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Most of us try and stay out of the doctor’s office. Max is no different. But in some cases, we just need some help from a doctor. Traditionally, these services were provided in a face-to-face office setting where our doctor can poke and prod us if needed. In the industry, we often call a common office visit the “evaluation and management” of a patient. The doctor is essentially evaluating and managing a problem. They have a whole set of billing codes dedicated to this.
But what if there is no need for the doctor to poke around? What if I just need a prescription refilled or five minutes of medical advice? Is there another way?
So today we are here to study up on telehealth. Like many things in healthcare, we have overcomplicated this. There are too many acronyms, technical definitions, and codes. I’m not proud of how complicated this has gotten. But today, we put some of that aside and stick to the basics.
I will even give you the billing codes used most often so you can check in on things.
These alternatives may help keep us out of the doctor’s office while still getting the services we need. Depending on the insurance, it may also help us keep some extra money in our pocket.
The COVID-19 pandemic opened a whole array of options for us to get medical services remotely. Typically, these are usually only available when care from a distance makes sense. In 2020, it makes a lot of sense. So much sense that even Medicare has opened up telehealth. Obviously, if we have a hernia or a broken elbow, we will likely need to be evaluated in person. But in some cases, our doctor or provider doesn’t need to touch us to help us evaluate and manage a problem.
So, what are our options for telehealth?
I am going to attempt to simplify this down to three main visit types. From a “digital” standpoint, we get farther and farther from our doctor as I move down the list.
- Video Visits
- Telephone Visits
- Email/Patient Portal Visits
There are also two more unique scenarios I think are worth calling out.
- Photos and Recorded Videos (sent to our doctor)
- Short Virtual Check-ins
Medicare and several payers have come right out and said they will now cover various forms of telehealth. Unfortunately, that doesn’t mean your insurance covers it. You will want to do your research and make sure you understand what your insurance covers. Then, find out how it will hit your out-of-pocket. Max is only here to guide, I never guarantee.
Video visits are generally two-way communication using an interactive audio and video telecommunications system permitting real-time communication between the provider and patient. That’s a fancy way of describing a secure Skype or Zoom call with your doctor. This is what most people think of when they think of telehealth. It is considered a substitute for an in-person visit. Video visits offer the ability to do an evaluation and management of an issue remotely over video and audio.
Normally, these video services could only be provided to “established” patients. Being an established patient just means we already have a relationship with our medical provider. The government waivers tied to the pandemic have opened these services up to new patients as well.
From a billing standpoint, the regular ‘evaluation and management’ billing codes are used for billing these services. So, on paper, these visits have a similar look (and price) to visits you have with your doctor when you physically set foot in their clinic.
Here are the codes that represent this kind of service.
- 99201 – 99205 for new patients
- 99211 – 99215 for established patients
Generally, as the visit gets more complex and time-consuming, the higher the code used. There are definitely some other codes that might be used for telehealth services, but these are the codes we will most often see.
Here is where I will try not to overcomplicate things. Your doctor’s office should put a special ‘place of service code’ or ‘modifier’ on the claim to tell your insurance company the services took place through a telehealth visit. That will become important for your insurance company to correctly waive out-of-pocket costs on these visits should they choose to do so. I will give you those tools in another post.
Alternatively, non-face-to-face telephone visits are handled a bit differently. These are services provided by your doctor or provider of care over the phone. Normally, they wouldn’t be as thorough of an exam as what you would experience with video evaluation.
These phone calls also generally cannot be billed if they are provided seven days after a formal evaluation and management with a provider. In other words, if you had a 99201 – 99205 or a 99211 – 99215 charged to you in the previous seven days and you speak to your provider over the phone, they should probably not be charging you for the telephone call.
The following billing codes can be used to represent a telephone call with your provider.
- 99441 – five to ten-minute evaluation and management service provided over the phone
- 99442 – eleven to twenty-minute evaluation and management service provided over the phone
- 99443 – twenty-one to thirty-minute evaluation and management service provided over the phone
Any time spent on the call over 30 minutes must be on the house because there isn’t a code for that. Oh, and if they happen to call you into the office as a result of the phone call, they probably can’t charge you for the phone call. This would generally be if the appointment occurred within 24 hours of the call.
Email/Patient Portal Visits
Another option is a non-face-to-face encounter with a medical provider through virtual communication. These are often referred to as “E-Visits”. They would normally be reserved for a patient who has already established care with a medical provider. In this case, there is no video, audio, or telephone conversation. It is all handled through an online patient portal or secure email. It is a patient-initiated, non-face-to-face, digital communication.
These are the billing codes I would expect to see for this scenario. As I mentioned, these are for “established” patients.
- 99421 – five to ten-minute online digital evaluation and management service
- 99422 – eleven to twenty-minute online digital evaluation and management service
- 99423 – twenty-one (or more) minute online digital evaluation and management service
Your provider office should only charge one of these over a 7-day period no matter how many times they communicate with you (it’s cumulative). That said, my understanding is that, unlike the phone visits, our doctor can still charge this even if we saw him or her in the last seven days.
The time on these codes represents the time it takes your doctor or provider of care to review your initial inquiry, review medical records, develop a plan for you, write prescriptions, and respond to you.
Photos and Recorded Videos (sent to our doctor)
Have you ever considered just sending a picture or a video of something to your doctor? They can evaluate the image/video and tell you what is wrong? They have a code for that too. This is sometimes called Virtual Care Communication (store and forward).
- G2010 represents the remote evaluation of a recorded video and/or images submitted by an established patient
There are some rules around this one as well. This code includes the follow-up call with the patient that occurs within 24 hours.
Just like the phone calls, your clinic should not be billing it if you had a formal evaluation and management service with your doctor in the previous 7 days of sending the files. They also cannot bill it if you have a formal evaluation and management service with them within 24 hours after submitting the images. In other words, if they call me in after looking at my boil photo, they shouldn’t charge me for looking at the image.
Virtual check-ins are very much like the short 5-10 minute telephone evaluation and management code above, it just goes beyond the phone call. It represents a brief technology-based communication with your provider that spans 5-10 minutes of medical discussion. Although it is similar to the 99441 telephone service, the code definition technically doesn’t define it as a “telephone only” code. The code represents any technology-based communication. My interpretation is that could include the telephone.
- G2012 represents this type of “virtual check-in” depending on your insurance
Just like the phone calls, your clinic should not be billing it if you had a formal evaluation and management service with your doctor in the previous 7 days. They also cannot bill it if you have a formal evaluation and management service with them within 24 hours of the check-in.
So there you have it – telehealth in a nutshell. It is what it is, and I am not proud of how complicated the billing on this has become. But now you have a high-level overview should you ever need it.
The video/audio visits try and substitute an in-person face-to-face visit. Virtual communication (phone/online portal), on the other hand, is a brief discussion to determine if a face-to-face visit is necessary.
In times of pandemic, these are great options to get help with an issue. In theory, it should even work in times of non-pandemic. I personally think this little nudge will push us further into the telehealth model, at least, where that model makes sense.
But how much should these services cost me? How should they be billed? More on that next time, here at Max Out of Pocket.
*Max is not a medical professional and none of this is medical advice. I am not promoting the use of telehealth. Talk over your telehealth options with your provider.
*I am not a “certified coder”. But then again, this stuff isn’t rocket science either once you know where to look. That said, it is not advisable to use Max as formal “regulatory support” for making an argument with your doctor’s billing office. If you are having a billing problem, feel free to contact me by email and I am always happy to try and help or point you in the right direction.
*If you happen to live in a rural community and seek services from a designated ‘rural health center’, as of 4/29/2020 it is still questionable if Medicare will pay the telephone codes 99441-99443. I don’t see any reason a commercial payer wouldn’t pay them, though.