After a long period of what seemed to be little headway in the ability to use Current Procedural Terminology (CPT) codes to bill for telemedicine services,
progress has been made.
The 2017 CPT manual has a new Appendix P that
lists 79 standard CPT codes for which a “95” modifier
can be used to indicate that the service was provided
via a real-time, interactive audio and video telecommunications system. A number of these codes are used
daily in most pediatric practices. For example, the list
includes the commonly used office or other outpatient
evaluation and management (E/M) codes for new patient (99201-99205) and established patient visits
(99212-99215). A variety of consultation codes are
included as well, e.g., 99241-99245. Finally, behavioral
health codes also are on the list, e.g., behavioral change
intervention codes 99406-99408.
If you are going to start or expand your billing for
telemedicine services, it is important to keep a num-
ber of considerations in mind. Each CPT code has
required elements (e.g., key components or time) that
you need to document for your encounter. If it is not
documented, then it did not happen and you will be
at risk if your services are audited.
Time spent in direct counseling and/or coordination
of care with the patient/caregiver that is greater than
50% of the total time of an E/M service can be used
to justify a given CPT code. However, you must document total time and percent spent in counseling and/or
coordination of care in the patient record. Since time
can be monitored automatically through an electronic
encounter, finding a way to include that in your documentation form may be an easy solution. Only the
physician’s face-to-face time with the patient/caregiver
is counted toward the level of service provided.
In addition, a video component is required for tele-
medicine encounters billed using a standard CPT code
with the 95 modifier. In addition to the video com-
ponent, there is the increasing use of peripherals that
families may have at home to enhance your ability
to assess the patient, including thermometers, stetho-
scopes, oxygen saturation monitors, spirometers, blood
pressure monitors, glucose monitors and otoscopes.
The inclusion of these assessments will help in satisfy-
ing the need for a certain number of required elements
for the CPT code being used.
Qualifying services also have to be “synchronous,”
i.e., they have to be real-time, interactive visits between
a patient/family and a clinician. The other main cat-
egory is “asynchronous” where clinical information is
supplied and considered at a later time. Email inter-
changes would be a common example of an asynchro-
nous encounter. An email is sent to a clinician and then
considered and acted upon at a later time. Radiograph
and ultrasound studies have been in the asynchronous
category for years, but a much larger number of en-
counters may be formatted this way. These will not
qualify for the process of using the 95 modifier.
Another important consideration is whether you actually will be paid for the service if you submit a claim
for payment. A number of states have legislative parity
that requires coverage of telemedicine services to be
the same as face-to-face visits. However, many health
insurance policies do not cover telemedicine services,
including some Medicaid programs under certain conditions. Check to see if your state’s Medicaid program
and your largest health insurers cover these services.
What lies ahead
A new place of service (POS) code, 02, has been
created for telemedicine services. The code took effect
on Jan. 1 and is required for clinicians reporting telemedicine services.
While the Centers for Medicare & Medicaid Services allows telemedicine services to be performed on
a Medicare beneficiary only in an approved site, other
payers may not have that restriction and may allow a
patient to be located in his or her own home or school.
When the patient presents to a site, such as a physician’s
office, the physician’s office may bill as the “
originating site.” The new POS (02) may apply to this fee, or
the payer may require that the POS used defines the
location, such as 11 for office. Always check with your
payers to determine how you would bill if the patient
was located in your office during a telemedicine service
with a remote physician.
Medicare will continue to expand the telemedicine
services eligible for payment in 2017. While Medicare
rarely applies to pediatric patients, it helps to establish
payment for services in all insurance plans. This inclusion acknowledges the increasing role that telemedicine
will play to meet the need for services
that otherwise might not be available
to your patients and families.
Dr. Dehnel is immediate past chair of the
AAP Section on Telehealth Care Executive
CPT manual lists 79 codes that can be billed if telemedicine used
• Coding fact sheet on telehealth services, http://bit.
• Centers for Medicare & Medicaid Services resource
on telemedicine services, http://go.cms.gov/2kPGNDb