Telehealth billing during the COVID-19 national emergency

Editor's note: The COVID-19 public health emergency (PHE) declaration expired in May 2023. This article serves as an archive of previous guidance that was relevant to the PHE at the time.

The Centers for Medicare & Medicaid Services (CMS) recently released numerous waivers along with new rules for billing professional telehealth services during the public health emergency (PHE) of COVID-19. These changes, currently in place for the duration of the PHE, aim to ensure that patients have access to physicians and other qualified healthcare providers while remaining at home. 

There are several types of services available to all Medicare beneficiaries, including telehealth, virtual check-ins and telephone visits, e-visits and remote patient monitoring. 

Telehealth

Services that are normally provided via in-person visits, such as outpatient clinic visits, inpatient visits, nursing facility visits and therapy services can be provided via telehealth. During the PHE, the services available for telehealth have been expanded. In addition, rules surrounding location, telecommunications equipment for telehealth services and the types of clinicians allowed to provide telehealth have been waived.

When providing these services, keep in mind the following:

• Providers can bill for telehealth visits at the same rate as in-person visits
• Medicare copayments for telehealth services for beneficiaries can be waived
  • This means the provider will only be reimbursed what Medicare pays (80% of the allowable). However, for dates of service March 18, 2020, through the end of the PHE, Medicare will waive all patient cost-sharing for COVD-19 testing and any telehealth visits where COVID-19 testing is ordered or performed, including telehealth visits, and e-visits, but not virtual check-ins. In order to get paid at 100% of the Medicare allowable, modifier CS should be appended to the telehealth visit.
• New and established patients qualify for telehealth visits
• Platform security requirements have been lifted, so real-time audio and visual technologies such as FaceTime, Google Hangouts, Skype, Zoom and others are allowed
  • CMS requires real-time audio with video for E/M visits; however, other payers may not. Be sure to check your commercial payers’ policies.
• Annual consent may be obtained at the same time the services are performed
• There are no location restrictions for the patient or provider
• Evaluation and management (E/M) level selection furnished via telehealth can be based on medical decision making or time, with time defined as all of the time associated with the E/M on the day of the encounter
  • CMS specifically gives this guideline for outpatient E/M codes 99201 through 99215. To date, this has not been addressed for other E/M codes.

Providers must review and familiarize themselves on CPT and CMS documentation guidelines in order to choose the appropriate CPT code for billing, based on the service provided and documented. Per CMS, non-traditional telehealth visits with dates of services on or after March 1, 2020, and for the duration of the PHE should be billed using a Place of Service (POS) code equal to what would have been in normal circumstances. 

In addition, modifier 95 should be appended to indicate the service was performed via telehealth.  Modifier CR, for catastrophe/disaster related services, is not required by CMS for telehealth services.

A complete list of all Medicare telehealth services can be found here.

Virtual check-ins and telephone visits

Virtual check-ins and telephone visits are communication technology-based services for patients. These services may be provided through telephone, audio/video/secure text messaging, email or use of patient portal. These services may also include captured video or images sent to a provider, sometimes called store and forward. 

For virtual check-ins and telephone visits, the following applies:

• Must not be related to an E/M service provided in the past seven days or leading to an E/M service or procedure in the next 24 hours (or soonest appointment)
• Includes five to 10 minutes of medical discussion, or more for telephone visits
• Can be provided to new or established patients

Virtual check-ins are billed with G2010, or G2012 for remote evaluation of recorded video and/or images submitted by the patient. 

Time-based telephone E/M services are reported with CPT codes 99441 to 99443. Codes 98966 to 98968 are also available for a broad range of other clinician types, such as licensed clinical social workers, psychologists, physical therapists, occupational therapists and speech language pathologists.

E-visits

E-visits are digital management/M services, such as communications through an online patient portal. There are two sets of codes for these services depending on provider type. For providers who can bill for E/M codes, online digital E/M services are billed with codes 99421 to 99423, based on cumulative time spent on the visit over seven days. For other clinicians, these services are billed using the same criteria, but with codes G2061 to G2063. 

Remote patient monitoring (RPM)

During the PHE, clinicians can provide RPM services to new and established patients for both acute and chronic conditions and for patients with only one disease. For example, RPM can be used to monitor a patient’s oxygen saturation levels using pulse oximetry. The applicable CPT codes include 99091, 99457 to 99458, 99473 to 99474, and 99493 to 99494.

Other considerations

For Medicare patients, many of the requirements to perform in-person visits as well as the frequency limitations on Medicare telehealth have been waived during the PHE. To help address workforce issues, CMS has also released many exceptions for physician supervision requirements as well as practitioner types allowed to furnish services. 

Other payers, including state Medicaid programs have released revised telehealth guidelines, many of which are similar to the Medicare guidance that has been published.  Before providing and billing for these services, be sure to read the CMS guidance in full, as well as all other applicable payer guidance.

Additional resources:

• MLN Connects — Billing for Professional Telehealth Services During the PHE (CMS)
• Medicare Telehealth/Telemedicine Waivers During the COVID-19 Public Health Emergency (MGMA)
• “Navigating telehealth billing requirements” (June 2018)