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 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). CMS has broadened the scope for reimbursement for virtual check-ins and other digital communications with patients to safely and effectively respond to this Public Health Emergency (PHE). In the interim, telehealth services will not be limited by program restrictions put in place by Medicare (Federal Register, 2020).

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.

Medicare telehealth guidelines pay for evaluation and management (E/M) and other services provided in a patient’s home. Evaluation and management (E/M) service codes cover these remote and communication technology-based services performed by a physician or non-physician practitioner (NPP). The Healthcare Common Procedural Coding System (HCPCS) codes are used by qualified clinical staff, such as nurses, in addition to physicians or NPPs for CMS telehealth risk adjustment. These services are for established patients and are to be patient-initiated, including education on the availability of these services before provision.

Previously, E/M guidelines only allowed code selection based on time spent on counseling and/or coordination. During the PHE period, CMS will now allow E/M services provided via telehealth to be based on medical decision making (MDM) or time. Time is defined as all of the time associated with the E/M on the day of the encounter, which may include non-face-to-face time spent in care coordination and may be cumulative over the course of the day. The definition of MDM will not change, and the components requiring the documentation of history and/or physical exams are suspended.

To assist with the E/M code selection, 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 patient by the provider, and the total time would include 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 selecting the appropriate E/M code. An example is if the total time of the visit was 24 minutes, which falls between E/M codes 99213 (23 minutes of total time) and 99214 (40 minutes of total time) (CMS, 2020). Office visits, as well as inpatient hospital visits, nursing home visits, and others would fall under these E/M services.

Medicare Telehealth Coding & Billing Guidelines

CMS guidelines for telehealthThe 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

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

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 coding in response to the 1135 waiver, virtual services and telemedicine providers, and the Medicare telemedicine reimbursement guidelines, on the YES Blog.

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CMS guidelines for telehealth

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