May 11, 2021

Get Paid for Virtual Healthcare: Untangling Telehealth Coding and Claims

Last updated May 20, 2021  |  Published May 11, 2021 by Helen Farnen

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Telemedicine has been around for many years, but its use exploded during the COVID-19 pandemic—accounting for 20% of healthcare visits in 2020. No longer just a trend, virtual and remote care is an accepted method of delivery. But providers still have questions; for example, how is telehealth defined by payers, and how should it be coded for maximum reimbursement?


Why It Pays to Understand Telehealth Billing

The growing demand for telehealthcare has become a big business. According to online network platform Doximity, by the time the dust settles telehealth is expected to have accounted for more than $29 billion of U.S. healthcare spending in 2020. And it could grow to $106 billion by 2023.

Patient adoption has also ballooned. The number of individuals who participated in a virtual care visit since the beginning of the COVID-19 pandemic increased by 57%, with those experiencing a chronic health condition increasing participation by 77%. Employers are onboard too—they see telehealth as a way to support employee wellness while maintaining productivity. In fact, 32% say that offering virtual health services is a top priority in 2021.

Medicare is Driving Reimbursement

The U.S. Centers for Medicare & Medicaid Services (CMS) took the lead on telehealth policies in early 2020, which affect how claims are paid. CMS added more than 200 Medicare-covered telehealth services to help combat COVID-19 and increase virtual care use. Later in the year, CMS permanently expanded coverage to include telehealth services. These final regulations explain how Medicare will pas for virtual office, hospital, and other healthcare requested by patients and provided by doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers going forward.

Types of Virtual Care

As part of their rules, CMS created specific definitions and coding for telehealth:

Telehealth Visits

These are visits conducted via telecommunications-based services (such as Skype or Zoom) in real-time between a new or established patient and a remote practitioner. These visits are considered the same as in-person care by CMS and are reimbursed at the same rate as an in-person visit, subject to Medicare deductibles and 20% coinsurance. However, at their discretion, providers may waive cost-sharing.

Commonly-used codes for telehealth visits include:

  • 99201-99205: New office/outpatient evaluation and management (E/M) visit
  • 99210-99215: Established office/outpatient E/M visit
  • G0425-G0427: Consultations, emergency department or initial inpatient (Medicare only)
  • G0406-G0408: Follow-up inpatient telehealth consultations for patients in hospitals or skilled nursing facilities (Medicare only)
  • Modifier 95 – Required by most commercial payers, use on an interim basis for Medicare telehealth billing

Medicare typically requires the Place of Service code “02” for telehealth services; however, practitioners billing Medicare telehealth services should use the same Place of Service code typically used when billing for in-person services during the COVID-19 public health emergency.

Virtual Check-In Visits

These visits are initiated by established patients for a brief “check-in” with their provider via phone or other communication technology. The visit can’t be associated with related medical care provided within the past seven days and must not result in a subsequent visit within the next 24 hours (or the soonest available appointment time). These visits are also subject to deductibles and copays under Medicare Part B.

Codes used for these visits are: 

  • G2012: Brief communication (5-10 minutes) technology-based service, new or established
  • G2010: Remote evaluation of recorded video and/or images submitted, new or established, including interpretation and follow-up within 24 business hours

E-Visits

Visits initiated by a patient and conducted via an online portal are covered by Medicare when the practice has an established relationship with the patient. The patient must generate the initial inquiry and communications can occur over a seven-day period. Medicare part B coinsurance and deductible apply to E-visits, and they may expire at the end of the public health emergency. The billing codes for E-visits are the following:

  • Telephone E/M visits: 99441 (5-10 minutes), 99442 (11-20 minutes), 99443 (21-30 minutes)
  • Digital E/M visits: 
    • Physicians: 99421 (5-10 minutes), 99422 (11-20 minutes), 99423 (21-30 minutes)
    • Qualified non-physicians: 98970 or G2061 (5-10 minutes), 98971 or G2062 (11-20 minutes), 98972 or G2063 (21 – 30 minutes)

Codes may also vary by healthcare speciality and provider. The American College of Physicians provides a comprehensive report

Individual States Have Their Own Rules

As of February 2021, 43 states and the District of Columbia have passed laws requiring some level of telemedicine coverage by commercial insurance payers. The level of reimbursement varies by state and insurance carrier. State regulations are subject to change. The Center for Connected Health Policy provides up-to-date status of all 50 states and D.C.

Commercial Insurance Covers Telehealth Too

In many cases, insurers must pay the same amount for telehealth as in-person visits. And some are limiting coverage until the end of the COVID-19 Public Health Emergency. America’s Health Insurance Plans provides a list of the major national insurance carriers and how they cover telehealth and other COVID-19 related care. However, it’s always a good idea to confirm how a payer reimburses virtual care and the specific codes to use.

RXNT Will Keep You Current With Telehealth

If you’re new to virtual care or you’re a seasoned veteran, having telehealth-friendly software takes the guesswork out of timely reimbursements. RXNT’s Electronic Health Records and Scheduling solutions work seamlessly with your favorite video-conferencing platform. And our Medical Billing software is continuously updated to keep pace with frequently changing ICD-10 and CPT codes, including telehealth. Schedule your demo to see how easy RXNT makes managing your telehealth visits.

Want to learn more? See what’s changed with CPT codes for 2021.

Ready to learn more?

Find out why our award-winning, certified solutions are the right fit for your practice. Since 1999, we have provided integrated, cloud-based Electronic Prescribing (eRx), Electronic Health Records (EHR) with patient portal, and Practice Management (PM) with medical billing and scheduling.

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