CMS Issues Expanded Telehealth Regulation

Date: March 19, 2020

Over the past few days, CMS and HHS have allowed for the expanded use of Telehealth services during the COVID-19 public health emergency.  CMS Administrator Seema Verma, in public remarks also posted on the CMS News Feed, noted that CMS would allow “people to communicate with their providers from home and limit the spread of the virus.”  This option for services applies whether patients have suspected symptoms of COVID-19 or not – it helps us keep non-emergent patients and the general public safe.

There are a number of ways to deliver telehealth.  In this situation where patients may be limiting their travel to physician offices except for emergencies or urgent care, most providers will use (1) phone-only or (2) simultaneous phone/video.

(1) For telephone calls with established-status Medicare Part B patients that are not for technician or medical assistant calls, or were not already paid for (post-op checks in a global period, for example), HCPCS Code G2012 may be appropriate.  CMS notes that this code is for 5-10 minutes of provider time.  You may have heard this described as a “Virtual Visit” code.  Other particulars about the use of this code and the required documentation are:

  • Note the patient’s consents to this type of visit
  • Document the discussion topic to include the medical necessity (e.g., history, action)
  • As noted above, document that this conversation took place with the provider, what time the call began and its length (at least 5 minutes)
  • Other restrictions related to billing G2012 are as follows:
    • The call was not related to an office visit that took place within the past 7 days
    • An office visit related to the call is not anticipated in the next 24 hours (or “next available” appointment).
    • Private payers and Part C Medicare plans may vary on coverage and payment.
  • National 2020 payment under Medicare Part B for G2012 is $14.81.

(2)  If the visit includes simultaneous video and phone, and the patient is a Part B beneficiary, it is possible to use our familiar outpatient Evaluation and Management (E/M) codes (99201-99205 and 99212-99215).  Importantly, without the possibility of a live fundus exam, IOP, gross visual fields, or motility, the level of service is limited.  It is likely that only CPT code 99202 for new patients and 99212 or 99213 (established patients) are possible.  CMS clarified mid-day 3/17/2020 that claims should be submitted with the POS as “telehealth” (02), and we feel you should use the CPT telemedicine modifier 95 for synchronous telemedicine service.  Use the current E/M rules to determine the level of service.  Note: eye exam codes (920xx) are not designated with a star (*) in CPT as Telehealth services so that coding option is not currently available.

There are a few new codes in 2020 for “Internet” or online evaluations of established patients.  They are not for use when the patient has “new patient status”.  The physician codes are as follows:

  • 99421 Online digital evaluation and management service, for an established patient, for up to 7 days; 5-10 minutes
  • 99422 11-20 minutes
  • 99423 21 or more minutes

CPT notes these restrictions on 99421/2/3:

  • These are patient-initiated services through secure platform (such as your patient portal) where there is a secure, electronic evaluation/assessment/management of the patient by the provider
  • If staff other than a provider does this, it is not a billable service.
  • These 3 codes are not to be used if:
    • Electronic communication of services takes place but the total is less than 5 minutes,
    • Solely for the communication of diagnostic test results,
    • Appointment scheduling,
    • Post-op checks, or
    • Other “non-E/M” services.
  • Cumulative and related “e-time” for the provider is tracked over 7 consecutive days and tallied up – then only ONE code for the total time is billed.
  • If there is an online service unrelated to an office visit on the same day or within 7 days it may be separately reported (see above for 99212, 99213, 99202).
  • If a related billable (e.g., office-based) E/M exam service happens on the same day or within 7 days, this online service is not billed.
  • Payment under Medicare Part B (national) is as follows:
    • 99421: $15.52
    • 99422: $31.04
    • 99423: $50.16

We are also asked about using the “phone call codes” in the 2020 CPT book.  These are codes 99441 – 99443 for physicians and 98966 – 98968 for NPs and PAs.  None of these codes are covered for Part B Medicare in 2020; check with other payers as they may vary.

We are happy to assist you with claims issues and other topics related to eye care during this public health emergency.  You can download our “App”, Corcoran 24/7 via one of the links below.

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