How to Correctly Do Medical Billing for Telemedicine

Telemedicine is an excellent alternative to traditional face-to-face way of providing healthcare services with cost-effectiveness, increased patient satisfaction and convenient high-quality care. Though it is an accepted practice, reimbursement issues are still plaguing healthcare providers. They need to bill and code the procedures delivered via telemedicine correctly to achieve appropriate payment. However, not every payer provides coverage for telemedicine services and the coverage policies differ from payer to payer. In order to make medical billing and coding for telemedicine services effective, healthcare providers should pay close attention to the following areas.

Verify for Telemedicine Coverage

Your entire effort will go in vain, if you submit your claims without knowing that your patient’s insurance does not cover telemedicine services. The best way to avoid such a situation is to call the payer and verify whether they cover for telemedicine before the first telemedicine visit. Once the insurance company representative confirms that telemedicine services are covered, you can proceed with the telemedicine visit. When you call the payer, make sure that the representative’s answers are documented correctly in the telemedicine insurance verification form. You can use this document to fight against a denied claim later.

Understand Each Payer’s Coverage Policy

While verifying telemedicine coverage, you should not only confirm that the insurance policy covers telemedicine services, but also understand the telemedicine coverage policy specific to each payer. You can ask what type of healthcare services delivered via telemedicine are covered, whether they specifically cover live video telemedicine, what are the criteria to qualify for telemedicine coverage, and whether there are any restrictions for the number of telemedicine visits in a year. The general telemedicine coverage guidelines for major payers are as follows:

• Medicare - When it comes to reimbursement, Medicare is complicated and restrictive. It covers fewer than 20 sections of telehealth services. The patient must meet the following criteria for Medicare reimbursement for telehealth services.
  • The patient must be seen at an authorized site such as skilled nursing facilities, doctor offices, public hospitals and certain private hospitals
  • The patient must be seen by an approved practitioner (nurse, doctor with medical degree, clinical psychologist)
  • The actual service must be included within the covered codes

  Medicare provides reimbursement only if the services are conducted in a facility located in a Health Professional Shortage Area (HPSA). This facility cannot be included within a Metropolitan Statistical Area (MSA) as well.

• Medicaid - Medicaid approved providing reimbursement for telehealth services in about 40 states. Even so, the actual reimbursement policy differs in each state with some covering real-time visits while others cover off-site services including telehome care. Certain remote monitoring services are also covered. However, Medicaid reimbursements are more expansive than those provided through Medicare.
• Private Payers - Private payer coverage leads to broader telehealth coverage. However, the actual reimbursement policies vary according to the payer. Many states have adopted telehealth parity statutes though. These insist that payers provide reimbursement in the same manner they provide coverage for in-person services.

Medical Coding

Most payers allow providers to bill for telemedicine using the appropriate evaluation and management CPT code (99201 – 05, 99211-15) along with a GT modifier. (This modifier tells the corresponding payer that the healthcare service is delivered via telemedicine). Medicare covers a very long list of CPT/HCPCS codes. Some of them are given below.

• G0406: Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth
• G0407: Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth
• G0408: Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth
• G0425: Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth
• G0426: Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth
• G0427: Telehealth consultation, emergency department or initial inpatient, typically 70 minutes communicating with the patient via telehealth
• 99201–99215: Office or other outpatient visits
• 99231 – 99233: Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days
• 99307 – 99310: Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days

Certain private payers insist that you use the following telemedicine specific code.

• 99444: Online medical evaluation - physician non-face-to-face E&M service to patient/guardian or healthcare provider not originating from a related E&M service provided within the previous 7 days

The codes used for reporting telehealth services may vary according to the payer and the state.

Facility Fees

If you are participating in a telemedicine program that bills through Medicare (sometimes, Medicaid), then you should have a clear understanding about facility fees. This is the amount paid to the local health facility that organized the telemedicine visit for the patient. As per the existing Medicare telemedicine model, a patient is required to come to an eligible originating site for the telemedicine visit with a healthcare provider at another remote or distant site. It is possible for that originating site to charge a facility fee to cover the costs of hosting the telemedicine visit. However, the originating site has to meet the following conditions.

• The facility must be physician or practitioner offices, hospitals, critical access hospitals (CAH), rural health clinics, federally qualified health centers, hospital-based or CAH-based renal dialysis centers, skilled nursing facilities (SNF) or community mental health centers (CMHC)
• The facility must be located within a Health Professional Shortage Area (HPSA)

You can bill HCPCS code Q314 to charge the facility fee. On the whole, it is quite difficult to assign the most appropriate codes and bill the claims according to each payer. It is a hectic job to call each payer and confirm the codes they accept and assign them accordingly. For busy practices, it will prove beneficial to rely upon an experienced medical billing company that provides medical billing and coding solutions for telehealth services to avoid confusion and receive timely payments.

OSI is a leading healthcare BPO company based in Tulsa, Oklahoma, focused on providing reliable medical billing and coding services.