Recommendations for Telemedicine Reimbursement

Since the SARS-CoV-2 worldwide pandemic, the field of medicine has turned toward telemedicine as a necessity for continued patient care. This technological platform has provided an avenue for patients to remain in contact with their primary care physicians. Although the pandemic caused several different facets of daily life to come to a halt, medicine does not have that luxury. Cancer patients still need to be in touch with their oncologists, mental health counseling and preventive health screenings continue to be essential, and newborns still need developmental check-ups.

Although the telemedicine industry has boomed with the current pandemic, it is likely that these services will continue to change the face of medicine.

Fortunately prior to the pandemic, several telemedicine services were in development. The Hospital and Health Systems 2016 Consumer Telehealth Benchmark Survey reported that 76% of hospitals and health systems have telehealth services available for patients or planned to implement them by the end of 2018.(1) One service that is free for medical providers is Doximity. Doximity may be used on a web-based platform or as an app on a device such as a cellphone or iPad. Additionally, this service is compliant with HIPAA.(2)

Although the telemedicine industry has boomed with the current pandemic, it is likely that these services will continue to change the face of medicine. With the availability of technology, high-quality medical care can be made accessible for patients who live hours away from the clinical office. Telemedicine also provides an avenue for postoperative or hospital discharge visits, as well as mental health services.(3) This service allows patients to be screened for potential visits such as dermatology or ENT clinics. Additionally, telemedicine may be used to provide streamlined care to the emergency department.

During this pandemic, the CMS expanded coverage for telemedicine services, with new guidelines that will remain active for the duration of this public health emergency. As telemedicine has continued to grow and become a normal part of medical care, it has been difficult to find concise guidelines for billing. This article provides an easy reference for medical offices.(4)

In telemedicine, healthcare services are provided primarily through telephone communication or with the use of a two-way video- and audio-based platform. These services are reimbursed differently by the federal and commercial insurance companies. Telemedicine may be conducted by medical physicians (MD/DO), nurse practitioners, or physician assistants.(5) Under the CMS expansion of telehealth under the 1135 waiver, Medicare will reimburse telemedicine visits for a variety of additional care providers, including psychologists, social workers, speech pathologists, and physical therapists.(6)

Telephone Services

For patients who do not have access to a video and audio system, the telephone is an easily accessible alternative. It is important to note that these services will only be covered by commercial and federal payers for established patients.(7) Additionally, the patient cannot have been provided services within the previous seven days. If the telephone call leads to a face-to-face encounter, whether in person or via telehealth within 24 hours, the telephone service does not qualify for any forms of reimbursement.

In order to bill for non–face-to-face telephone services, certain documentation must be included in the clinic note. Providers must include the following:

1. Notation that the patient consented to having the consult held via telephone;

2. Names of all people present on the call;

3. Chief complaint or reason for telephone visit;

4. Relevant history, background, or test results;

5. Assessment;

6. Plan and next steps; and

7. Total time spent on medical discussion.

The particular billing code used depends on the total time spent with the patient. Payments for non–face-to-face telephone services currently can differ between payers, and we highly recommend that you consult with individual payers regarding reimbursement for these codes. Billing code 99441 indicates a total time spent of 5 to 10 minutes of medical discussion, with an approximate reimbursement rate of $13.91 to $27.15. CPT 99442 indicates a total time spent of 11 to 20 minutes, with an approximate reimbursement rate of $26.96 to $53.79. CPT 99443 indicates a total time spent of 21 to 30 minutes, with an approximate reimbursement rate of $39.79 to $80.28. If time spent with the patient exceeds 30 minutes, the clinician should use CPT 99443, because further reimbursement is not available.(8,9)

Fortunately, federal payers currently are matching the reimbursement rate of commercial health insurance payers, which varies between companies and states. However, using telephone services with patients has a substantially lower reimbursement rate compared with more advanced telehealth services.

Telemedicine Using a Video and Audio Platform

Currently reimbursement by federal payers and commercial carriers is equivalent to that for a face-to-face visit. Under the CMS waiver, providers may see new and established patients. Additionally, the U.S. Department of Health and Human Services for Civil Rights has waived penalties for the use of noncompliant HIPAA technologies such as FaceTime or Skype during the COVID-19 public health emergency.(8) However, free telemedicine services that are HIPAA compliant are available for medical offices to use, such as Doximity.

Several key points must be remembered for video and audio telehealth visits. There must be a two-way video and audio platform that permits real-time communication between the clinician and patient.(8) The patient must verbally consent to receive care virtually. Services may be billed based on key components such as the history, exam, and medical decision, or they may be based on time. Total time of encounter should be well documented in the clinic note. If billing is based on time, the clinic note should include the total time of visit and documentation that 50% or more of the time was spent on counseling and coordinating care.(9) It is important to note that the time spent setting a patient up for a telehealth visit does not count toward the total visit time.(8)

Medical screenings required by the Emergency Medical Treatment and Labor Act may be provided via telehealth for the duration of the public health emergency.(8) Additionally, Medicare annual wellness exams also may be conducted using a telehealth platform. The annual Medicare visit includes a questionnaire and physical exam. For the physical exam, document as thoroughly as possible. For example, if a patient has hypertension, have them take their blood pressure during the encounter.

Telehealth visits utilizing a video and audio system should be billed by applying standard evaluation and management (E&M) codes with the placement of service code (POS) 11 indicating an office visit and modifier 95 signifying that the encounter was via telehealth.(8,10,11) This will ensure equivalent reimbursement to an in-office visit.

Conclusion

Using telemedicine has been a very beneficial technologic advance in the field of medicine. With the current CMS waiver, clinics are able to care for their patients virtually. However, the use of telehealth is not available to all. Certain populations such as the homeless and areas in rural communities do not have access to a two-way video and audio system. In these instances, many providers must resort to telephone visits. Unfortunately, telephone visit reimbursement is low compared with telehealth encounters. Currently, there is a movement to equivalate telephone service charges to in-office visits in the hope of offsetting the loss of potential income, especially in rural areas. In recent times, with the COVID-19 outbreak, many rural practices have been forced to close due to lack of reimbursement from federal and commercial payers. If comparable compensation is provided to these clinicians, continued care will remain available to those communities, thereby aiding in alleviating the nation’s hospital capacity burdens.

Telemedicine is quickly becoming the future of medicine. The accessibility of such a service is useful in times of a pandemic or for patients who must travel a far distance to the closest clinic. This technology can be beneficial for surgeons as well, because this platform allows for nurse practitioners and physician assistants to assist in follow-up visits. As telemedicine becomes integrated into medicine, clear guidelines are necessary for proper federal and commercial payer reimbursement.

Key take home points:

• Documentation is key for reimbursement. It may be useful to set up a charge page that includes in-office visits, telemedicine visits, telephone visits, and chronic disease codes.

• Telemedicine can be provided by clinicians with a medical degree (MD/DO), physician assistants, and nurse practitioners.

• Telephone visits may be billed only for existing patients.

• Telephone visits are reimbursed based on the total amount of time spent with the patient. CPT codes used for telephone encounters range from 99441-99443. It is important to document: (1) patient consent; (2) names of all people present on the call; (3) the reason for the visit; (4) relevant history, background, or test results; (5) assessment; (6) plan and next steps; and (7) total time spent on medical discussion.

• For a telehealth visit to be reimbursed as an in-office visit, the encounter must be conducted on a video- and audio-based platform that permits real-time communication between the provider and the patient.

• For equivalent reimbursement, telehealth video/audio visits should be billed using E&M codes with POS 11 and modifier 95.

References

1. Roga A. Telehealth adoption to double by 2018. Hospitals & Health Networks. June 12, 2017. Available from: bit.ly/2NVqTm0.

2. Doximity. Our Commitment to Security. www.doximity.com/about/security . Accessed August 2020.

3. American Psychiatry Association. Telepsychiatry and COVID-19. www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19 . Accessed September 2020.

4. Centers for Medicare and Medicaid Services. List of Telehealth Services. www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes . Accessed August 2020.

5. American Medical Association. Telemedicine during the COVID-19 public health emergency frequently asked questions. 2020. www.ama-assn.org/system/files/2020-05/telemedicine-during-phe-faqs.pdf . Accessed August 2020.

6. Centers for Medicare and Medicaid Services. Medicare telemedicine health care provider fact sheet. March 2020. www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet . Accessed August 2020.

7. Center for Care Innovations. Telephone visits: definitions, coding, and documentation. 2020. www.careinnovations.org/wp-content/uploads/1.-Telephone-Visits-Definitions-Coding-Documentation_CP3-Toolkit.pdf . Accessed August 2020.

8. American Academy of Family Physicians. COVID-19: frequently asked telehealth questions. 2020. www.aafp.org/patient-care/emergency/2019-coronavirus/telehealth/faq.html. Accessed August 2020.

9. Eramo LA. Telehealth coding guide: code it right, get paid. Medical Economics. 2020;97(12):16-19.

10. Centers for Medicare and Medicaid Services. Telehealth. April 2020. www.cms.gov/Medicare/Medicare-General-information/telehealth . Accessed August 2020.

11. American Academy of Family Physicians. What coding modifiers to use for Medicare telehealth services and COVID-19 testing. April 9, 2020. www.aafp.org/journals/fpm/blogs/gettingpaid/entry/coronavirus_modifier_coding.html . Accessed August 2020.