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Telemedicine for Medicare Patients FAQ

  • How are Telehealth or Telemed terms defined?

    Recommendations
    Answer

    The relatively rapid expansion of remotely provided clinical services from non-reimbursed items to more mainstream (and even reimbursed) services, has resulted in some current definition inconsistencies among different coding/payer methodologies (and sometimes even within a single payer). The following definitions rely heavily on Medicare's policies/procedures. Private payers may have different codes, definitions and requirements for reporting these services.

    Telehealth (or Telemonitoring) is “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.”  Telehealth is a broad term and can refer to clinical and non-clinical services involving medical education, administration, and research.  Telehealth includes technologies such as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit data for monitoring and interpretation.  For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services.

    Telemedicine is more narrowly defined.  Per CMS, “Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.  This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”  This is referred to as an “Interactive” system.

    Some technologies used in the broader category of telehealth do not meet the definition of telemedicine. These are referred to as “asynchronous, or store and forward, applications”, and include the use of a camera (e.g., audio clips, video clips, still images) to record (store) an image that is transmitted (forwarded) to another site for review at a later time.  Per CMS guidelines, asynchronous technology is permitted only in federal telehealth demonstrations programs conducted in Alaska or Hawaii.

    Teleconsultations is another broad term that includes using telecommunications between a patient and a health professional for use in rendering a diagnosis and treatment plan. Generally, in order to bill Medicare, the service provided should meet the definition of telemedicine.

    Answer

    The relatively rapid expansion of remotely provided clinical services from non-reimbursed items to more mainstream (and even reimbursed) services, has resulted in some current definition inconsistencies among different coding/payer methodologies (and sometimes even within a single payer). The following definitions rely heavily on Medicare's policies/procedures. Private payers may have different codes, definitions and requirements for reporting these services.

    Telehealth (or Telemonitoring) is “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.”  Telehealth is a broad term and can refer to clinical and non-clinical services involving medical education, administration, and research.  Telehealth includes technologies such as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit data for monitoring and interpretation.  For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services.

    Telemedicine is more narrowly defined.  Per CMS, “Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.  This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”  This is referred to as an “Interactive” system.

    Some technologies used in the broader category of telehealth do not meet the definition of telemedicine. These are referred to as “asynchronous, or store and forward, applications”, and include the use of a camera (e.g., audio clips, video clips, still images) to record (store) an image that is transmitted (forwarded) to another site for review at a later time.  Per CMS guidelines, asynchronous technology is permitted only in federal telehealth demonstrations programs conducted in Alaska or Hawaii.

    Teleconsultations is another broad term that includes using telecommunications between a patient and a health professional for use in rendering a diagnosis and treatment plan. Generally, in order to bill Medicare, the service provided should meet the definition of telemedicine.

  • Are the services reported differently if you are the hosting facility vs. the consulting provider?
    Recommendations
    Answer

    Yes.  CMS requires the reported telemedicine services include both an originating site and a distant site. The originating site is the location of the patient at the time the service is being furnished.  The distant site is the site where the physician or other licensed practitioner delivering the service is located.

    A telehealth facility fee is paid to the originating site.  Claims for the facility fee should be submitted using HCPCS code Q3014:  "Telehealth originating site facility fee."  Originating sites include: the office of a physician or practitioner, Hospitals, Critical Access Hospitals (CAH), Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Hospital-based or CAH-based Renal Dialysis Centers (including satellites), Skilled Nursing Facilities (SNF), and Community Mental Health Centers.

    Until 2014, only originating sites in low population density rural counties were eligible for telehealth reimbursement.  As of January 1, 2014, originating sites in rural portions of urban and high population counties may also be eligible for reimbursement.  Below is the link for a telehealth calculator to determine if your originating site is eligible for Medicare payment.

    http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

    Answer

    Yes.  CMS requires the reported telemedicine services include both an originating site and a distant site. The originating site is the location of the patient at the time the service is being furnished.  The distant site is the site where the physician or other licensed practitioner delivering the service is located.

    A telehealth facility fee is paid to the originating site.  Claims for the facility fee should be submitted using HCPCS code Q3014:  "Telehealth originating site facility fee."  Originating sites include: the office of a physician or practitioner, Hospitals, Critical Access Hospitals (CAH), Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Hospital-based or CAH-based Renal Dialysis Centers (including satellites), Skilled Nursing Facilities (SNF), and Community Mental Health Centers.

    Until 2014, only originating sites in low population density rural counties were eligible for telehealth reimbursement.  As of January 1, 2014, originating sites in rural portions of urban and high population counties may also be eligible for reimbursement.  Below is the link for a telehealth calculator to determine if your originating site is eligible for Medicare payment.

    http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

  • What codes are used by the consulting provider to report telemedicine?
    Recommendations
    Answer

    In addition to being able to utilize Office or other outpatient codes (99201-99205) and subsequent hospital codes (99231-99233), the 2020 Medicare (HCPCS) telehealth descriptor codes and RVUs are listed below:

    Code

    Descriptor

    Total Typical Time

    Work
    RVUs

    G0425

    Emergency Department or initial inpatient telehealth consultation

    30 minutes

    1.92

    G0426

    Emergency Department or initial inpatient telehealth consultation

    50 minutes

    2.61

    G0427

    Emergency Department or initial inpatient telehealth consultation

    70 minutes

    3.86

    G0406

    Follow-up inpatient telehealth consultation, limited

    15 minutes

    0.76

    G0407

    Follow-up inpatient telehealth consultation, Intermediate

    25 minutes

    1.39

    G0408

    Follow-up inpatient telehealth consultation, complex

    35 minutes

    2.00

    Code, 99490 is for chronic care management and remote monitoring of chronic conditions.

    More important, CMS added the following list of services to the Medicare telehealth list on a Category I basis to facilitate correct coding for changes brought about by COVID. They are:

    Code

    Descriptor

    90853

    Group Psychotherapy

    96121

    Psychological and Neuropsychological Testing

    99334-99335

    Domiciliary, Rest Home or Custodial Care services, Established patients

    99347-99348

    Home visits, Established Patient

    99483

    Cognitive Assessment and Care Planning Services

    G2211

    Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M)

    G2212

    Prolonged Services

    Medicare also created a third temporary category of criteria for adding services to the list of Medicare telehealth services for the COVID public health emergency.  These are services added to the list that will currently remain on the list through the calendar year in which the PHE ends.  Category 3 Services include:

    Code

    Descriptor

    99336-99337

    Domiciliary, Rest Home, or Custodial Care services, Established patients

    99349-99350

    Home Visits, Established Patient (CPT codes)

    99281-99285

    Emergency Department Visits, Levels 1-5

    99315-99316

    Nursing facilities discharge day management (CPT codes)

    96130- 96133; 96136-96139

    Psychological and Neuropsychological Testing (CPT codes)

    97161-97168; 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507

    Therapy Services, Physical and Occupational Therapy, All levels

    99238-99239

    Hospital discharge day management

    99469, 99472, 99476)

    Inpatient Neonatal and Pediatric Critical Care, Subsequent

    99478-99480

    Continuing Neonatal Intensive Care Services

    99291-99292

    Critical Care Services

    90952, 90953, 90956, 90959, 90962

    End-Stage Renal Disease Monthly Capitation Payment

    99217; 99224-99226

    Subsequent Observation and Observation Discharge Day Management

    During the COVID-19 pandemic CMS has granted an 1135 waiver allowing the ED E/M codes (99281-99285) to be furnished via telehealth, meaning real time two-way audio and visual interaction. The place of service (POS) code used on the claim should be the same as if the service were rendered face-to face; for the ED that would be POS 23. Include modifier 95 to each claim.   This is true even if the patient is not physically in the ED such as in a remote location or even the patient home.  It is also allowed that the emergency physician may be in a different location even at home.  These waivers are retroactive to services provided after March 6, 2020. CMS also added the telephone services codes (99441- 99443) to the telehealth waiver list and increased the payment for those codes to match the office or other outpatient code values.

    Other new relevant additions to telemedicine-covered codes include the ability to utilize more psychoanalysis and evaluation codes along with prolonged psychiatric evaluation codes.

    The CMS Waiver

    Under the CMS waiver, telehealth services may be now be provided in all areas (not just rural), and any Medicare beneficiaries may receive these services from any location, including their homes. This applies to both new patients and those with whom the furnishing physician has a pre-established relationship under the waivers

    During the pandemic, CMS will reimburse for audio-only telephone calls.

    CMS has temporarily added separate codes (CPT codes 98966-98968 and CPT codes 99441-99443) to the list of approved telehealth services. 

    Valued the same as the office and outpatient evaluation and management (E/M) codes.

    Telephone services should not be reported for a follow up call related to a procedure by your same group.

    Clinicians may provide remote evaluation of patient video/images and virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. These services were previously limited to established patients.  Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits. E-visits are non-face-to-face communications with their practitioner by using online patient portals. (HCPCS codes G2061-G2063).  Clinicians may provide remote patient monitoring services to both new and established patients. These services may be provided for both acute and chronic conditions and can now be provided for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry. (CPT codes 99091, 99457-99458, 99473-99474, 99493-99494).

    As of early 2020, 32 states and the District of Columbia had laws requiring private payers to reimburse for telehealth services. 49 states and the District of Columbia provide reimbursement through Medicaid. The coverage varies by state, payer type, and individual characteristics of the encounter (patient setting, geographic location, type of provider, live video vs. electronically transmitted health information).  As clinical practice in the emergency department grows to accommodate telehealth technology, the code set will require ongoing review and expansion.

    CMS has recently confirmed that there are no specialty specific restrictions on billing for Telehealth consultation, emergency department or initial inpatient, HCPCS codes G0425-G0427, so emergency physicians could bill for these services if they are the consulting provider, as demonstrated in the 2 examples below:

    1. Emergency physician in a non-trauma designated hospital ED has a major trauma such as a roll over motor vehicle accident present to the ED.  He/She calls another emergency physician at a Level 1 trauma center to discuss management and potential transfer of the patient. The patient is not transferred and remains in the smaller facility with significant input and direct management by the physician at the level 1 trauma center.
    2. Emergency physician in a smaller hospital ED sees a complex sepsis, stroke, or acute MI patient and calls an emergency physician at a larger academic medical center to discuss management of the patient and potential transfer  of the patient. The patient is not transferred and remains in the smaller facility with significant input and direct management by the physician at the level 1 trauma center.
    Answer

    In addition to being able to utilize Office or other outpatient codes (99201-99205) and subsequent hospital codes (99231-99233), the 2020 Medicare (HCPCS) telehealth descriptor codes and RVUs are listed below:

    Code

    Descriptor

    Total Typical Time

    Work
    RVUs

    G0425

    Emergency Department or initial inpatient telehealth consultation

    30 minutes

    1.92

    G0426

    Emergency Department or initial inpatient telehealth consultation

    50 minutes

    2.61

    G0427

    Emergency Department or initial inpatient telehealth consultation

    70 minutes

    3.86

    G0406

    Follow-up inpatient telehealth consultation, limited

    15 minutes

    0.76

    G0407

    Follow-up inpatient telehealth consultation, Intermediate

    25 minutes

    1.39

    G0408

    Follow-up inpatient telehealth consultation, complex

    35 minutes

    2.00

    Code, 99490 is for chronic care management and remote monitoring of chronic conditions.

    More important, CMS added the following list of services to the Medicare telehealth list on a Category I basis to facilitate correct coding for changes brought about by COVID. They are:

    Code

    Descriptor

    90853

    Group Psychotherapy

    96121

    Psychological and Neuropsychological Testing

    99334-99335

    Domiciliary, Rest Home or Custodial Care services, Established patients

    99347-99348

    Home visits, Established Patient

    99483

    Cognitive Assessment and Care Planning Services

    G2211

    Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M)

    G2212

    Prolonged Services

    Medicare also created a third temporary category of criteria for adding services to the list of Medicare telehealth services for the COVID public health emergency.  These are services added to the list that will currently remain on the list through the calendar year in which the PHE ends.  Category 3 Services include:

    Code

    Descriptor

    99336-99337

    Domiciliary, Rest Home, or Custodial Care services, Established patients

    99349-99350

    Home Visits, Established Patient (CPT codes)

    99281-99285

    Emergency Department Visits, Levels 1-5

    99315-99316

    Nursing facilities discharge day management (CPT codes)

    96130- 96133; 96136-96139

    Psychological and Neuropsychological Testing (CPT codes)

    97161-97168; 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507

    Therapy Services, Physical and Occupational Therapy, All levels

    99238-99239

    Hospital discharge day management

    99469, 99472, 99476)

    Inpatient Neonatal and Pediatric Critical Care, Subsequent

    99478-99480

    Continuing Neonatal Intensive Care Services

    99291-99292

    Critical Care Services

    90952, 90953, 90956, 90959, 90962

    End-Stage Renal Disease Monthly Capitation Payment

    99217; 99224-99226

    Subsequent Observation and Observation Discharge Day Management

    During the COVID-19 pandemic CMS has granted an 1135 waiver allowing the ED E/M codes (99281-99285) to be furnished via telehealth, meaning real time two-way audio and visual interaction. The place of service (POS) code used on the claim should be the same as if the service were rendered face-to face; for the ED that would be POS 23. Include modifier 95 to each claim.   This is true even if the patient is not physically in the ED such as in a remote location or even the patient home.  It is also allowed that the emergency physician may be in a different location even at home.  These waivers are retroactive to services provided after March 6, 2020. CMS also added the telephone services codes (99441- 99443) to the telehealth waiver list and increased the payment for those codes to match the office or other outpatient code values.

    Other new relevant additions to telemedicine-covered codes include the ability to utilize more psychoanalysis and evaluation codes along with prolonged psychiatric evaluation codes.

    The CMS Waiver

    Under the CMS waiver, telehealth services may be now be provided in all areas (not just rural), and any Medicare beneficiaries may receive these services from any location, including their homes. This applies to both new patients and those with whom the furnishing physician has a pre-established relationship under the waivers

    During the pandemic, CMS will reimburse for audio-only telephone calls.

    CMS has temporarily added separate codes (CPT codes 98966-98968 and CPT codes 99441-99443) to the list of approved telehealth services. 

    Valued the same as the office and outpatient evaluation and management (E/M) codes.

    Telephone services should not be reported for a follow up call related to a procedure by your same group.

    Clinicians may provide remote evaluation of patient video/images and virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. These services were previously limited to established patients.  Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits. E-visits are non-face-to-face communications with their practitioner by using online patient portals. (HCPCS codes G2061-G2063).  Clinicians may provide remote patient monitoring services to both new and established patients. These services may be provided for both acute and chronic conditions and can now be provided for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry. (CPT codes 99091, 99457-99458, 99473-99474, 99493-99494).

    As of early 2020, 32 states and the District of Columbia had laws requiring private payers to reimburse for telehealth services. 49 states and the District of Columbia provide reimbursement through Medicaid. The coverage varies by state, payer type, and individual characteristics of the encounter (patient setting, geographic location, type of provider, live video vs. electronically transmitted health information).  As clinical practice in the emergency department grows to accommodate telehealth technology, the code set will require ongoing review and expansion.

    CMS has recently confirmed that there are no specialty specific restrictions on billing for Telehealth consultation, emergency department or initial inpatient, HCPCS codes G0425-G0427, so emergency physicians could bill for these services if they are the consulting provider, as demonstrated in the 2 examples below:

    1. Emergency physician in a non-trauma designated hospital ED has a major trauma such as a roll over motor vehicle accident present to the ED.  He/She calls another emergency physician at a Level 1 trauma center to discuss management and potential transfer of the patient. The patient is not transferred and remains in the smaller facility with significant input and direct management by the physician at the level 1 trauma center.
    2. Emergency physician in a smaller hospital ED sees a complex sepsis, stroke, or acute MI patient and calls an emergency physician at a larger academic medical center to discuss management of the patient and potential transfer  of the patient. The patient is not transferred and remains in the smaller facility with significant input and direct management by the physician at the level 1 trauma center.
  • What modifiers are used when reporting telemedicine services?
    Recommendations
    Answer

    Claims for professional services should be submitted using the appropriate service code, and the modifier "GT" or “GQ.”

    GT modifier- Providers at the distant site submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service along with the modifier GT, “via interactive audio and video telecommunications system” (e.g., G0426 GT). Appending the GT modifier with a covered procedure code indicates that the distant site physician certifies that the beneficiary was present at an eligible originating site when the service was furnished.

    GQ modifier- Providers participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system.”

    NOTE:  While Medicare contractors may require the GT or GQ modifier and do not allow CPT consultation codes, some private payers request CPT consultation codes without the Medicare modifiers.  Medicaid policies also vary state to state.  Since payer polices vary, you are advised to check with the local payers with which you participate regarding use of these modifiers or modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.

    Answer

    Claims for professional services should be submitted using the appropriate service code, and the modifier "GT" or “GQ.”

    GT modifier- Providers at the distant site submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service along with the modifier GT, “via interactive audio and video telecommunications system” (e.g., G0426 GT). Appending the GT modifier with a covered procedure code indicates that the distant site physician certifies that the beneficiary was present at an eligible originating site when the service was furnished.

    GQ modifier- Providers participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system.”

    NOTE:  While Medicare contractors may require the GT or GQ modifier and do not allow CPT consultation codes, some private payers request CPT consultation codes without the Medicare modifiers.  Medicaid policies also vary state to state.  Since payer polices vary, you are advised to check with the local payers with which you participate regarding use of these modifiers or modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System.

  • Can I report remote critical care services when utilizing telemedicine?
    Recommendations
    Answer

    Yes.  In order to report remote video-conferenced critical care, the physician(s) in the distant site must have real-time access to the patient's medical record including progress notes, nursing notes, medications, vital signs, laboratory tests, and radiographic images. The physician must also be able to enter orders, video-conference with the on-site health care team, speak to family members, and observe the patient.  The review and/or interpretation of diagnostic information is included in reporting remote critical care and should not be reported separately.

    Critical care E/M codes (99291 and 99292) describe critical care services provided at the bedside and environs were approved by CMS for the COVID public health emergency. Remember to apply the appropriate modifiers.

    Answer

    Yes.  In order to report remote video-conferenced critical care, the physician(s) in the distant site must have real-time access to the patient's medical record including progress notes, nursing notes, medications, vital signs, laboratory tests, and radiographic images. The physician must also be able to enter orders, video-conference with the on-site health care team, speak to family members, and observe the patient.  The review and/or interpretation of diagnostic information is included in reporting remote critical care and should not be reported separately.

    Critical care E/M codes (99291 and 99292) describe critical care services provided at the bedside and environs were approved by CMS for the COVID public health emergency. Remember to apply the appropriate modifiers.

  • What are the telemedicine reporting requirements for non-Medicare payers?
    Recommendations
    Answer

    Non-Medicare payers may want you to report telemedicine services using Medicare’s HCPCS codes as described above or the regular Emergency Department E/M CPT codes with either the GT or 95 modifier, or no modifier. You are advised to contact your local carrier for final instructions on billing telemedicine services.

    Answer

    Non-Medicare payers may want you to report telemedicine services using Medicare’s HCPCS codes as described above or the regular Emergency Department E/M CPT codes with either the GT or 95 modifier, or no modifier. You are advised to contact your local carrier for final instructions on billing telemedicine services.

  • Where can I get more information about telehealth?
    Recommendations
    Answer
    1. Centers for Medicare and Medicaid Services. “Telemedicine and Telehealth.” Available online at: http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html?redirect=/telehealth 
    2. ACEP Emergency Telehealth Section. https://www.acep.org/how-we-serve/sections/telehealth/
    Answer
    1. Centers for Medicare and Medicaid Services. “Telemedicine and Telehealth.” Available online at: http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html?redirect=/telehealth 
    2. ACEP Emergency Telehealth Section. https://www.acep.org/how-we-serve/sections/telehealth/
  • How is telehealth covered during the COVID-19 public health crisis?

    Recommendations
    Answer

    See Separate COVID-19 Teleheath Waivers FAQ

    Answer

    See Separate COVID-19 Teleheath Waivers FAQ

Updated March 2021

Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.

For information about this FAQ/Pearl, or to provide feedback, please contact David A. McKenzie, ACEP Reimbursement Director at (469) 499-0133 or dmckenzie@acep.org.

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