Category

Telemedicine

2018 Reimbursement Codes for Telemedicine

CY 2018 Medicare Telehealth Service Codes with Example Pricing: Reflects the National Payment Amount based on the Calendar Year (CY) Physician Fee Schedule Total Non-Facility RVUs and CY 2018 Modifier ($35.99), where available.  Note that Facility and Non-Facility Pricing are sometimes the same (e.g., where code is a facility-only code).

 

Code Description Payment
90785 Psychiatric treatment interactive complexity add on code – refers to 4 specific communication factors during a visit that complicate delivery of the primary psychiatric procedure $14.76
90791 Psych diagnostic evaluation $136.40
90792 Psych diagnostic evaluation with additional medical services such as physical examination and prescription of pharmaceuticals are provided in addition to the diagnostic evaluation $152.60
90832 Psychotherapy, 30 minutes with patient $66.22
90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedures: 99201-99255, 99304-99337, 99341-99350) $69.10
90834 Psychotherapy, 45 minutes with patient $88.54
90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedures: 99201-99255, 99304-99337, 99341-99350) $87.10
90837 Psychotherapy, 60 minutes with patient $132.80
90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedures: 99201-99255, 99304-99337, 99341-99350) $115.17
90845 Psychoanalysis $95.01
90846 Family psychotherapy (without the patient present), 50 minutes $106.89
90847 Family psychotherapy (conjoint psychotherapy)(with patient present), 50 minutes $111.21
90951 ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month $960.57
90952 ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 or more face-to-face visits by a physician or other qualified health care professional per month Contact MAC for pricing
90954 ESRD related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month $827.77
90955 ESRD related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 or more face-to-face visits by a physician or other qualified health care professional per month $464.63
90957 ESRD related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month $654.65
90958 ESRD related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 or more face-to-face visits by a physician or other qualified health care professional per month $444.12
90960 ESRD related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month $288.28
90961 ESRD related services monthly, for patients 20 years of age and older; with 2-3 or more face-to-face visits by a physician or other qualified health care professional per month. $242.57
90963 ESRD related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents. $554.33
90964 ESRD related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents. $484.79
90965 ESRD related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents. $461.03
90966 ESRD related services for home dialysis per full month, for patients 20 years of age and older. $241.85
90967 ESRD related services for home dialysis less than a full month, per day; for patients younger than 2 years of age. $18.35
90968 ESRD related services for home dialysis less than a full month, per day; for patients 2-11 years of age. $15.84
90969 ESRD related services for home dialysis less than a full month, per day; for patients 12-19 years of age. $15.47
90970 ESRD related services for home dialysis less than a full month, per day; for patients 20 years of age and older. $7.92
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language , memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report. $95.37
96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment $22.67
96151 Health and behavior re-assessment $21.95
96152 Health and behavior intervention, each 15 minutes, face-to-face, individual $20.87
96153 Health and behavior intervention group (2 or more patients) $4.68
96154 Health and behavior intervention family (with the patient present) $20.15
96160 Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument $3.96
96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument $3.96
97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes. $35.27
97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes. $30.59
97804 Medical nutrition therapy; group (2 or more individuals), each 30 minutes. $16.19
99201

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A problem focused history;
  • A problem focused examination;
  • Straightforward medical decision making.
$45.35
99202

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Straightforward medical decision making.
$76.30
99203

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A detailed history;
  • A detailed examination;
  • Medical decision making of low complexity.
$109.77
99204

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of moderate complexity.
$167.35
99205

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.
$210.54
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. $21.95
99212

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A problem focused history;
  • A problem focused examination;
  • Straightforward medical decision making.
$44.63
99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Straightforward medical decision making.
$74.14
99214

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these 3 key components:

  • A detailed history;
  • A detailed examination;
  • Medical decision making of low complexity.
$109.41
99215

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.
$147.56
99231

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • A problem focused interval history;
  • A problem focused examination;
  • Medical decision making that is straightforward or of low complexity.
$39.95 (total facility)
99232

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • An expanded interval history;
  • An expanded examination;
  • Medical decision making of moderate complexity.
$74.14 (total facility)
99233

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • A detailed history;
  • A detailed examination;
  • Medical decision making of high complexity.
$106.17 (total facility)
99307

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • A problem focused interval history;
  • A problem focused examination;
  • Straightforward medical decision making.
$45.35
99308

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • An expanded problem focused interval history;
  • An expanded problem focused examination;
  • Medical decision making of moderate of low complexity.
$70.54
99309

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • A detailed interval history;
  • A detailed examination;
  • Medical decision making of moderate complexity.
$93.21
99310

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 components:

  • A comprehensive interval history;
  • A comprehensive examination;
  • Medical decision making of high complexity.
$138.56
99354 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service) $132.80
99355 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service) $100.41
99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and management service) $94.93 (total facility)
99357 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service) $94.29 (total facility)
99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes $14.76
99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes $28.43
99495

Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit, within 14 calendar days of discharge
$166.99
99496

Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of high complexity during the service period
  • Face-to-face visit, within 7 calendar days of discharge
$236.45
99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate $87.10
99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure) $75.94

View full list

Getting Reimbursed for Telemedicine in Virginia


In order to serve the needs of Virginia’s diverse and distributed population, state leaders have been out in front of the new healthcare delivery options made possible by telemedicine. In 2010, Virginia became just the 10th state to require private payer parity for telehealth visits.

History of telemedicine regulations in Virginia

 

  •  Senate Bill 675, Health insurance; mandated coverage for telemedicine services (2010) – On March 2, the Virginia Legislature unanimously approved a bill (SB 675) that would require private health insurers, health care subscription plans and HMOs to cover for the cost of health care services provided through telemedicine technology.
  • SB 1227 Telemedicine services; provision of health care services. (2015) – Enacted on February 26th, 2015, SB 1227, expanded access to care for minor illnesses by amending Virginia law to clarify that a prescriber licensed in Virginia may prescribe Schedule VI controlled substances via telemedicine, provided the prescriber conforms to the same standard of care expected of an in-person visit.

Private payer reimbursement for telemedicine in Virginia

Virginia can be considered a leader in achieving private payer reimbursement parity for telehealth.  In 2010, they became just the 10th state to mandate reimbursement for this important method of patient care.

Definition
The law defines telemedicine services as, “The use of electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient or consulting with other health care providers regarding a patient’s diagnosis or treatment.”

Exclusions
Reimbursement is not required for the following:

        • An audio-only telephone conversation
        • An electronic mail message
        • A facsimile transmission

Policies Included
The law applies to all insurance policies, contracts, and plans delivered, issued for delivery, reissued, or extended on and after January 1, 2011, or at any time thereafter when  any term of the policy, contract, or plan is changed or any premium adjustment is made.

It does not apply to short-term travel, accident-only, or limited or specified disease policies or contracts, nor to policies or contracts designed for people eligible for Medicare, or any other similar coverage under state or federal governmental plans.

Parity
Insurers must reimburse treating providers for the diagnosis, consultation, or treatment of the insured delivered through telemedicine “on the same basis” that insurer is responsible for coverage for the provision of the same service through face-to-face contact.

Copayments and Maximums
An insurer may offer a health plan containing a deductible, copayment, or coinsurance requirement for a health care service provided through telemedicine as long as it does not exceed the deductible, copayment, or coinsurance applicable if the same services were provided face-to-face. Insurers may not impose any annual or lifetime dollar maximum on coverage for telemedicine services other one that applies to all items and services covered under the policy.

Patient Site Requirements
A policy can not distinguish between patients in rural or urban locations.

Code of Virginia Physician Regulations
Virginia’s State Medical Board

Telemedicine Definition
For the purpose of regulating physician practices in Virginia “telemedicine services,” as it pertains to the delivery of health care services, means the use of electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient or consulting with other health care providers regarding a patient’s diagnosis or treatment. “Telemedicine services” does not include an audio-only telephone, electronic mail message, facsimile transmission, or online questionnaire.”

Practitioner-Patient Relationship
Practitioners recognize the obligations, responsibilities, and patient rights associated with establishing and maintaining a practitioner-patient relationship. Where an existing practitioner-patient relationship is not present, a practitioner must take appropriate steps to establish a this relationship. Relationships may be established using telemedicine services provided the standard of care is met.

Identity and Consent
A practitioner is discouraged from rendering medical advice and/or care using telemedicine services without (1) fully verifying and authenticating the location and, to the extent possible, confirming the identity of the requesting patient; (2) disclosing and validating the practitioner’s identity and applicable credential(s); and (3) obtaining appropriate consents from requesting patients after disclosures regarding the delivery models and treatment methods or limitations, including any special informed consents regarding the use of telemedicine services.

Documentation
Evidence documenting appropriate patient informed consent for the use of telemedicine services must be obtained and maintained.

The medical record should include, if applicable, copies of all patient-related electronic communications, including patient-practitioner communication, prescriptions, laboratory and test results, evaluations and consultations, records of past care, and instructions obtained or produced in connection with the utilization of telemedicine services.

Prescriptions
Prescribing medications, in-person or via telemedicine services, is at the professional discretion of the prescribing practitioner.

Frequently Asked Questions (FAQ)

How to Launch a Successful Telehealth Program for DC Metro Area Medical Practices

Telemedicine is all about convenience for any patient but it’s also a powerful tool that transforms patient engagement, while increasing revenue for an independent practice. There are a number of factors to consider when developing a telemedicine program.  Luckily, at MSNVA, we have narrowed down the key ingredients that will help physicians launch a successful telemedicine program with minimum risk.

For example, many of our network physicians and their support staff have brought up the fact that some patients don’t like to schedule follow-up visits to discuss diagnostics and would rather just get a telephone call from their physician.  The main reasons for this are inconvenience of taking time off again, driving time, and cost, which leave the practices out of that revenue.  With DoctorsTelemed, the front-end staff can simply schedule patients for follow-up visits at the time of the first appointment and even collect the co-payment for that future visit in advance.

For primary care physicians with a heavy patient load of Medicare subscribers, the opportunity to provide patients with chronic care management programs while increasing revenue is almost too easy.  Practices should focus on at least two chronic conditions like Diabetes and High Blood Pressure, identify the patients and offer to enroll them in a program using DoctorsTelemed.  Schedule your patients monthly for monthly 20-minute sessions for up to 12 months, the system will automatically bill Medicare for the appropriate codes 99487, 99489 or 99490, which reimburses at an average rate of $40 – $45/session or $480 – $540/patient/year depending on the area where physicians practice.

Another key benefit is keeping specialist consultations in-house, thereby giving patients real-time access to specialty care while retaining more revenue.  Some DoctorsTelemed providers are already implementing this model, by assigning one exam room for the exclusive use of telemedicine.  This model works well in primary care settings and for specialists who do surgeries and need to have pre-operation physical clearance for their patients.

Under Medicare billing rules, for example, the consulting practitioner can bill for the level of service provided.  Physicians/practitioners submit the appropriate Current Procedural Terminology (CPT®) procedure code for covered professional telehealth services along with the ‘GT’ modifier (‘via interactive audio and video telecommunications system’). By coding and billing the GT modifier with a covered telehealth procedure code, the distant site physician/practitioner certifies that the beneficiary was present at an eligible originating site when the telemedicine service was provided. To claim the facility payment, physicians/practitioners bill Healthcare Common Procedure Coding System (HCPCS) code ‘Q3014, telehealth originating site facility fee,’ with the short description ‘telehealth facility fee.’

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