Final Rule for Telehealth and Digital Services

Overview of the 2023 Physician Fee Schedule

The Centers for Medicare & Medicaid Services (CMS) released the final rule for the 2023 Physician Fee Schedule (PFS) on November 1, 2022. This final rule introduces crucial updates for telehealth and digital service providers, including new codes that will influence the growth of these sectors. Medical billers and coders must address various questions regarding the coding and reimbursement of digital and telehealth services.

CPT Codes for Digital and Telehealth Services

Medical Billing CPT Codes

The following CPT codes are applicable for online digital evaluation and management (E/M) services. Clinicians can bill for these independent services, which involve sending messages rather than conducting video or telephone consultations. These codes pertain to established patients and account for cumulative time over a seven-day period:

– 99421: 5-10 minutes
– 99424: 11-20 minutes
– 99423: 21 minutes or more

Important Considerations

– Verbal agreement from CMS is required.
– Patients must submit requests for services through the portal.
– Documentation of the service must be included in the patient’s medical record.
– These codes should not be used to address concerns if an E/M service has already been provided.
– If the inquiry pertains to a new issue that has not been resolved within the past seven days, billing is permitted.
– Decision-making complexity or online service time may be used to select the E/M service if a face-to-face service occurs within seven days of the online service.
– Surgeons cannot bill for these services during the global period.
– Services must be delivered via a HIPAA-compliant platform, such as secure email or electronic health record portals.
– Only one service can be billed every seven days.
– Time spent by clinical staff and on other separately reported services, like care management, is excluded.

Online Digital without E/M Service Billing

These codes are designated for non-physician healthcare professionals who do not perform E/M services. In the Medicare payment schedule, these codes have an invalid status indicator and do not have assigned RVUs. They represent cumulative time within a seven-day period for established patients:

– 98970: 5-10 minutes
– 98971: 11-20 minutes
– 98972: 21 or more minutes

Telehealth Visits

Telehealth visits will be reimbursed for all traditional Medicare members, regardless of the originating site or location. A pre-existing relationship with the patient is not necessary for these visits, which can utilize platforms like Skype or FaceTime. Billing for telehealth appointments, whether audio-only or audio-video, is similar to in-person visits. The following codes apply to synchronous visual/auditory evaluation and management visits:

– 99201 – 99205: New patient office/outpatient E/M visits
– 99210 – 99215: Established patient/outpatient E/M visits
– G0425 – G0427: Initial emergency department telehealth consultations (Medicare only)
– G0406 – G0407: Additional inpatient consultations for patients in hospitals or SNFs (Medicare only)

Modifier 95

Most commercial payers temporarily adopt Medicare telehealth billing guidelines.

Telephone E/M Services

E/M services conducted over the phone or via audio-only channels cannot be used to refer patients for an E/M service or procedure scheduled within the next 24 hours or derived from an E/M service occurring within the next seven days. These services are temporarily covered by Medicare and some Medicaid programs.

Enhancing Reimbursements

Effective January 2023, the provisions outlined in the Final Rule are expected to significantly impact the future of telehealth and digital services within the Medicare Program and beyond. However, regulations surrounding billing for these services are still evolving, with each payer—Medicaid, Medicare, and private insurers—having distinct requirements for charging digital and telehealth services.