cpt telemed visit

2024 Telehealth CPT Codes: Cheat Sheet

Charika Wilcox-Lee, VP, Revenue Cycle Management

Keeping track of telehealth reimbursements accurately directly impacts your healthcare organization’s bottom line. We’ve compiled a list of telehealth CPT codes to help you better navigate telehealth billing for your care program.

Source: American Academy of Sleep Medicine (AASM)

CMS Telehealth & RPM Billing Guidelines [PDF]

In recent years, the Centers for Medicare & Medicaid Services (CMS) have released the physician fee schedule with expanded reimbursement for remote patient monitoring (RPM). The guidelines notably increase reimbursement for other services like remote therapeutic care and chronic care management, while making slight adjustments to allowances for RPM.

Top 4 Common Telehealth Billing Mistakes—And How to Avoid Them

The surge of telehealth adoption in recent years has led to regulatory changes and telemedicine coverage expansion that greatly benefits healthcare providers—if reimbursement is done correctly. Here are the top four common mistakes when billing for telehealth, and how you can avoid them.

Mistake #1: Not keeping up with the correct billing codes

As Medicare regulations change in response to public healthcare needs, the billing codes that you’re already familiar with could change as well. Submitting claims with the wrong code could result in delayed reimbursement and in some worst cases, be flagged for abuse.

Avoid by : Staying up to date with additions or deletions to the list of Medicare telehealth services .

Mistake #2: Not maintaining post-visit documentation

Ensuring that you document the right information during telehealth visits is key to getting prompt payment. For a start, touch base with your administrative team to understand the type of information you should be keeping a record of.

Avoid by : Creating a checklist that you can go over before the telehealth visit for cross-checking purposes.

Mistake #3: Not training your team on telehealth billing processes

Your team already has to keep track of thousands of CPT codes on a daily basis. With the new batch of telehealth CPT codes added to the mix, things can easily get very complicated for your team.

Avoid by : Training your team on the types of codes, processes, and all things reimbursement.

Mistake #4: Not checking with the patient’s insurance beforehand

While most major private payers provide coverage for telemedicine, it’s prudent to call up the payer and confirm if the services offered are covered. The good news is, that you’ll only need to verify this once for that particular policy.

Avoid by : Being more diligent about checking insurance coverage before the patient’s first telehealth visit. Use an insurance verification form to log the call and make sure you’re asking the right questions.

8 Key Updates to Telehealth Reimbursement in 2024

CMS has   released its final rule   for Medicare payments under the Physician Fee Schedule (PFS), introducing significant changes that will impact healthcare providers across the country. To help you stay informed and prepared, we've compiled the eight key updates you need to know.

Telehealth Reimbursement Resources & Expert Support

At Health Recovery Solutions, we provide a host of resources on reimbursement and telehealth billing modeled after best practices that we established from working with our healthcare partners—and we’re ready to help. Whether you're in the early stages of researching the benefits of telehealth and remote patient monitoring for your patients or you have an existing program in place and you're considering options to maximize the value of RPM, our team of experts is here to support you. 

Contact | Patient Info | Foundation | AASM Engage JOIN Today   Login with CSICloud

• AASM Scoring Manual
• Artificial Intelligence
• COVID-19 Resources
• EHR Integration
• Emerging Technology
• Insomnia Toolkit for Clinicians
• Patient Information
• Practice Promotion Resources
• Provider Fact Sheets
• #SleepTechnology
• Telemedicine

• Annual Meeting
• Career Center
• Case Study of the Month
• Change Agents Submission Winners
• Compensation Survey
• Conference Support
• Continuing Medical Education (CME)
• Maintenance of Certification (MOC)
• State Sleep Societies
• Talking Sleep Podcast
• Young Investigators Research Forum (YIRF)

• Leadership Election
• Board Nomination Process
• Membership Directory
• Volunteer Opportunities
• International Assembly

• Accreditation News
• Accreditation Verification
• Accreditation: Contact Us
• Program Changes

AASM accreditation demonstrates a sleep medicine provider’s commitment to high quality, patient-centered care through adherence to these standards.

• AASM Social Media Ambassador
• Advertising
• Affiliated Sites
• Autoscoring Certification
• Diversity, Equity and Inclusion
• IEP Sponsors
• Industry Programs
• Newsletters
• Patient Advocacy Roundtable
• President’s Report
• Social Media
• Strategic Plan
• Working at AASM
• Practice Standards
• Coding and Reimbursement
• Choose Sleep
• Advanced Practice Registered Nurses and Physician Assistants (APRN PA)
• Accredited Sleep Technologist Education Program (ASTEP)
• Inter-scorer Reliability (ISR)
• Coding Education Program (A-CEP)
• Individual Member – Benefits
• Individual Member – Categories
• Members-Only Resources
• Apply for AASM Fellow
• Individual Member – FAQs
• Facility Member – Benefits
• Facility Member – FAQs
• Sleep Team Assemblies
• Types of Accreditation
• Choose AASM Accreditation
• Special Application Types
• Apply or Renew
• Event Code of Conduct Policy
• Guiding Principles for Industry Support
• CMSS Financial Disclosure

Telemedicine Codes

Telemedicine and telehealth are used interchangeably throughout the United States healthcare system, in reference to the exchange of medical information from one site to another through electronic communication. Reporting of telemedicine/telehealth services varies by payer and state regulations.

AASM Telemedicine/Telehealth Resources

• AASM Coding FAQs
• AASM Telemedicine Video Library

CMS Telemedicine/Telehealth Codes

The codes below are commonly reported for Medicare patients:

CMS finalized the creation of two additional G codes that can be billed by practitioners who cannot independently bill for E/M services. G2250 and G2251 are billable by certain non-physician practitioners, consistent with the scope of these practitioners’ benefit categories.

CPT Telemedicine Codes

Modifier 95 indicates a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. The 2020 CPT® manual includes Appendix P, which lists a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.

HCPCS LEVEL II CODES

There are also HCPCS Level II codes that describe telemedicine services.

Place of Service (POS) Code for Telemedicine

On January 1, 2017 the Center for Medicare and Medicaid Services (CMS) introduced place of service (POS) code 02 to identify telemedicine services. The descriptor for POS code 02 is “The location where health services and health related services are provided or received, through telecommunication technology.” Use of the telehealth POS code certifies that the service meets all of the telehealth requirements. Many private payers have also begun requiring use of POS code 02 for telemedicine services.

GT/GQ Modifiers

Medicare previously required providers to submit claims for telehealth services using the appropriate procedure code along with the telehealth GT modifier (“via interactive audio and video telecommunications systems”) or GQ modifier (“via an asynchronous (delayed communications) telecommunications system”). As of January 1, 2018, the GT modifier is only allowed on institutional claims billed under Critical Access Hospital (CAH) Method II since institutional claims do not use a POS code. If the GT modifier is billed by other provider types, the claim line will be rejected. The GQ modifier is still required when applicable (e.g., for those providers participating in the Alaska or Hawaii federal telemedicine demonstration programs).

Additional CMS Telemedicine/Telehealth Resources

• Complete list of CMS Telehealth Services
• General Provider Telehealth and Telemedicine Toolkit
• Medicare Telehealth Frequently Asked Questions (FAQs)
• Medicare Telehealth Services

Note: CPT Copyright 2021 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

An official website of the United States government

The .gov means it’s official. A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

Billing for telehealth

Reimbursements for telehealth continue to evolve. Find resources on billing and reimbursement for Medicare, Medicaid, and private insurers.

Medicare payment policies

Read the latest on the Centers for Medicare & Medicaid Services (CMS) coverage for telehealth.

Medicaid and Medicare billing for asynchronous telehealth

Billing is allowed on a state-by-state basis for asynchronous telehealth — often called “store and forward.” Asynchronous health lets providers and patients share information directly with each other before or after telehealth appointments.

Billing tips for providers

Use the tip sheet Billing for Providers - What Should I Know? (PDF) to learn more about reimbursement for telehealth services with Medicare, Medicaid, and private payors.

Billing and coding Medicare Fee-for-Service claims

Read the latest guidance on billing and coding Medicare Fee-for-Service (FFS) telehealth claims.

Billing Medicare as a safety-net provider

Find out what Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are able to bill Medicare for when it comes to telehealth.

State Medicaid telehealth coverage

Medicaid reimbusement policies vary state to state. Access resources to find out what you need to know.

Private insurance coverage for telehealth

Many commercial health plans have broadened coverage for telehealth services.

Connection denied by Geolocation Setting.

Reason: Blocked country: Russia

The connection was denied because this country is blocked in the Geolocation settings.

Please contact your administrator for assistance.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Springer Nature - PMC COVID-19 Collection

Coding Telemedicine Visits for Proper Reimbursement

Gary n. gross.

Internal Medicine, Southwestern Medical Center, University of Texas, Dallas, TX USA

Purpose of Review

Coding for patient visits and monitoring via telehealth have expanded over the past years with a wide acceptance of telemedicine as a consequence of the coronavirus pandemic. Coding topics of interest to the allergist/immunologist in regard to services provided via telemedicine will be of increasing importance in the coming years.

Recent Findings

CPT coding for telephone as well as synchronous face-to-face telehealth visits has changed over the past few years. With the need for distancing and patient protection during the coronavirus pandemic, telehealth services have increased dramatically. The introduction of newer devices to remotely monitor patients will increase and be incorporated into patient care.

This review will summarize current codes available for designating what services have been provided. The area of telemedicine is changing and will continue to evolve as other platforms for visits are designed and other methods of monitoring patients become available. Coding for these services will be an ongoing need for the provider.

Introduction

Current procedural terminology (CPT) has recognized the need for designations of procedures done using technology. Although initial codes focused primarily on telephone visits, in 2017, CPT recognized a new place-of-service (POS) code designating “The location where health services and health related services are provided or received, through a telecommunication system.” This POS “02” was a step forward in awareness of the need for distant patient encounters and procedures. Further codes for both monitoring and evaluating via telehealth will be discussed. Table ​ Table1 1 lists current CPT codes available for designating services provided.

Current CPT codes [ 1 ]

Telehealth Coding

Two words must be remembered whenever coding is discussed. The two words, “it depends,” define the lack of consistency in coding throughout the industry. Coding is generally driven by The Centers for Medicare & Medicaid Services (CMS) and CPT (although they do not always align). CPT codes exist for procedures, but some carriers may not recognize or reimburse for the codes [ 2 ]. Some carriers may create their own limits on reimbursing for codes, arbitrarily considering procedures bundled with evaluation and maintenance (E&M) visits. Codes may be paid for certain disease states but not for others. Insurers vary with regard to expectations of what place-of-service to use or how to bill for some procedures. New modifiers for telehealth visits further complicate billing. The modifiers –GT and -95 are used by some carriers for telehealth visits and vary depending on the insurer. Similarly, place of service may be either “02,” the telecommunication POS mentioned above, or remain “11” which designates the office location. Therefore, one must be flexible and informed. Keeping track of each carrier’s latest provider information and appealing denials with alternative codes may be necessary.

As with conventional patient encounters, documentation is key. For telehealth visits, there is also the need to document the patient’s consent for the encounter via telehealth. Most of the telehealth codes are for providers who could bill for evaluation and management (E/M) services such as physicians, physician assistants (PAs), and nurse practitioners (NPs). These providers are considered qualified healthcare providers (QHP).

Non-face-to-face Telehealth Patient Visits

Telephone services (99441–99443).

These codes are non-face-to-face E/M services used by QHP. They are designed for telephone calls initiated by an established patient and have certain restrictions. If the call includes the decision to see the patient in the next 24 h or next available urgent appointment, it cannot be billed. Similarly, if the call refers to an E/M service reported by the QHP within the past 7 days, the telephone codes cannot be used. Thus, these calls are initiated by the patient or guardian of the patient and stand apart from other E/M visits as described.

• 99441 - 5–10 min of medical discussion
• 99442 - 11–20 min of medical discussion
• 99442 - 11–30 min of medical discussion

An established patient, who has not been seen in the past month, calls the office because of a recent ant bite. The patient wants to speak to the physician since the physician also treats the son for anaphylaxis to wasps and the patient is concerned. The physician talks to the patient about the kinds of reactions that might occur and notifies him of what symptoms he should be aware of. Out of an abundance of caution, the physician reminds the patient about using an epinephrine autoinjector. The conversation takes 25 min. The staff calls in the autoinjector to the pharmacy and is on the phone for 15 min waiting for the pharmacist.

The patient is billed 99443 for the physician time. The staff time would not enter into the total time. The note in the chart would document that the visit was via telephone and that the patient called the clinic about the problem. The discussion would be documented and the note would indicate the patient had not been seen and no E/M visit was anticipated. The note would also indicate that 25 min was spent in discussion.

Online Digital Evaluation and Management Services (99421–99423)

These codes are electronic communication codes. The problem may be new to the physician or QHP but the patient must be established. These services are patient-initiated through HIPAA-compliant secure platforms or portals.

These services include evaluation, assessment, and management of the patient.

These services are reported once during a 7-day period and therefore time is cumulative.

The time includes (1) review of the initial inquiry, (2) review of patient records or data pertinent to assessment of the patient’s problem, (3) interaction with clinical staff focused on the patient’s problem and development of management plans, (4) physician or other QHP generation of prescriptions or ordering of tests, and (5) subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service.

These services require permanent documentation storage (electronic or hard copy) of the encounter.

If within 7 days of the initial patient-initiated contact a separate E/M visit (in person or synchronous telemedicine) occurs, then the Online Digital visit is not billed but the time is incorporated into the subsequent E/M visit. If the Online Digital visit is initiated within 7 days of a previous E/M visit for the same or related problem, the Online Digital visit is not reported. If a new or different problem is being addressed in the Online Digital visit, then the visit is billable and should be reported.

• 99421-5–10 min (over a 7-day period)
• 99422-11–20 min (over a 7-day period)
• 99423-21 or more minutes (over a 7-day period)

Remember that only physician or other QHP time is used in the calculation. Staff time is not included.

An established patient who was seen 3 days ago for allergic rhinitis wakes up with hives. She uses the practice’s HIPAA compliant portal to message her doctor about the hives. The PA responds to the message and gathers information about the hives, the patient’s activities, and ultimately prescribes an antihistamine. The encounter takes 10 min. Two days later, the patient messages again saying the hives are better but not gone. She wants stronger medicine. The PA responds to the message and offers to prescribe a short course of corticosteroids. The PA describes the possible side effects of the steroids and also tells the patient what should be done if the hives do not clear. The PA spends 12 min with the encounter. The patient does not call back and does not come to the office for the hives. The PA bills the patient 99423 since the sum of the two encounters was 22 min within a 7-day period and the hives were not related to the allergic rhinitis the patient had been seen for 3 days before the hives.

The chart would document that the patient contacted the clinic for a new problem. All time spent by the PA would be documented to support the total time billed. It would be documented that no E/M visit was anticipated for this new problem.

Healthcare Common Procedure Coding System (HCPCS) have 2 levels of commonly used codes. Level 1 codes are CPT codes and level 2 codes are alphanumeric codes. One group of HCPCS codes are “G codes.” The G codes are used to identify professional healthcare procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. Two “G codes” are relevant to telehealth and do not yet have matching CPT codes [ 3 ].

was in the 2019 physician fee schedule and is used for remote evaluation of established patient’s submitted videos or still images. The purpose of the evaluation is to determine whether or not an E/M visit is necessary. It may be billed if the evaluation does not lead to an E/M visit and does not occur within 7 days of a previous E/M visit. To bill for the evaluation, the physician or other QHP must evaluate the image within 24 business hours and follow-up with the patient in the form of a 5–10 min discussion with the patient.

An established patient develops a rash and is uncertain about its cause. The patient sends the physician a picture of the rash. The physician evaluates the photo and determines it is a hive. The physician calls the patient and tells him that these are common and if they last more than 6 weeks or get worse he can check back, but that he does not need to have an E/M visit.

Documentation of this remote evaluation would include the picture in the chart and the provider’s note that the picture was viewed and that no visit would be necessary unless the hives lasted more than 6 weeks. The presumed diagnosis of acute urticaria would also be included.

was also included in the 2019 physician fee schedule. It has been referred to as a “virtual check-in.” It is considered to be a call or video check in to see if an E/M visit is needed. Similar to some other e-codes, it cannot be billed if there was a related E/M service within the previous 7 days or it leads to an E/M visit within the next 24 h or soonest available appointment. The code is used for established patients having direct interaction with the billing practitioner (not the staff). The service must be medically reasonable and necessary but there is no limitation on frequency. The code assumes 5–10 min of medical discussion.

An established patient calls the nurse practitioner and describes a large, local reaction they have from a mosquito bite. The patient wants to know if they need to come in or go to the ER. The nurse practitioner informs the patient about the type of reaction and tells the patient they only need to come in if they have trouble breathing or if the reaction spreads. The patient is reassured and watches the reaction as it gradually goes away. The practitioner can bill G2012.

The documentation for this virtual check in would include the main points of discussion including the bite and the likely diagnosis as well as the 5+ min the provider is on the platform talking with the patient.

Face-to-face Telehealth Patient Visits

The Centers for Medicare & Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient. These are visits commonly considered “office visits” but delivered via synchronous audio and video contact with the patient. The usual E/M visit codes (99201–99215) would apply.

Prior to 2021, these E/M visits level of service was determined by history, physical exam, and medical decision-making as documented in the CPT book each year. If more than 50% of the face-to-face time with the patient and/or family was used in counseling and/or coordination of care, time becomes the key factor in determining level of service.

Beginning with CPT 2021, time alone may be used to select the appropriate level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). This “time” requires a face-to-face encounter with the physician or other QHP. Time spent with staff such as registering in the office or making future appointments is not used in the calculation of time. Also, note that the new patient level one code (99201) has been deleted.

Medical decision-making (MDM) includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Beginning in 2021, MDM may be used independently in establishing a level of service (without consideration of history or physical exam as was required previously). These changes were designed to reduce duplication and unnecessary, repetitious documentation, and should also make coding for telehealth E/M visits easier.

The telemedicine E/M visits are coded just as an in-office E/M visit would be but possibly with the addition of a modifier or a different place of service code depending on the insurance company. Some provisions for telemedicine have been waived during the pandemic to allow more patients access to medical care and to avoid exposure to others in waiting rooms and offices. The telemedicine waivers include evaluation of new patients via telehealth, beneficiaries living in any geographic area and accessing telemedicine from their homes, and use of smartphones and audio only connections for some services. Whether all these waivers will remain in place following the pandemic is unknown.

An established patient calls the office to set up an appointment and is offered a telemedicine option. The patient finds this attractive since it will save him time in traffic and reduce his time away from work. It is for a follow-up to see how he is doing after starting immunotherapy a month ago. The patient signs into the doctor’s telehealth platform and gives verbal consent for the visit. They discuss symptoms, reactions to injections, medications, and concerns of the patient regarding future injections if he goes on vacation. The face-to-face time with the physician is 22 min and the code billed is 99213 (less than the minutes currently typical for 99214 and within the 20–29 min designated for 2021).

These telemedicine visits will require documentation similar to in-person visits. They will include the notation that the patient consents to the telehealth visit. Since the visits for new patients require physical examinations, the best way to document and bill these visits will be based on time. Until 2021, the notation that over 50% of the time with the patient was related to counseling and/or coordination of care is also needed. For follow-up visits before 2021, only two major components of the E/M visit are necessary, so history and medical decision-making with documentation could be used. It may be easier since most telemedicine visits are largely counseling and coordination of care, to base these encounters on total time also and indicate that greater than 50% was devoted to counseling/coordination of care. Typical documentation will include the consent for the visit, the discussion with the patient, the differential diagnosis, the plan of care, and the total “face-to-face” time spent on the visit. The further notation that > 50% of the time was related to counseling and coordination of care (assuming it was) should also be documented.

Remote Monitoring

In addition to patient encounters whether non-face-to-face or face-to-face, the allergist/immunologist may also do remote monitoring of the patient. The 2020 CPT book lists the following codes for remote patient monitoring (RPM). Although some requirements for telehealth services have been modified during the pandemic, RPM services have never been limited by geography to rural or medically underserved areas, nor is there any “originating site” restriction for RPM services. In fact, RPM services can be provided anywhere the patient is located, including at the patient’s home.

• 99453 Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
• 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days (provided monitoring occurs at least 16 days during the 30-day period)
• 99457 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 min.
• 99458 Each additional 20 min

As more devices become available to monitor asthma and other diseases treated by the allergist/immunologist, these codes will become more widely used just as blood pressure monitoring and diabetes monitoring are today.

An established patient is in the office and has poorly controlled, moderately severe persistent asthma. You provide the patient with a home spirometer that will transmit the FEV1 and FVC to your office. The patient is instructed on how to set up and use the device. He provides data via the portal for 20 days of the next month and you and your staff retrieve the data and analyze it. The time involved in retrieving and analyzing the information is 18 min. You modify the patient’s treatment program and describe the new treatment program during a telemedicine visit.

Billing would be 99453, 99454, and 99457 (each one unit). The E/M visit would be billed based on the time spent with the patient in describing the new treatment plan.

The documentation for these services might include a statement such as “we have provided this patient a remote spirometer and taught the patient its proper use. The patient has used it and transmitted information to us 20 days this month and the staff and I have spent 18 min total in the monitoring and responding to this patient in regard to asthma management based on results of the information transmitted.”

An older CPT code used for remote patient monitoring is 99091. This older code requires 30 min to bill based on a 30-day period. It is also limited to physicians and QHPs. There must be a face-to-face visit within 1 year and consent must be given and documented. The platform used must both collect and transmit data in real time or near real time to be eligible.

Another set of spirometry codes (94014, 94015, 94016) relate to patient-initiated remote spirometry, transmission of tracings, and review and interpretation by a physician or QHP. The second code (94015) does not include review and interpretation by a physician or other QHP whereas the third code (94016) is the review and interpretation by the provider. 94014 is an inclusive code of the latter two.

Interprofessional Telephone/Internet/Electronic Health Record Consultations

Codes 99446, 99447, 99448, 99449, and 99451/99452 are used to report a consultation when there is an interprofessional electronic consultation regarding assessment and management of a patient who is not seen face-to-face by the consulting provider. The patient may be a new patient to the consultant or an established patient with a new problem. The patient should not have been seen by the consultant for a face-to-face encounter in the past 14 days. Similarly, there should not be a transfer of care or a face-to-face encounter within the following 14 days of the consultation. Greater than 50% of the time for service must be devoted to the verbal or internet discussion. These codes should not be reported more than once within a 7-day interval. The consulting provider delivers a written or verbal report to the patient’s treating provider. The patient or family must give verbal consent (documented in the record) for the consult.

• 99446 reported by the consulting provider for 5–10 min of consultative discussion/review
• 99447 11–20 min
• 99448 21–30 min
• 99449 31 min or more

Code 99451 is reported by the consultant for 5 min or more time but does not require that more than 50% of the time be consultative time as opposed to data review. Furthermore, 99451 requires a written report.

Code 99452 is billed by the treating/requesting provider. This code is for time spent in preparing the consult and/or time communicating with the consultant for 16 min or more time.

Conclusions

Telemedicine will continue to be a significant part of the allergy/immunology practice even after the pandemic. Both Medicare and commercial insurance companies have made special provisions for telehealth during the pandemic in order to make medical care more readily available for patients who are concerned about their symptoms and also concerned about possible exposure to illness in a healthcare facility. Such provisions as allowing telephone calls (without video) to be sufficient for a “face-to-face” telemedicine visit for patients who do not have access to computers or other means of communicating via video connections will probably not continue after the pandemic [ 3 , 4 ]. The leniency on what platforms can be used by practices for telehealth visits will also likely change after the pandemic. These possible changes will likely be rolled out at different times for different carriers so it will be critical to review EOBs and look at insurers’ websites and newsletters.

It will be important to learn the codes and understand what codes different insurers require in order to be properly reimbursed for your work. Remembering to get consent for visits, to document what was done, to adhere to procedures that are medically necessary, and to code correctly will help practices receive payment for these services. It would be helpful to medicine in general if the commercial insurance companies and CMS provided a uniform approach and guideline for telemedicine coding. Until such time that these stakeholders provide a consistent and uniform coding guide to telemedicine, remember that “it depends” as you select the appropriate code, modifier, and place of service for telemedicine encounters.

Compliance with Ethics Guidelines

The authors declare no conflicts of interest relevant to this manuscript.

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Telemedicine and Technology

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Telemedicine CPT Codes and Billing: A Detailed Guide

Telemedicine and telehealth are two terms that people often use interchangeably. Telehealth is more concerned with the exchange of medical data from one source to the other through some form of electronic communication interface.

On the other hand, telemedicine is more related to providing the practice of medicine remotely with the help of technology.

These are somewhat similar, yet some people believe that each practice carters to a specific type of service. This is not the case, as both of these terms are broad and encompass different types of services.

Types of Digital Services

There are three types of digital or virtual services. Physicians and other healthcare providers offer Medicare patients and beneficiaries any of the three services.

These services include Medicare telemedicine visits, E-visits, and virtual checkups. Each of them encompass different definitions and complies with different CPT codes. They also carry a varied patient relationship with the provider.

Related: Complete guide on starting a telemedicine business

Billing and Documenting Telemedicine Codes

The year 2020 presented one of the unprecedented times that people had ever witnessed. One of the very interesting healthcare innovations that came out of this time was the introduction of telehealth codes. In the midst of the covid-19 uncertainties, people had to scramble in chaos when it came to receiving healthcare.

Your board and payers are the ones that will give you the most important rules that apply specifically to you and your situation. The telemedicine codes are not new, and they have existed for a long time.

Telephonic Codes

The first set of codes includes the telephonic codes. They dictate what you can do and your billing process when interacting with the patient over the phone. Some medical coverage will not include this set of codes. This does not mean that they do not apply to the fee schedule. Instead, these codes fall into the evaluation and management family of codes.

Healthcare professionals will often provide their contact numbers to patients. This allows the patients to reach out to the doctor for general queries. However, if there needs to be a true consultation over the phone, the healthcare provider can charge the patient for the remote interaction.

This is where CPT codes come in, and they dictate a system of charging the patients for telemedicine practice according to different factors. The telephonic codes are divided by the duration. Healthcare professionals must document the telephonic conversation and its medical necessity in this instance.

Online Digital Health Codes

The second set of codes is for the online digital telemedicine services. This is what took over the healthcare industry during the coronavirus pandemic. It involves the online platforms that enable physicians and patients to video conference and monitor vitals. These codes are also divided by timeframes, and they require an online, two-way visual conversation.

Related: How to develop a telemedicine application

Rules on Billing and Telemedicine Codes

With the onset of digital healthcare and its incredible prospect for the future, patients and physicians need to be aware of them. It would help if you remembered that while some of these rules may be covered while others may not be. Healthcare practices need to find out about this from the payers individually.

Some payers clarified what you can and cannot do. Billing codes is a subject that can be confusing for practitioners. It is very important to understand what your allowances are from your board, along with your coverage.

You should also be considerate of the HIPAA requirements . They relaxed the rules on the security of information during crises. This is because people often have to reach doctors in the state of an emergency. You cannot tell whether the board decision-makers at HIPAA will intervene in the future.

This is why healthcare workers need to stay on top of the legislation. You may have to store and record patient data if you have coverage. But, make sure that you are not violating any rights to the privacy rule. To ensure that you are complying, you have to keep your HIPAA updated.

A breach could be devastating for a healthcare professional’s practice. It can lead to you losing your license. This is also a reason to ensure you always check Medical Review Policy.

Every payer has put out a medical review policy for telehealth and telemedicine. Overall, the steps to keep your telemedicine practice safe will involve checking with your payer and making sure that your HIPAA is updated.

Coding And Modifiers For Telehealth Services

• 95 – If you are going to bill for telehealth more often, you have to get used to the 95 modifiers. This modifier refers to asynchronous telemedicine service rendered by an interactive video or audio communication system in real-time.
• CR – This modifier pertains to the service you have rendered related to a catastrophe or disaster. You can apply this modifier for emergencies.
• GQ – You can apply this modifier via asynchronous communication. Some plans want you to build this while others do not require it. This modifier was around even before the coronavirus outbreak. This is part of a federal telemedicine project.
• GT – This modifier applies to an interactive video and audio telecommunication system. You have to bill this code under the CAH Method 2. The CAH method  is short for critical access hospitals. Some payers will reimburse based on appendix-P. However, appendix P is very rare.  

Box 24B: Place of Service Codes

There are about 70 different places of service codes. Most healthcare providers are used to one of them, which is the number 11. This number refers to the office, while the number 2 means telehealth, and the number 12 means home.

For clients that go to the patient’s place of employment, the number is 18. There are also place-of-service codes for hospitals, nursing homes, and assisted living facilities. Similarly, you also have the telehealth site locations.

If you are going to provide telehealth, you will have to document the site locations so you do not forget about them. The site location includes the “originating site” and the “distant”. The originating site declares the patient’s location, and the “distant” code refers to where the healthcare provider is present at the time.

Billing managers should be aware that the originating site location will not include the home. The home is not normally considered an original location, but it is now included in the originating location due to the coronavirus pandemic. The 1135 waiver covers this part of the change.

New Diagnosis Codes

For nurse practitioners offering telemedicine services, it is important to note that there are new diagnosis codes. These codes are related to the covid-19 virus, and they represent respiratory infections, upper respiratory infections, pneumonia, coughs (r05), and shortness of breath (r0602) , unspecified fever (r50.9).

As a nurse practitioner, you will have to update your diagnosis codes since you will most likely deal with this. These codes can also be subject to further updates and replacement. This is why you have to stay on top of all the regulatory changes.

How to Bill for Telemedicine Visit?

Understanding the nuances of billing and coding for telemedicine can be difficult, especially considering their changes. These changes were a response to the public health emergency. Payers, including CMS and private payers, have significantly expanded their telehealth availability regarding coverage and payment.

This helps increase patients’ access to healthcare providers in times of uncertainty. The telemedicine codes allow patients to receive care remotely and get reimbursed appropriately. For some practitioners, billing a code can be very confusing. Understanding the best ways to bill for the services they provide will optimize reimbursement and allow them to continue practice operations.

Mentioned below, is a list of codes that can allow you to bill for some of the common telehealth services during the covid19 pandemic.

CPT: G2012 (5 – 10 mins)

This is a virtual check-in code. A virtual check-in code is designed to be a 5 to 10-minute phone call or video chat. This phone call or video interaction helps a patient determine the issue they are currently experiencing and whether it warrants a more extensive visit via in-person or telemedicine.

This is not meant to be an extensive evaluation, and you can also perform it with the help of a staff member and not necessarily with a provider.  When using this code in the billing process, you can use your usual place of service. For a regular clinic, the place of service would be 11, and you would not need to apply any modifiers.

CPT Code: G2010

This next new code that has become available to allergists during the coronavirus pandemic involves remote review of images and video. An example of this is  a patient sending an image through the patient portal to review and give opinions. For outpatient clinics, the place of service will be 11, and you will not have to use any modifier.

Telephone care is a service that most often goes uncompensated. Many doctors have previously provided free over-the-phone care to their patients. Nonetheless, during public health emergencies, payers have recognized that telephone care is much significant for some patients. These patients do not have video conference availability.

Therefore, the codes already established for telephone care are being reimbursed. Below is a list of codes that healthcare professionals can use for billing telephone visits.

• 99441 (5-10 minutes)
• 99442 (11-20 minutes)
• 99443 (21-20 minutes)

The place of service will depend on where you are practicing from, and the modifiers are typically not necessary. Next, you have synchronous face-to-face video visits. In other words, the telemedicine visits. These codes are billed using the standard codes that a healthcare provider normally uses for patient care.

Previously, it has been very difficult to get telemedicine coverage delivered to new patients. This is because many states and payers have requirements. These requirements need individuals to establish patients of the specific practice. Moreover, states require a physical exam on file before a healthcare professional or billing manager could bill for telemedicine services.

During the public health emergency, this has been waived, and you now have the opportunity to provide your new patient’s telemedicine care easily. You can do this by using your standard codes, which are 99201, 99202, 99203, 99204, and 99205 . You can bill them using a time-based approach or medical-decision billing approach.

For established patients, the rules will apply the same way. The codes are 99211, 99212, 99213, 99214, and 99215 . This applies to either time-based billing or medical decision-making.

Historically, the place of service designated for telemedicine is 02 , which designates telemedicine visits. However, many payers have reimbursed telemedicine care at a lower rate than live visits.

To simplify coding and billing processes, the guidance for most pairs has been to use the usual place of service to guarantee payment parity and optimize your reimbursement. Therefore, while using a place of service 11, you would then use a modifier 95 or GT to designate the telehealth services.

This is not a uniform recommendation amongst all payers. TRICARE and Aetna, along with a number of state medicare plans still give the guidance to use 02 as the place of service. The best way to find out how to bill would be to reach out to your payer for advice.

A new code that people can use during the public health evaluation for most payers includes the digital health evaluation code. You can also refer to this code as the E-visit code.

You would use this code when a patient reaches out to you for medical guidance via a secure electronic guidance portal such as the HIPAA compliance portal. Generally, this code would only apply if the patient initiates the visit.

An interesting thing about billing for digital health evaluation or E-visit codes is that they are accumulative time-based systems that run over seven days.

Healthcare professionals have to add up the time they spent reviewing, responding, and researching for a single patient for seven days. Once they review the time, they can add it all up and bill for the accumulative amount of time.

The codes for digital evaluation are:

• 99421 ( 5-10 minutes)
• 99422 (11-20 minutes)
• 99423 ( greater than or equal to 20 minutes)

COVID-19 Regulatory Changes and Updates

Several changes took place regarding telehealth services. On March 17 th CMS issued guidance towards the Secretary Azar’s Waiver Authority. This broadens the access to Medicare services for telehealth. Although telemedicine services are not new, CMS announced waivers for them because more and more people are now using them.

Typically, when you bill telemedicine services to medicare, they only pay for certain services. It’s also worth keeping in mind that there are about 101 CPT codes that qualify for telemedicine, according to medicare.

This has broadened immensely during the public health emergency. You can now find several different codes that are eligible. You also no longer have to use the modifier GT and as you can use the modifier 95 instead. This is the modifier that most commercial insurance use to indicate when billing for a telemedicine service and not a physical practice.

Medicare Requirements

When you bill these services to medicare, they only pay for certain specific ones. You will have to bill with the modifier GT, indicating that the service was telemedicine. There are about 101 CPT codes that qualify for telemedicine practices. These services must be patient-initiated, which means that physicians will only apply them if a patient reaches out to the doctor and not the other way around.

Geographical Restrictions waived

There are many restrictions that the federal authorities have waived to make telemedicine health services more widely available. Telehealth services were not popular before the pandemic because you could not perform the service for any patient in any area of the country. Instead, there were particular locations.

To bill for telemedicine services, patients had to be in a rural area where they did not have easy access to medical facilities or a healthcare provider. Therefore, Medicare would cover them for their digital checkups and monitoring.

As the public health emergency came about and authorities started mandating social distancing policies to reduce exposure and spread of the virus, the decision-makers lifted this waiver. This allows any physician to perform and bill for digital healthcare service regardless of the patient’s location.

Originating Location Requirement Waived

Another element of the billing restrictions was that the patient could not be in the comfort of their home. They instead had to travel to a nearby hospital or clinic that had types of equipment set up for them to perform audio and visual interactions. This qualified as an originating site in the modifiers.

However, since the covid19 pandemic encouraged every patient to stay within their premises, this restriction has also been waived. A patient’s home now qualifies as an originating site as well.

Final Words

It is important to realize that much of the telehealth expansion is temporary. This is not to say that telehealth expansion and payers are not currently in place. These expansions and new billing updates are likely to extend and change in response to the CMS recommendations.

Cultural Diversity & Social Justice Training: How to Offer Culturally-Competent Care See Details

Telehealth Reimbursement Alert: Federal Register Releases Allowed 2022 Telehealth CPT Codes & Services

MARLENE MAHEU, PhD

UPDATED 11/9/21 Many long-awaited decisions regarding telehealth CPT codes were released earlier this week, signaling a new frontier for telehealth reimbursement. Federal policy changes of this magnitude directly change Medicare and federal Medicaid programs, and more broadly, put direct pressure on third-party carriers to follow suit. In the unpublished version of the 2022 Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) announced landmark changes in support of telehealth, and particularly, telebehavioral health, but only for specified conditions.  The entire document will reportedly be available on November 19, 2021.

CMS Administrator Chiquita Brooks-LaSure announced the changes by stating, “Promoting health equity, ensuring more people have access to comprehensive care, and providing innovative solutions to address our health system challenges are at the core of what we do at CMS,” She continued, “The Physician Fee Schedule final rule advances all these strategic priorities and helps build a better Medicare program for the future.”

Key points for behavioral clinicians include:

• In line with much legislation enacted last year to deliver immediate assistance to millions of U.S. citizens due to the COVID pandemic, CMS eliminated geographic barriers and allows patients at home to access telehealth services for diagnosis, evaluation, and treatment of specified conditions mental health disorders.
• The requirement for a “non-telehealth visit must be furnished at least every 12 months for these services.” They also stipulated that “exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record).”
• Services added to the Medicare telehealth services list will remain on the list through December 31, 2023, to allow additional time for CMS to evaluate whether the services should be permanently added to the Medicare telehealth services list.
• In yet another document, as of September 2021, CME has issued a new set of CPT code modifiers, two of which are relevant to telehealth CPT code billing. Medicare telehealth services practitioners use “02” if the telehealth service is delivered anywhere except for the patient’s home. If the patient is in their home, use “10”. For telehealth, the 95 modifier code is used as well. For details, see the CMS document titled   Place of Service Codes for Professional Claims Database (updated September 2021).

In the sections below, direct quotes are taken from the unpublished version of the 2022 Physician Fee Schedule made available for public inspection before the official publication date in the Federal Register.

Audio-Only Telephone Care

The New CMS ruling allows payment for telephone sessions for mental and behavioral health services to treat substance use disorders and services provided through opioid treatment programs. Direct wording from the unpublished version of the 2022 Physician Fee Schedule made available for public inspection is provided below. (Page numbers are not provided in the original document.)

After consideration of public comments, we are finalizing as proposed creation of a service-level modifier for use to identify mental health telehealth services furnished to a beneficiary in their home using audio-only communications technology. We are also amending our regulation at § 410.78(a)(3) to specify that an interactive telecommunications system can include i nteractive, real-time, two-way audio-only technology for telehealth services furnished for the diagnosis, evaluation, or treatment of a mental health disorder as described under paragraph (b)(4)(iv)(D), under the following conditions: the patient is located in their home at the time of service as described at § 410.78 (b)(3)(xiv); the distant site physician or practitioner has the technical capability at the time of the service to use an interactive telecommunications system that includes video; and the patient is not capable of, or does not consent to, the use of video technology for the service.

We are also clarifying that SUD services are considered mental health services for purposes of the amended definition of “interactive telecommunications system” to include audio-only services under § 410.78(a)(3). We anticipate that this will positively impact access to care for mental health conditions and contribute to overall health equity. [Emphasis added by Telehealth.org]

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) – Telecommunications Technology

Mental health sessions furnished through Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology, including telephone calls, will also be covered. As outlined by CMS, this provision intends to continue expanding access to vulnerable populations, including those in rural areas.

1. Revising the Definition of an RHC and FQHC Mental Health Visit a. Payment Rules for RHC and FQHC Visits and Medicare Telehealth Services Section 1861(aa)(1) of the Act defines RHC services as physicians’ services and such services and supplies that are furnished as an incident to a physician’s professional service, and items and services, as well as certain vaccines and their administration. It also includes services furnished by a PA, NP, clinical psychologist, or clinical social worker and services and supplies furnished as an incident to these services as would otherwise be covered if furnished by a physician or incident to a physician’s service. In the case of an RHC in an area with a home health agency shortage, part-time or intermittent nursing care and related medical supplies may be furnished by a registered professional nurse or licensed practical nurse to a homebound individual under certain conditions. Section 1861(aa)(3) of the Act defines FQHC services to include the specified RHC services and preventive services, as well as required primary preventive health services.

Depression Screening and Referrals from RHCs and FQHCs: Mental Health Counselors Included, Too!

Under section D.18 Preventive Care and Screening: Screening for Depression and Follow-Up Plan in the Physician Fee Schedule, the following section describes the use of non-physicians to offer “follow-up services” after patients are screened by primary care physicians in RHCs & FQHCs. It is worthy of note mental health counselors are included, whereas they have been previously excluded.

Follow-Up Plan: The follow-up plan must be related to a positive depression screening, for example: “Patient referred for psychiatric evaluation due to positive depression screening.” Examples of a follow-up plan include but are not limited to: * Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologists, social workers, mental health counselors, or other mental health services such as Family or group therapy, support group, depression management program, or other services for the treatment of depression * [Emphasis added by Telehealth.org]

Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options Should a patient screen positive for depression: * A clinician should only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan. * A clinician should complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. For the CMS Web Interface Measure Specifications collection type: A depression screen is completed on the date of the encounter or up to 14 days before the date of the encounter using an age-appropriate standardized depression screening tool, AND if positive, a follow-up plan must be documented on the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression

Physician Repercussions of New CME Rulings

Dealing a blow to physicians, the conversion factor per relative value unit under the 2022 fee schedule will be reduced to $33.59, down from $34.89 in 2021, a drop of $1.31. The AMA has been quick to respond, stating, The AMA is strongly advocating for Congress to avert this and other looming cuts to Medicare physician payments that, overall, will produce a combined 9.75 percent cut for 2022. 

Why Are the Federal Register Releases & Physician Fee Schedules of Relevance to Telebehavioral Health Professionals?

The Federal Register is the daily journal of the United States government and the official dissemination channel for any changes related to CPT codes by CMS. Working closely with various stakeholders such as the American Medical Association, the American Psychological Association, and other national professional associations, the Centers for Medicare & Medicaid and Services (CMS) proposes new telehealth CPT codes every year. The proposed codes are open for comment from all stakeholders for a few weeks, the comment period is closed, and new codes are published in the Federal Register in November. They take effect on January 1 of the following year. This process is an attempt to update payment policies, payment rates, and other provisions for services. While third-party carriers differ in payment rates by state, Medicare payments for the same code can vary by zip code.

What about Private Payers?

Typically, 3rd party or private insurance carriers in the United States are given the discretion to decide which telehealth CPT codes to reimburse and at which rate. Employers and consumers seeking telehealth reimbursement for 2020 would do well to speak with their carriers before next year to negotiate plans and make informed choices about insurance plans. A third-party carrier can deny procedures reimbursed by Medicare and are, frankly, often are excluded. In most states, private insurers slowly adopted the approved CPT codes, but they are not usually required by state law to follow suit in many states. However, with the tsunami created by COVID, in some states such as California and New York, telehealth laws were recently updated with much more enforcement and penalties for noncompliance imposed by the state insurance commissioner in each state. In short, more states are requiring telehealth reimbursement. Clinicians wishing to continue offering telehealth services then are encouraged to contact their state insurance commissioner’s office as well as their state and national professional associations for more information about local regulations requiring telehealth reimbursement for the future.

Other Telehealth.org Articles of Relevance

For billable CPT codes, see Telehealth.org’s previous articles related to telehealth CPT codes below.

• RPM CPT Codes
• CMS Congressional Report: 85.4% of all Telehealth Providers Used Mental Health CPT Codes
• Future of Telehealth Reimbursement: Offering Medicare Telehealth Services?
• Counselors and marriage and Family Therapists may want to speak with the governmental staff of their national professional associations for updates on the issues discussed in Telehealth.org’s Medicare Telehealth Reimbursement: Act Introduced to Allow Counselors to be Reimbursed by Medicare for updates to the Mental Health Access Improvement Act .

BCTP®-III Telehealth Training & Certificate

Join the elite professionals who have immersed themselves in the depths of telehealth training, obtained monthly group consultation to tailor their learning to their needs, and earned the coveted BCTP®-III distinction!

Accepting Telehealth Jobs: 5 Big Legal & Ethical Mistakes to Avoid

Do you have questions about being employed or looking for employment from a digital health company? Online employment can pose dilemmas that leave clinicians at a loss for how to proceed. This program will answer your questions about how or reasonably uphold your legal and ethical mandates.

Mastering Telehealth Billing Guidelines 2024: A Blueprint for Success

In this comprehensive 1.5-hour program, you’ll navigate the evolving landscape of telehealth billing, ensuring you stay updated on essential topics like CPT and modifier codes, Medicare reimbursement, digital therapeutics, and more.

Disclaimer: Telehealth.org’s content is educational and not a substitute for legal, ethical, or clinical advice. Please exercise due diligence before making decisions. Our views do not intend to offend any organization, company, or individual. Trademark mentions imply no endorsement. Some content is ChatGPT-assisted. Links to external sites are for extra information; we’re not responsible for their content or accuracy, and our privacy policy does not extend to them. Using this site constitutes your agreement to Telehealth.org our Privacy Policy and Terms and Conditions .

Please share your thoughts in the comment box below.

I’m not sure I fully understand. Who is being left out of the new rules? And which Medicare clients won’t be able to receive telehealth services? My reading of the rules is that telehealth will be able to continue.

Jeremy, Thank you for commenting. We have revised our comments to make them clearer and also added the November 1, 2021 CMS list of approved CPT codes and associated services. If you download the file, you will see a number of behavioral codes that were approved for the COVID pandemic and several others that have been approved over the years. Let us know if you have any other questions.

Licensed Counselors and Marriage and Family Therapists have the same education requirements as the Licensed Clinical Social Workers so it is not sensible to fund one and not all three. Social workers have always have a strong lobby so have been funded. Many people will be deprived of needed services if Licensed Counselors and Marriage and Family Therapists are not also recognized. If concern is really about helping those that need behavioral health services, this is defeating the goal.

Dale Marie, Thank you for your comment. This battle is not new. A political battle has been waging for decades over whether or not counselors and MFTs can be reimbursed for serving Medicare beneficiaries. In this article, we discuss one of the more recent legislative efforts is being waged to reimburse these groups of providers, but we’ve not seen any updates as recently as Friday when we last checked: Medicare Telehealth Reimbursement: Act Introduced to Allow Counselors to be Reimbursed by Medicare If and when anyone gets news about a change in policy, please take 5 minutes to post it here for us all to see.

Great, thank you for the clarification. This is not true for me, as I am a psychologist in a FQHC, but are these new rules suggesting that licensed mental health counselors in FQHC’s are not able to bill for telephone services?

Is it once per calendar year for in person visits? I also read each telehealth visit had to be within 6 months of an in-person visit which means all patients need to be immediately seen in person before any further psychiatric telehealth is permitted. Since I see patients every 3 months when stabilized for psych meds, I essentially need to see them in person every other visit if that is true. Do you have further information regarding this? Also any rules about the providers working from home for telehealth?

Laura, Thank you for your questions. The Federal Register is the official US federal government dissemination channel for updates. We are consultants, trainers & publishers and not billing specialists. We disseminate the news that we find. However, many people would agree that official policy announcements from the Federal Register supersede previous rulings. You may want to have your billing agent research this to get confirmation from CMS. As for working from home, traditional telemedicine has been practiced by clinicians working from their homes for decades. In fact, that’s one of the big draws for the industry since day 1. The patient’s location has been the issue, not the practitioner’s. There are a few rules, such as the fact that the clinician working from home must live in an approved jurisdiction. It involves state licensing law and not federal CME reimbursement requirements. As the years wore on, some states such as Alaska started requiring providers to be in Alaska when serving Alaskans, but most states haven’t gone that far. You may also want to know that there are several other key stipulations that are wise to fully understand. See this 1-hour webinar devoted to this topic: Telehealth Working from Home: Legal & Ethical Compliance

Lmhc’s have a higher education requirement than Social Workers. We are not coordinators like LICSW but we do it. We are clinically qualified to tx. Mental Health and substance abuse clients

Anyone who believes that LMHC’s have a higher education requirement than LCSW’s NEED to do some due diligence before making statements. LICSW’s do have extensive education and it is within our scope of practice to treat substance abuse clients (noting CEU’s) In fact, historically LCSW’s were the only ones to receive reimbursement from insurance companies like psychologists and md’s. To be clear, An LMHC focuses SOLELYon a patient’s mental health (that may be changing in some schools as CARF is demanding some of the changes), whereas an LCSW helps clients with their mental health and other areas of their lives. LCSWs also work on finding ways to change an individual’s environment to adapt to their needs. They take Holistic Approaches when working with clients and try to connect clients with resources to help them reach their goals. LMHCs take a more Individualistic approach to improve development problems interfering with a client’s wellbeing. And we know what the research says… Holistic Approaches are what is efficaticacious over the long term.

Can you please suggest who I can contact regarding, “exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record).” I see clients virtually in 3 states where I am licensed. Normally I’m told to submit claims to the BCBS or Medicare jurisdiction in the state where my practice has an address (only one state) regardless of client location. If I fly to go see a client in their state, I’m supposed to bill the BCBS or local Medicare jurisdiction for that state, where I don’t have in-network contracts, nor a practice address, and it would be processed as out of network. I know there are ways to get an address in another state, but if I do not have to spend more money on such a thing, I won’t. There then might be income tax problems when physically providing for and billing a service when I’m physically in another state.

William, Thank you for your question. I wish I had a better answer but all I can say is to contact the payer in all such specific billing questions. If the payor is Medicare or Medicaid, you may want to consider meditating a bit before jumping on the call. 🙁 Perhaps someone else reading this article has a better answer for William?

With regard to Tricare billing, when I called them today (1.4.2022) the rep said to keep using POS 11, not 10 if client is in their home. Does anyone have any info about when this will actually be effective?

Hello Lisa, In another announcement that TBHI Telehealth.org reported on November 23, CMS announced that “The change in the telehealth policy will take effect on January 1, 2022, and be implemented on April 4, 2022.” How that applied to Tricare, we don’t know. See our full announcement summary here:

To comment on the retort from the LICSW regarding LMHC’s get your facts straight. I have 24 more credits than any LICSW course of study from any school in the US which I needed to graduate and sit for my licensure exam. We both do the same job. In some States we can work in schools but in no States can we get paid for MEdicare clients. I believe both occupations are excellent with all groups they service.

“In yet another document, as of September 2021, CME has issued a new set of CPT code modifiers, two of which are relevant to telehealth CPT code billing. Medicare telehealth services practitioners use “02” if the telehealth service is delivered anywhere except for the patient’s home. If the patient is in their home, use “10”. For telehealth, the 95 modifier code is used as well“ 02 and 10 are place of service codes, which are entered on the Place of Service field of the claim line to indicate where the service was provided. They are not modifiers (which are placed after a HCPCS/CPT code).

Alec, you are correct. Thank you for taking the time to comment. This change in requirements was announced in one of our earlier articles and will take place in April of this year.

Register for Free

Telehealth.org Services

Advertisement

Most Popular Blog Topics

• Introduction
• Article Information

Models were adjusted for patient demographic, geographic, and relationship characteristics. Error bars represent 95% CIs. AOR indicates adjusted odds ratio.

a Preperiod (period in which all states in the analysis had active licensure waivers) spanned March 2020 to April 2021.

b Distance between patient and clinician was measured between the centroid of their respective zip codes.

c Licensure was ascertained from publicly available, National Provider Identifier–linked data.

Data Sharing Statement

See More About

Sign up for emails based on your interests, select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Get the latest research based on your areas of interest.

Others also liked.

• Download PDF
• X Facebook More LinkedIn

Bressman E , Werner RM , Cullen D, et al. Expiration of State Licensure Waivers and Out-of-State Telemedicine Relationships. JAMA Netw Open. 2023;6(11):e2343697. doi:10.1001/jamanetworkopen.2023.43697

Manage citations:

© 2024

• Permissions

Expiration of State Licensure Waivers and Out-of-State Telemedicine Relationships

• 1 Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia
• 2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
• 3 Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
• 4 Elevance Health, Indianapolis, Indiana
• 5 Texas A&M University, College Station
• 6 Harvard University, Cambridge, Massachusetts
• 7 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
• 8 Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Physicians generally must hold a license recognized in the state in which their patients are located. 1 At the COVID-19 pandemic’s onset, almost all states implemented temporary licensure waivers, which allowed patients to obtain care from out-of-state clinicians via telemedicine. 2 , 3 Over the course of the pandemic, most waivers expired. 4 To inform the ongoing debate about reforming physician licensure to facilitate telemedicine, we compared out-of-state telemedicine relationships in states where licensure waivers expired vs states where waivers continued.

Using Elevance Health claims data from January 2019 to June 2022, we identified patients living in 3 states where licensure waivers expired in mid-2021 (Colorado, Maine, Wisconsin) and 5 states where waivers continued at least through June 2022 (California, Georgia, Indiana, New Hampshire, New York). Patients without at least 90% of days covered in 2020 to 2022 were excluded. The University of Pennsylvania Institutional Review Board deemed this cross-sectional study exempt from review and informed consent because deidentified data were used. We followed the STROBE reporting guideline.

Out-of-state telemedicine relationships were defined as unique patient-clinician pairings with at least 2 visits, 1 of which was via telemedicine, in the preperiod (March 2020 to April 2021, when all states had active waivers). In the postperiod (July 2021 to June 2022, when waiver status varied by state), for each relationship, we captured whether there were any visits (primary outcome) and any telemedicine or in-person visits specifically (secondary outcomes).

Using multivariate logistic regression where the unit of analysis was out-of-state relationship, we estimated the association between the outcomes and state waiver status, adjusting for patient demographic (age, sex, race and ethnicity), geographic (rural, urban, suburban; distance to clinician), and relationship (number and type of preperiod visits, prepandemic relationships, known licensure in patients’ state) characteristics. We conducted similar regressions for subgroups of relationships, including clinician specialty, number of preperiod visits, distance apart, and state licensure status (eAppendix in Supplement 1 for details).

Two-sided P  < .05 indicated statistical significance. Statistical analyses were performed with Stata 15.1 (StataCorp LLC).

During the preperiod, we identified 45 087 unique patients (27 554 females [61.1%], 17 533 males [38.9%]; mean [SD] age, 39.8 [18.9] years) and 55 845 out-of-state telemedicine relationships ( Table ). In states with expired vs continued waivers, more patients were from rural areas (14.7% vs 10.3%; P  < .001) and patient-clinician distances were greater (>804.7 km: 59.5% vs 40.1%; P  < .001).

In states with expired waivers, out-of-state relationships were less likely to have any postperiod visits (adjusted odds ratio [AOR], 0.76; 95% CI, 0.72-0.80) ( Figure ). The AOR was 0.65 (95% CI, 0.60-0.71) among relationships with 4 or more preperiod visits and was 0.65 (95% CI, 0.61-0.71) for those with patient-clinician distance over 321.9 km. There was no differential receipt of visits when the out-of-state clinician held a license in the patient’s state and among relationships with mental health practitioners. Out-of-state relationships were less likely to have both telemedicine (AOR, 0.90; 95% CI, 0.84-0.96) and in-person (AOR, 0.73; 95% CI, 0.68-0.77) visits after waiver expiration.

Out-of-state telemedicine visits surged while licensure waivers were active. 3 , 5 This study highlighted the harms to access to care when the waivers expired. When the waivers expired, patients did not switch from telemedicine to in-person care but rather tended to stop seeing the physician altogether. This finding was most evident when the patient and clinician were over 321.9 km apart.

The results support the need to reform state licensure. 6 Among the small number of telemedicine relationships in which out-of-state physicians held a license in states where patients resided, there was no decrease in continuity.

When waivers expired, out-of-state telemedicine did not simply stop. This finding may be attributed to many clinicians being unaware of the changes in state regulations. This study was limited by the sample of states with accessible data, the differences in their populations, and the possibility for residual confounding.

Accepted for Publication: October 6, 2023.

Published: November 15, 2023. doi:10.1001/jamanetworkopen.2023.43697

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Bressman E et al. JAMA Network Open .

Corresponding Author: Eric Bressman, MD, MSHP, University of Pennsylvania, 423 Guardian Dr, 13th Floor, Philadelphia, PA, 19004 ( [email protected] ).

Author Contributions: Dr Bressman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Bressman, Werner, Cullen, Kowalski, Mehrotra.

Acquisition, analysis, or interpretation of data: Bressman, Werner, Cullen, Ukert, Barsky, Kowalski.

Drafting of the manuscript: Bressman.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Bressman, Werner, Cullen.

Administrative, technical, or material support: Cullen, Ukert, Barsky, Mehrotra.

Supervision: Werner, Mehrotra.

Conflict of Interest Disclosures: Dr Kowalski reported owning stock in Elevance Health, Amazon, and other companies. Dr Mehrotra reported receiving grants from the Commonwealth Fund during the conduct of the study and personal fees from Black Opal Ventures, the Commonwealth of Massachusetts, the Pew Charitable Trust, NORC, and Sanofi outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

• For Ophthalmologists
• For Practice Management
• For Clinical Teams
• For Public & Patients

Museum of the Eye

• Managing Your Practice
• Managing Your Practice Topics
• Emergency Preparedness and Cybersecurity
• Practice Forms Library
• Practice Management News & Advice
• Lean Management
• Video Library
• My Green Doctor
• Ophthalmology Job Center
• Benchmarking & Salary Tools
• Academy Consultations
• Consultant Directory
• Coding Topics
• Ask the Coding Experts
• Cataract Surgery
• Codequest Events
• Coding for Injectable Drugs
• EM Documentation
• Ophthalmic Coding Specialist (OCS) Exam
• Savvy Coder
• Friday Coding Sessions
• Friday Intensive Classes
• Submit an Instruction Course
• Codequest Courses
• Mid-Year Forum
• Webinar Recordings
• Upcoming Webinars
• IRIS Registry
• Merit-Based Incentive Payment
• Medicare & MIPS
• Promoting Interoperability
• Improvement Activities
• Avoid a Penalty
• Medicare Participation Options
• Medicare Advantage Plans
• New Medicare Card
• Provider Enrollment, Chain and Ownership System (PECOS)
• Membership Benefits
• Renew/Pay Dues
• AAOE Membership
• AAOE Board of Directors
• Practice Views
• AAOE Content Committee
• Volunteer Opportunities
• For Practice Management /
• Ask the Coding Experts /

Coding Top 5 - July 2024

Narrow your results, select code type, select topic.

• Cataract/Anterior Segment
• Coding Competency
• Coronavirus
• Oculofacial
• Pediatric/Strabismus
• Revenue Cycle Management
• Telemedicine
• Testing Services
• Trauma Coding

Select Category

About Our Coding Experts

About Our Coding Experts

Our expert staff have decades of combined experience, covering all aspects of coding and reimbursement.

John T. McAllister, MD Secretary, Federal Affairs

Michael X. Repka, MD, MBA Medical Director, Government Affairs

Joy Woodke, COE, OCS, OCSR Director, Coding and Reimbursement

Matthew Baugh, MHA, COT, OCS, OCSR Manager, Coding and Reimbursement Heather H. Dunn, COA, OCS, OCSR Manager, Coding and Reimbursement

Ask the Experts!

Email  [email protected]

Note: Coding regulations and edits can change often. Academy coding advice is based on current information. Visit aao.org/coding  for the most recent updates. Information provided by our coding experts is copyrighted by the American Academy of Ophthalmology and intended for individual practice use only.

• Mark Complete

The Academy coding experts receive questions daily at [email protected] and [email protected] . We are committed to providing accurate responses so that practices are confident in their billing and coding. Here are the top 5 coding questions that Academy coding experts answered this month:

• Correct NDC for Avastin From a Compounding Pharmacy
• Long-Term High-Risk Medication and Level of Office Visit
• Not Billing Procedure in Order to Bill Office Visits
• Global Period for Super K and AMT
• When is Documenting Vital Signs Required?

All content on the Academy’s website is protected by copyright law and the  Terms of Service . This content may not be reproduced, copied, or put into any artificial intelligence program, including large language and generative AI models, without  permission from the Academy.

• About the Academy
• Jobs at the Academy
• Financial Relationships with Industry
• Medical Disclaimer
• Privacy Policy
• Terms of Service
• Statement on Artificial Intelligence
• For Advertisers

FOLLOW THE ACADEMY

Medical Professionals

Public & Patients

Coding Scenario: Coding for Audio-only Visits

Audio-only (Telephone Evaluation and Management)

Note: These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments.

How do I code an audio-only visit for a new or established patient for COVID-19-related or non-COVID-19-related care?

Audio-only scenario notes.

Beginning March 1, 2020, and for the duration of the COVID-19 public health emergency, CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443).

Many private payers are also covering telephone E/M services as telehealth services delivered using audio-only.

• Whether physicians report the audio-only encounter to a private payer as an office visit (99201-99215) or telephone E/M service (99441-99443) will depend on what the physician is able to document from the encounter. Physicians should report the code that appropriately reflects services rendered.
• UHC will allow office visits (99201-99215) via audio-only for Medicaid and commercial patients. Audio-only encounters for Medicare Advantage members must use the appropriate telephone E/M code (99441-99443).

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

The following codes may be used by physicians or other qualified health professionals who may report E/M services:

• 99441: telephone E/M service; 5-10 minutes of medical discussion
• 99442: telephone E/M service; 11-20 minutes of medical discussion
• 99443: telephone E/M service, 21-30 minutes of medical discussion

As noted above, most payers are waiving cost-sharing for telephone E/M services. Physicians may elect to waive cost-sharing for Medicare beneficiaries. However, Medicare will not cover the beneficiary’s cost-sharing and the service will be paid as usual.

COVID-19-related services should be assigned the appropriate COVID-19 ICD-10 diagnosis code. Coding guidance can be found on the CDC website . Cost-sharing waivers may not be applied to claims that do not include an appropriate COVID-19 ICD-10 diagnosis code.

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as:

• if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem,
• when CPT codes 99339-99340 and 99374-99380 are used for the same call,
• during the same month with CPT codes 99487 and 99489, and
• when performed during the same service period at CPT codes 99495-99496.

Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies. The Center for Connected Health Policy is tracking COVID-19 Related State Actions .

  Also in This Section

Virtual-Digital

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.