the latest information from relevant healthcare authorities.
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