The Medical Group Management Association’s most recent MGMA Stat poll asked medical practice leaders, "What is your biggest coding/billing challenge for telehealth and telephone visits amid COVID-19?" Top responses included:
- Inconsistent payer rules: Respondents reported the variance among payers on which codes will be paid results in administrative burden in trying to account for evolving billing requirements, especially with place of service (POS) codes and modifiers.
- Pay parity and accuracy: Other respondents noted issues with accurate payments for billed services, as well as parity for approved services.
- Documentation: As many providers are new to providing telehealth services after a rapid expansion following regulatory waiver implementation, learning and consistently applying new rules for accurately documenting those services was a frequent challenge cited by respondents.
The poll was conducted April 28, 2020, with 419 applicable responses.
Understanding how to code accurately and bill for telehealth and telephone encounters has been challenging for many practices amid the rapid expansion of telehealth services during the COVID-19 public health emergency (PHE), especially among practices that had no previous experience in telehealth and the complexities of reimbursement for these services. Common issues include selecting the proper place of service (POS) code and modifier, and identifying the correct CPT or HCPCS codes.
For practices previously offering telehealth services, regulatory waivers and updates from the Centers for Medicare & Medicaid Services (CMS) and new visit codes, laboratory testing codes and Z codes developed by the American Medical Association (AMA) added a layer of complexity in understanding this new landscape.
- Medicare Telehealth/Telemedicine Waivers During the COVID-19 Public Health Emergency (MGMA Government Affairs)
- COVID-19 coding and guidance (AMA)
- “Telehealth billing during the COVID-19 national emergency” (MGMA insight article)
Coding and billing telehealth
The changes that occurred amid the rapid relaxation of rules and regulations set forth by CMS and the AMA presented numerous challenges in coding and billing.
Provider documentation is vital when deciding on appropriate code selection for telehealth. Face-to-face encounters via telecommunication must include the date of service and platform used. Telehealth codes require notation of audio/video communication between treating provider and patient, as well as findings and treatment plan. Telephone or email visits are considered non-face-to-face and must be documented as such. Date of service and whether it was audio-only or via secure patient portal must be documented. Findings must be documented by the provider based on patient communication.
Additionally, the types of Medicare telehealth services carry with them unique HCPCS and CPT codes, which also vary based on the patient relationship with provider.
Summary of Medicare telemedicine services
Place of service (POS)
Clarifying POS can be perplexing since CMS has relaxed rules on how to report services. CMS requires that the POS for the hosting facility align with the facility type. For example, if it is an outpatient hospital facility, POS 22 should be used, while POS 11 should be used for a private office. Check with your payers if you are billing as the hosting facility:
|Performing physician or qualified healthcare provider (QHP)
|Definition of site
It is imperative to familiarize providers, coders and billing staff on documentation requirements, POS, reason for visit, COVID-19 PHE waiver rules, payer rules and federal/state requirements. The AMA provides ample information on how to code telehealth scenarios with the POS.
According to CMS, code G0071 should be used for distant site services by rural health clinics (RHCs) and federally qualified health centers (FQHCs). Effective July 1, 2020, through the end of the COVID-19 PHE, code G2025 with modifier 95 should be used to indicate synchronous telemedicine service rendered. Reimbursement is based on the Prospective Payment System (PPS) rate and will be paid at the $92 rate. Please review CMS MLN announcements and your Medicare administrative contractor for further details on how to file claims.
- New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE) [CMS]
- MGMA COVID-19 Recovery Center — Operational resources for responding to COVID-19
- “Coding guidance for new ICD-10-CM and lab testing codes for COVID-19” — MGMA Stat data story
- Medicare Telehealth RVUs — MGMA COVID-19 resource
— Andrew Hajde, CMPE, assistant director, Association Content, contributed to this article.
Would you like to join our polling panel to voice your opinion on important practice management topics? MGMA Stat is a national poll that addresses practice management issues, the impact of new legislation and related topics. Participation is open to all healthcare leaders. Results of other polls and information on how to participate in MGMA Stat are available at: mgma.com/stat.