CMS Guidelines for Telehealth Coding & Billing During PHE

CMS Guidelines for Telehealth Coding & Billing During PHE


The Centers for Medicare & Medicaid Services (CMS) has decided to update the CMS PHE billing and coding guidelines for telehealth or in-home provider services due to the urgency of the current 2019-Novel Coronavirus (COVID-19) pandemic (CMS, 2020). In the interim, telehealth services will not be limited by Medicare program restrictions (Federal Register, 2020). If your organization or team needs coding assistance with the CMS telemedicine guidelines during the PHE, contact YES HIM Consulting today to discuss our many Coding Support options available.

CMS guidelines for telehealthInstead, it will give greater flexibility for repayment for these expanded physician services that were previously restricted to healthcare facilities only if they were located in a rural area.

If you have questions about what telehealth services are included, read our previous article, “Medicare Telehealth Services Now Included in Expanded Payment Protocol.” Our next article will dive into the temporary telemedicine policy and regulatory revisions. Review our previous articles on the CMS telemedicine updates in the times of COVID-19, which discuss telehealth coding system rules and guidelines in response to the 1135 waiver, virtual services and telemedicine providers, and the Medicare telemedicine reimbursement guidelines, on the YES Blog.

Medicare telehealth guidelines pay for evaluation and management (E/M) and other services provided in a patient’s home, and E/M service codes cover these services performed by a physician or non-physician practitioner (NPP). HCPCS codes are used for CMS telehealth risk adjustment for PHE billing. These services are for established patients and are to be patient-initiated, including education on the availability of these services before provision.

During the PHE period, CMS will now allow E/M services provided via telehealth to be based on medical decision making (MDM) or time, instead of time spent on counseling or coordination. Time is defined as all of the time associated with the E/M on the day of the encounter, including non-face-to-face time spent in care coordination over the course of the day. The components requiring the documentation of history and/or physical exams are suspended.

CMS telemedicine guidelines state that providers may use the typical times assigned in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule public use file (CMS, 2020). The median intraservice time is the time spent face-to-face with the provider, and the total time includes services such as reviewing tests prior to the visit. If the total time of the visit falls between the time designation of two CPT codes for E/M, other components, such as medical decision making, may assist in code assignment. Office visits, as well as inpatient hospital visits, nursing home visits, and others would fall under these E/M services.

CMS guidelines for telehealth have been expanded to cover phone calls as well, using codes 99441-99443 for reimbursement. Reimbursement for a 5-10-minute call, 99441, will be the same rate as 99212-99442, and reimbursement for an 11-20-minute call will be the same rate as 99213 and 99443. A call greater than 20 minutes will have the same reimbursement rate as 99214.

Medicare Telehealth Coding & Billing Guidelines

CMS guidelines for telehealth - cms telehealth codesThe CMS telehealth codes used for remote or communication technology-based services are the following (CMS, 2020):

G2010 – “Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, 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” (AASM, 2020).

G2012 – “Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, 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” (HCPCS, 2020).

99421-99423 – Online digital evaluation and management service, for an established patient, for up to 7 days

99441-99443 – Audio-only telehealth services using a telephone

G2061-G2063 – Qualified non-physician healthcare professional online assessment and management service, for an established patient

Does your facility need assistance navigating the new policies and guidelines for coding telehealth services during the COVID-19 PHE? Or does your facility have questions regarding the revised CMS guidelines for telehealth? Contact the YES Coding Support Team for assistance on the telehealth coding system rules and guidelines.

YES HIM Consulting

CMS guidelines for telehealth

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