Guideline for Supplying and Maximizing Reimbursement for Telehealth Services

By CAREL VISSER

Guideline for Supplying and Maximizing Reimbursement for Telehealth Services

Telemedicine (Telehealth) involves the exchange of medical information from one site to another through electronic communication to improve a patient’s health.

With COVID-19 spreading throughout the United States the big five insurance companies (Medicare, Aetna, Blue Cross Blue Shield, Cigna and United Healthcare) have relaxed their requirements for submitting Telemedicine claims for the next 60 to 90 days. This is intended to help the vulnerable and senior patients in particular and all others who are self-quarantining so they don’t need to venture out to visit their physicians. This relaxation covers COVD-19 related issues as well as other medical conditions that don’t require physical tests.

For the duration of the relaxed Telemedicine submission requirements the HHS Office for Civil Rights (OCR) will waive penalties for HIPAA violations against healthcare providers that serve patients in good faith with everyday technologies like Skype and FaceTime.

Practitioners that will benefit from this service include physicians, nurse practitioners, physician assistants, nurse midwifes, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dieticians and nutrition professionals.

This article deals with non-COVID-19 visits, what is allowed and how they are billed.

Medicare Telemedicine Fact Sheet

The HHS Office of Inspector General (OIG) has given healthcare providers the option of waiving or reducing cost-sharing for telehealth services.

Medicare pays for three types of virtual services.

Medicare Telehealth Visits

• Provider must use interactive audio and video telecommunications that provides real time communication between the provider and the patient at home.
• The Health and Human Services (HHS) will not conduct audits to ensure prior relationship between provider and patient.
• Visits are considered same as in-person visits in terms of payment rate.
• Place of Service (POS) 02 is used for billing with normal diagnosis codes and procedure codes with no modifiers
• Cost-sharing may be waived

Virtual Check-in

• Brief communication between provider and patient by telephone or exchange of information through video or image
• Initiated by patient
• Existing relationship between provider and patient is required
• 5 to 10 minutes of medical discussion
• POS 02 for billing with HCPCS code G2012
• Cost sharing may apply

E-Visits

• Patient initiated non face-to-face visits using online patient portals
• Must be existing relationship between patient and provider
• POS 02 plus CPT codes 99421 – 99423 and HCPCS codes G2061 – G2063
• Coinsurance and deductible will apply

Aetna Telemedicine Fact Sheet

Telemedicine for Commercial Plans

• Pays for 2 way synchronous (real-time) audiovisual interactive medical services between patient and provider
• Use normal CPT and HCPCS codes with either GT or 95 modifiers
• Reimbursed at current fee schedule
• All cost-sharing for waived for telehealth services

Telemedicine for Medicare Advantage Plans

• Medicare policies on telehealth apply.
• POS 02 with normal CPT and HCPCS codes and no modifier
• Telehealth transmission fees not payable – deemed part of service.

BCBS Telemedicine Fact Sheet

Telemedicine for Commercial Plans

• Primary care providers, behavioral health providers and specialists are all approved for supplying telemedicine services.
• This service is available for 90 days and will be reimbursed at current fee schedule. This timeframe will be reassessed as needed
• Normal office visit costs for patients apply
• For general medical care normal Evaluation and Management (E/M) codes (99201 – 99215) apply with POS 02 and modifier 95 or GT

Telemedicine for Medicare Advantage Plans

• All referral requirements for all service types have been relaxed
• Out-of-network providers will be paid for medically necessary services if in-network providers are not available
• Primary care physicians, behavioral health providers and specialists can bill for virtual visits
• Virtual visit program will be in effect for 90 days
• Normal office visit cost share responsibility will apply
• Normal E/M services CPT codes for office visits will be used with POS 02 and modifier 95 or GT
• Reimbursement rates same as in person visits

Cigna Telemedicine Fact Sheet

• Normal CPT and HCPCS codes reimbursed for all synchronous real-time virtual visits by telephone, video or both.
• HCPCS code G2012 reimbursed for brief communication by telephone (usually 5 to 10 minutes) and all cost share waived.
• POS where care happened
• Append GQ modifier
• Normal reimbursement for care applies
• Virtual care program will continue to May 31
• All in-network providers can make use of this service
• Failure to secure referrals for care that is emergent, urgent or with extenuating circumstances will not be penalized during this period if there is proof of staff shortage. In normal circumstances referrals to other physicians, specialists and facilities apply.
• Standard cost shares (copays, coinsurance and deductibles) apply for virtual visits

United Healthcare Telemedicine Fact Sheet

Telemedicine for Commercial Plans

• All in network providers can participate in telehealth program
• Program lasts 90 days until June 18, 2020
• Telehealth services recognized by CMS with modifier GT will be paid
• Telehealth services recognized by AMA with modifier 95 will be paid
• Reimbursement rates are the same as in person visits

Telemedicine for Medicare Advantage Plans

• Medicare policies on telehealth apply.
• POS 02 with normal CPT and HCPCS codes and no modifier

There are numerous medical insurance companies, too numerous to be covered in a single article. It would be prudent to check with each payer on how they are dealing with telehealth in this critical period before submitting claims. A rule of thumb would be to follow the Medicare guidelines for plans associated with Medicare (POS 02 and no modifier) and to use the modifiers GT or 95 for commercial plans with POS 11.

The author, Carel Visser, is the COO of Florida Business Systems which provides medical billing and revenue management services. He is a qualified medical biller and coder dealing directly with the day to day business of the company and providing training to companies in medical billing and revenue management skills. Email address cvisser@flbsystems.com and website www.flbsystems.com