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Understanding telemedicine coding terminology is essential, as a misunderstanding or misuse of the Common Procedural Terminology (CPT) code may lead to inaccurate billing and negatively impact your health system. Definitions vary from jurisdiction to jurisdiction, and Medicare and Medicaid may not have the same understanding of a code or set of codes. Be prepared to modify your claims based on the payer.
Before you start billing patients for telehealth visits, ensure you have a solid understanding of these key terms:
Originating Site
The originating site is where the patient is when the telehealth encounter occurs. Medicare defines the originating site as being limited geographically, and by the specific site the patient is located in at the time of the interaction. The patient must be:
- In a Rural Health Professional Shortage Area (HPSA) in a rural census tract
- From an entity that participates in a federal telemedicine demonstration project approved by the Secretary of HHS as of December 31, 2000
- In a county outside a Metropolitan Statistical Area (MSA)
- In a specific eligible site (hospitals, practitioner offices, Skilled Nursing Facilities, etc.)
Distant Site
Healthcare providers can’t be outside the United States when offering telehealth services. Due to the RCIU LLC v. United States Department of Health and Human Services court decision, Medicare can’t reimburse telehealth services by providers outside the United States. The Medicare Act has banned foreign payments.
Telehealth Codes To Describe Services
Common Procedural Terminology (CPT) codes constitute the system by which Medicaid, Centers for Medicare and Medicaid Services (CMS), private payers, coders, and billers navigate and discuss coverage. The American Medical Association (AMA) defined the codes, which fall under three major categories. These include:
Category I – Codes under this category have descriptors that correspond to a procedure or service. They range from 00100 – 99499 and are ordered into sub-categories based on procedure type and anatomy.
Category II – These are alphanumeric tracking codes that are supplementary and used for performance measurement. Their use is optional and not needed for correct telehealth coding.
Category III – Codes under the third category are temporary and used for new and developing health services, procedures, and technology. They’re applied to assist with data collection, assessment, and payment of new services that don’t meet the criteria for a Category I code.
Telemedicine Coding Modifiers
Modifiers are two-digit, two-character, or alphanumeric indicators that provide additional information to payers to ensure providers are paid accurately for all telehealth services administered. Providers can use more than one modifier with a procedure code. However, some modifiers are incompatible with other categories and can only be used with a particular code.
CPT modifiers intended for telehealth coding include:
GQ – Indicates asynchronous telehealth services. They are only used in Alaska or Hawaii.
GY – Notice of Liability Not Issued, Not Required Under Payer Policy. Reports that an Advanced Beneficiary Notice (ABN) was not issued because the service is excluded or does not meet any Medicare benefit definition.
GT – Used by Critical Access Hospital distant site professionals billing under CAH Optional Method II. The modifier is applied to an institutional claim and pays 80% of the Professional Service Fee rate.
G0 – Identifies telehealth services applied for diagnosing, evaluating, or treating symptoms of acute stroke.
FR – Indicates the supervising practitioner is present through two-way audio and visual communication.
Handling telehealth coding and billing is challenging as a medical professional with a full schedule. Horizon Healthcare RCM can spearhead your coding efforts while you focus on patient care.
What Services Qualify for Telehealth Billing?
Certain CPT codes describe telehealth services and are applied to ensure accurate telehealth billing. The most common telehealth services include:
Evaluation and Management CPT Codes
There is no separate code that solely describes telemedicine. Instead, outpatient office visit codes are primarily used for telehealth services. 2021 Outpatient Evaluation and Management Guidelines let healthcare professionals bill CMS and private payers based on time or medical decision-making (MDM). CPT codes 99202-99215 are impacted.
When reporting Evaluation and Management CPT codes, the Time Component should describe total non-face-to-face (F2F) and face-to-face time per patient every 24-hour day. The documentation should include:
- Reason for visit
- Evaluation and planning
- Medically appropriate physical exam
- Total number of minutes spent on patient care
The AMA requires sound medical decision-making for valid and precise telehealth coding and billing. Healthcare providers should document and be ready to explain:
- The number and complexity of problems addressed in the telehealth encounter
- The amount or complexity of data to be reviewed and evaluated. This step reduces note bloat by not requiring repetitive test data.
- Risk of complications or patient management morbidity, including social determinants and rationales for not admitting a patient or intervening in their care in any capacity.
Remote Physiological or Patient Monitoring (RPM)
Remote Physiological or Patient Monitoring (RPM) is a set of codes for patients who require chronic, post-discharge, or senior healthcare services. Remote monitoring allows healthcare professionals to keep track of potential health issues and maintain patient data between face-to-face office visits.
Practitioners with a National Provider Identifier (NPI) can perform and bill RPM. However, for valid telehealth coding and billing, you must follow the incident-to rules for different services. All data must be uploaded and transmitted automatically. Manually entered data is invalid and ineligible for billing.
Use these codes:
99453 – Staff service; initial device setup; bill after 16 days of monitoring
99454 – Staff or facility services; covers initial device payment; bill after 16 days of receipt of and monitoring readings, bill every 30 days.
99457 – QHP services; 20 minutes of Non-F2F and F2F time spent in analysis and via synchronous communication with the patient.
99458 – Add-on code; full additional 20 minutes for services described in 99457
Follow Telehealth Billing Guidelines With Horizon Healthcare
Medical coding is sophisticated and vital to your revenue cycle management. Accurate, secure, and efficient coding processes help establish and maintain a healthy cash flow and satisfy industry compliance. Messy medical records hurt healthcare organizations by increasing the chances of rejected claims. Inaccuracies in one area of your health system can have a cascading effect that jeopardizes your entire structure.
The Horizon Healthcare RCM team is ready to step up and lend a hand with your telehealth coding efforts. We identify and remediate coding and billing errors in your system to promote flexibility, profitability, and compliance for your organization. Once you connect with us, you can access our team of certified coders and their up-to-date technology suite.
Ready to simplify the telehealth coding and billing process? Reach out today.
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