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The importance of establishing Medical Necessity when coding and billing for Telehealth

Posted By Evelyn Santos, CCS
 healthcare partner

A means of communicating to your medical provider without driving to the clinic for a face-to-face evaluation is accomplished through Telehealth/Telemedicine.  This practice has been around for years and used minimally, mostly in rural areas where specialty services was unavailable.  The access to specialty services via Telehealth sprung up out of necessity.  The same can be said of Telehealth amidst the COVID-19 Pandemic

Documentation is just as important in the world of Telehealth as in face-to-face visits.  Reporting whether the visit was by video and audio or just audio is important.  The reason for the visit, discussion of the visit as well as assessment of the evaluation and plan should be provided in the note.  It should be clear who provided the service and with patient consent. 

As in face-to face visits, Telehealth communication must meet medical necessity in the documentation, establishing a chief complaint warranting medical evaluation, description of discussion and any prescriptions and/or orders.  It is recommended that the same template used in face to face encounters be used to ask questions, evaluating the patient’s signs and symptoms, revisiting past medical history and current medications and therapies. 

There are modifiers that are applicable in certain circumstances. 

                Modifier 95 synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system. This modifier may be appended for services typically performed face-to-face but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. (CPT® 2020 Professional Edition, American Medical Association, Chicago p. 812).

                Modifier CS (cost sharing) used on visits and tests for Medicare patients receiving COVID-19 testing-related services and testing. For use in Alaska and Hawaii: GQ. For use by CAH method II hospitals: GT. For Services furnished for purposes of diagnosis and treatment of an acute stroke:  GO.


Specific to COVID-19 public health emergency (PHE):

                Modifier CS-95 is appended to telehealth services related to COVID-19, in that order.

It is imperative that the coder/biller for the provider/facility is knowledgeable of the Telehealth guidelines as well as familiar with payer specific requirements and expectation. 

The Office of Inspector General (OIG) has Telehealth on radar, particularly during the increasing utilization as a result of the COVID-19 pandemic mandating stay at home orders and the need for social distancing in public places. 

Eclat Health Solutions has Telehealth experience in medical coding and billing as well as the knowledge to work with you and your payer for proper reimbursement of Telehealth services rendered.


Frequently Asked Questions on Telehealth and COVID-19 PHE:

Question: How does a health care provider bill for telehealth services?

Answer: The IFC directs physicians and practitioners who bill for Medicare telehealth services to report the place of service (POS) code that would have been reported had the service been furnished in person. This will allow our systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. We believe this interim change will maintain overall relativity under the PFS for similar services and eliminate potential financial deterrents to the clinically appropriate use of telehealth. During the PHE, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services furnished via telehealth. Practitioners should continue to bill these services using the CMS1500/837P.


Question: Will CMS require specific modifiers to be applied to the existing codes?

Answer: For telehealth services furnished during the PHE, CMS is allowing practitioners to use the POS code that they would have otherwise reported had the service been furnished in person. To identify these services as Medicare telehealth, CMS is requiring that modifier 95 be appended to the claim. There are also three additional scenarios where modifiers are ordinarily required on Medicare telehealth claims. When a telehealth service is furnished via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii, the GQ modifier is required. When a telehealth service is billed under CAH Method II, the GT modifier is required. Finally, when telehealth service is furnished for purposes of diagnosis and treatment of an acute stroke, the G0 modifier is required.


Question: If a beneficiary previously received testing for COVID-19, can the facility/practitioner be paid for retesting the beneficiary prior to the performance of the procedure?

Answer: CMS has not established national policy, either through rulemaking or a national coverage determination, regarding coverage of pre-procedure COVID-19 testing. Absent national policy, coverage of these tests are determined by the Medicare Administrative Contractors. Providers are reminded that all services provided must be reasonable and necessary and medical necessity must be documented in the medical record.


Question: How should the CS modifier, which removes application of beneficiary cost-sharing (deductible and co-payment), be applied to telehealth services and/or E/M visits?

Answer: The CS modifier should be applied for certain evaluation and management services related to COVID-19 testing, whether they are furnished in person or via telehealth. These services are medical visits for the HCPCS evaluation and management categories described below when an outpatient provider, physician, or other providers and suppliers that bill Medicare for Part B services orders or administers COVID-19 lab test U0001, U0002, or 87635. Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020, and the end of the PHE; result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes:

  • Office and other outpatient services • Hospital observation services • Emergency department services • Nursing facility services • Domiciliary, rest home, or custodial care services • Home services • Online digital evaluation and management services

Cost-sharing does not apply to the above medical visit services for which payment is made to: • Hospital Outpatient Departments paid under the Outpatient Prospective Payment System • Physicians and other professionals under the Physician Fee Schedule • Critical Access Hospitals (CAHs) • Rural Health Clinics (RHCs) • Federally Qualified Health Centers (FQHCs)

For services furnished on or after March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services. Additionally, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services furnished via telehealth. And the billing practitioner should report the POS code that reflects the place the service would have been furnished if furnished in-person.



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