Documentation and Billing for Telemedicine Visits during COVID-19

Due to the urgency to expand the use of technology to help patients who need routine care, and to keep vulnerable patients or patients with mild symptoms in their homes while maintaining access to the care they need, under the guidance of President Trump, CMS broadened access to Medicare Telemedicine services.

Under the new 1135 waiver effective March 1, 2020, Medicare patients will be able to receive certain services at their home through Telemedicine and other virtual services, including evaluation and management visits, mental health counseling and preventive health screenings. This waiver will be valid through the duration of COVID-19 Public Health Emergency.

In order to proactively support our customers during these trying times and help them work through the COVID-19 emergency we have developed the below frequently asked questions presentation.

1. Which providers are eligible for Telemedicine services?

Please see the below list of providers who can furnish and get reimbursed for covered Telemedicine services at this time:

  • Physicians
  • Nurse Providers
  • Physician Assistants
  • Nurse Midwives
  • Certified Nurse Anesthetists
  • Clinical Psychologists
  • Clinical Social Workers
  • Registered Dietitians
  • Nurse Professionals

2. How will the Telemedicine services be paid?

The Telemedicine services will be considered the same as in-person visits and will be paid at the same rate as regular, in-person visits.

3. What technologies are available to provide Telemedicine services?

With regards to technology, the provider must use an interactive audio and video telecommunications system that permits real-time communication between the provider site and the patient at home. Considering ease-of-use and HIPAA compliance, some of the good platforms available for use (with no order of preference) include:

Having said that, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency (Source: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html).  Facebook Live, Twitch, TikTok and similar video apps that are public facing should not be used to provide care virtually.

4. What are the key methods of providing virtual services, including documentation and billing options?

Below are three main types of virtual services that providers can provide to their patients:

ServiceApplicable CodesModifierPOS1MediumPatient Visit Documentation2
Telemedicine Visit99201 – 99205
99211 – 99215
For complete list of codes, click here
95 for Medicare;

GT or other, for non-Medicare

Also check payer rules

11•  Audio/Video•  Schedule your patients as you normally would

•  At the time of the televisit, your MA and patient may log into Telemedicine platform to get the visit started

• Make sure to notate in the EHR that the service was performed via Telemedicine

• Indicate the location of the patient e.g. at home

• Document in the EHR as you would for an in-office visit

• For time-based 99201 – 99215 services provided via Telemedicine (real time, interactive audio/visual), a provider does not need to use the level of history or exam to select the service

•  Provider can bill by Total Time or override level based on Medical Decision Making (MDM)

•  If you are billing based on time then you must record total time spent and where that time was spent. Billable time is counted based on providers time and not staff time

•  Provider may want to document detailed assessment and plan based on complexity of the disease

•  Unlike Virtual Check-in visits, you do not need to keep the recordings for your Telemedicine visits. Your documentation for these visits is your office visit note, just as if you were completing an in-person visit

•  Per latest Medicare guidelines, if the patient does not have access to a smart phone or computer, do not bill office visit codes 99201 – 99215. Instead consider using Virtual Check-in or Phone Visit for a phone call with a patient

Virtual
Check-in Visit
• G2010
(Remote evaluation of recorded video/image e.g. via email, text etc.) 

•  G2012
(5-10 minute medical
discussion via phone)

Check payer rules11•  Audio
•  Image
•  Applicable to new and established patient who initiates a communication

•  Patient must verbally consent to the services

•  Not related to a visit in the past 7 days and does not lead to a medical visit in the next 24 hours

•  You must record the time spent and save any images sent to you to the patient’s chart

Phone Visit99441 – 99443 (Physician)

98966 – 98968
(NP, PA Registered Dieticians, Social Workers, Speech Language pathologists and Physical & Occupational Therapists)

11•  Audio•  99441 – 99443 are applicable to new and established patient who initiates a communication

•  98966 – 98968 are applicable to established patient who initiates a communication

•  Patient must verbally consent to the services

•  Not related to a visit in the past 7 days and does not lead to a medical visit in the next 24 hours

•  You must record the time spent

E-Visits
Via Patient Portal
99421 – 99423 (E&M Providers including Physician, NP, PA)

G2061 – G2063 (Non-E&M Providers e.g. Physical Therapist)

Check payer rules11•  Portal•  99421 – 99423 are applicable to new and established patient who initiates communication

•  G2061 – G2063 are applicable to established patient who initiates communication

• Patient must verbally consent to the services

•  Patient communicates with provider without going to the providers office by using online patient portal

•  The communications can occur over a 7-day period

•  You must record the time spent

*Notes: 

  • 1 Coding for Phone Calls, Internet and Telemedicine Consultations, click here
  • 2 Examples of documentation and billing for Virtual visits, click here
  • 3 Examples of 99202 and 99212 coding during telemedicine visits, click here
  • 4 Examples of 99213 coding during telemedicine visit, click here

5. Are there any additional documentation requirements for a Telemedicine visit?

For virtual visits involving time-based coding, evidence of time must be documented. For Telemedicine visit including a synchronous real-time and interactive video-phone call, the call data is not required to be stored. Similarly, for a Phone visit the call data is not required to be saved, you only need to document the visit and time spent. However, for Virtual Check-in visit the  asynchronous images or videos and related data must be stored.

6. Does the provider need to obtain consent from the patient for a virtual visit?

While it is not required that an informed consent be obtained from a patient prior to the service, however Medicare recommends that the patient be notified that virtual service via third-party Telemedicine platform may have potential security and privacy risks.

7. Are new patient visits included in Telemedicine services?

For Medicare Telemedicine services, the patient must have an established relationship within the past three years but can also be a new patient. To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. For more information on establishing patient-provider relationship specific to your State, please refer to a website here.

8. Can ancillary staff bill for virtual services e.g. MA’s, Nurses and other non-Physician staff?

There are only two categories of staff that can bill for Telemedicine services. For Telemedicine and Virtual Check-in visits respectively, the provider must be able to bill for an E/M visit. A Nurse, MA or Technician performing these services would not be able to bill. In situations where the physician does not communicate directly with the patient, the service is not billable.

For E-Visits, the codes ranging from 99421-99423 can be used if the services were provided by an E/M provider e.g. Physician, NP, PA etc. The non-E/M providers e.g. Physical Therapists can use codes ranging from G2061-G2063.

 

9. Can the practitioner provide Telemedicine services from location other than their office, e.g. practitioner’s home?

Yes, a practitioner can provide services from a location other than the practitioner’s practice, such as practitioner’s home. In this scenario, such address must be listed on the claim. CMS is no longer requiring that providers enroll their home address (or other alternate address) with their MAC and will disregard discrepancies between a provider’s enrolled address and the address at which services were provided during the COVID-19 emergency.

10. Can a practitioner provide Telemedicine service out of their state?

Per waiver 1135, in order to render Telemedicine services, a provider does not have to be licensed in the state that the patient is located. However, we recommend that you refer to your state specific guidelines by clicking here.

11. Does the Medicare coinsurance and deductible apply to the virtual visits?

For Medicare, it is optional for providers to lower or waive copays. For non-Medicare payers it is recommended to check specifically with the respective payers in your jurisdiction.

12. Are there any specific requirements for Telemedicine visit documentation for Federally Qualified Health Center’s (FQHC’s) and Rural Health Center’s (RHC’s)?

For FQHC’s or RHC’s, the geographic and site restrictions still apply. In other words, the FQHC’s and RHC’s can serve as the originating site for Telemedicine services, however the patient has to be present at the site and not their home. Evaluation or discussion is not related to a visit in the past 7 days and does not lead to a medical visit in the next 24 hours. Both FQHC’s and RHC’s need to use HCPCS code “G0071” with modifier “GT”.

13. How can providers e-prescribe controlled substances during COVID-19 emergency?

As it relates to e-prescribing for controlled substances, while COVID-19 public health emergency remains in effect, DEA-registered providers may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

  • The prescription is issued for a legitimate medical purpose by a provider acting in the usual course of his/her professional practice
  • The Telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system
  • The provider is acting in accordance with applicable federal and state laws

14. How does Accelerated/Advance Payment Program help providers with cash flow?

In order to increase cash flow to providers impacted by the COVID-19 emergency, CMS has announced establishment of an Accelerated/Advance Payment Program. Under this program, providers can request advanced payments to help cover costs for a 120-day period following receipt of the advanced payment. Amounts advanced under this program will be recouped from the provider’s Medicare billings commencing at the end of such 120-day period. Details on the eligibility, and the request process are outlined here.

15. Is COVID-19 emergency going to impact MIPS reporting in 2020?

On March 22, 2020, CMS announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19. Firstly, the deadline for attestation for 2019 MIPS reporting has been extended to April 30, 2020.

Additionally, if MIPS eligible clinicians attest by April 30, 2020 on 2 or more MIPS performance categories (Quality, Improvement Activities and/or Promoting Interoperability) as an individual or group, they will be scored on those performance categories and receive a 2021 MIPS payment adjustment based on their 2019 MIPS final score.

However, for MIPS eligible clinicians who do not submit their 2019 MIPS data by the extended deadline of April 30, 2020, CMS will reweight the MIPS performance categories. These MIPS eligible clinicians will have all 4 performance categories weighted at 0 percent and will receive a MIPS final score equal to the performance threshold, resulting in a neutral payment adjustment for the 2021 MIPS payment year.

Disclaimer:

This information is provided as a tool to help you understand the latest changes in Telemedicine billing as a result of COVID-19 emergency. TriumpHealth employees and staff have created this presentation to the best of their knowledge and ability, and make no representation or guarantee that this presentation is error-free. TriumpHealth has no liability or responsibility to any person or entity with respect to any loss of revenue, or indirect damages resulting from the potential use of this information.

by Tej Gill, VP – Healthcare Solutions | TriumpHealth