Telehealth for Primary Care—Modifiers and CPTs Used in Billing

Mar 27

Telehealth is becoming an ever-more important aspect of healthcare, especially for primary care. It offers many benefits to both patients and doctors, such as increased access, convenience, and better health outcomes. Yet using telehealth services also makes medical billing more complicated. This article will cover how medical billing for primary care can be accomplished when using telehealth services.

Telehealth Billing Codes and Modifiers

To bill correctly for telehealth visits, primary care practices need to know the most significant Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes and modifiers. The modifiers and codes differentiate telehealth visits from standard in-person visits and allow for payment.

Common Telehealth CPT Codes Utilized under Primary Care, as of January 2025:

99202-99215: These are for office or other outpatient E/M visits to new (99202-99205) and established (99211-99215) patients and can be adapted for telehealth by time spent or the complexity of medical decision-making.
99421-99423: These are for digital E/M services to established patients for aggregate time on or within 7 days.
99441-99443: Reminder: Medicare will no longer use these telephone evaluation and management service codes (for established patients) starting January 1, 2025.
98000-98015: These are new 2025 CPT codes that specifically include audio-video and audio-only telehealth visits for new (98008-98011) and established (98000-98007, 98012-98015) patients, distinguished by level of medical decision-making and time.
98016: This new 2025 code is for brief services involving communication technology, such as virtual check-ins, that are 5 to 10 minutes in duration.

Most Often Used Modifiers for Telehealth:

95: This adverb indicates that a telemedicine service was offered through a live audio and video communication system.
93: This is a modifier applied to telemedicine services that are rendered in real time by phone or other audio-only systems.
GT: This telehealth code for services delivered through real-time audio and video communication is almost exclusively assumed by the 95 code, especially for Medicaid.
G0: This descriptor describes a service that is offered outside of a geographical area (used most commonly with telehealth).
GQ: This is an adjustment for telehealth service provided through an asynchronous telecommunications network.
FQ: This Medicare modifier is utilized by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) for telehealth.

Telehealth Place of Service (POS) Codes (Applicable on or after December 31, 2024):

POS 02: Telehealth provided elsewhere, not at the home of the patient.
POS 10: Telehealth delivered in the patient's home.

It is essential to use the correct POS code since it affects payment.

Key Considerations for Telehealth Billing

Established vs. New Patients: Most insurance carriers, including Medicare, now allow you to bill for telehealth services for both established and new patients if some conditions are fulfilled.

Originating Site: Temporary waivers during the COVID-19 public health emergency permitted extra locations for patients to have telehealth services. It is a good practice to stay current with the latest regulations regarding the originating site (where the patient is during the telehealth visit).

Documentation Requirements: Adequate documentation is very critical for all telehealth encounters. This would consist of the form of communication employed (video or audio), duration of the encounter, patient consent to utilize telehealth, and all relevant medical information to validate the services delivered. The documentation must be the same level of detail as in an in-person encounter.

Payer Policies: Telehealth payment policies for Medicare, Medicaid, and private payers can be quite unique. It is best to research each payer separately regarding what they cover, code, and reimburse for. Mandates in several states also exist that require an equal payment for telehealth to in-person service.

Consent: Get and record patient consent for telehealth services. This includes being mindful of possible charges and equipment to be utilized.

Technology: Make sure that the telehealth platform utilized is HIPAA-compliant to safeguard patient security and confidentiality.

How Medical Billing for Telehealth Functions within Primary Care

Patient Encounter: The patient receives a telehealth encounter with their primary care provider via video conferencing, secure messaging, or phone where permitted.
Documentation: The provider fully documents the encounter, history, examination (as appropriate through telehealth), medical decision-making, diagnoses, and treatment plan. The technology mode employed and length of encounter are also documented.
Coding: The appropriate CPT/HCPCS code is selected, along with the applicable telehealth modifier(s) and the appropriate POS code, based on the documentation. For services provided via audio-only, the -93 modifier is significant beginning 2025.
Claim Submission: The claim will be submitted to the appropriate payer (insurance agency, Medicare, or Medicaid) by the medical billing staff.
Payer Processing: The payer verifies the claim to ensure that it complies with their coverage and coding rules for telehealth services.
Reimbursement: If the claim is approved, the telehealth service is reimbursed to the primary care practice. The reimbursement rate may vary based on the payer and the service provided.
Denial Management: When a claim is denied, the billing staff has to figure out why it was denied, correct any necessary corrections, and resubmit the claim or appeal the decision.

Issues in Telehealth Billing

Changing Rules: Telehealth rules and payer policies can change, so we must continue to check and adapt the way we bill.
Coding Challenge: It is sometimes difficult to select the appropriate codes and modifiers for telehealth services with new codes being added.
Reimbursement Discrepancies: Telehealth reimbursement rates may still vary from in-office visits with some payers, affecting revenue.
Technical Issues: Ensuring technology functions effectively for providers and patients can be an issue.
Valuing Skills: Some are of the opinion that the way we bill time currently does not necessarily value physicians' skills with telehealth.

Best Practices in Billing Telehealth in Primary Care

Stay Current: Keep your information current regarding the latest telehealth billing regulations from CMS, state Medicaid agencies, and large private payers.
Proper Training: Properly train all clinical and billing staff on telehealth coding and documentation guidelines.
Proper Documentation: Emphasize the significance of precise and informative records of each telehealth consultation.
Verify Payer Policies: Prior to providing telehealth services, ensure the patient has coverage and that payer policies include billing for telehealth.
Use Technology Well: Leverage telehealth platforms that meet HIPAA guidelines and are compatible with your Electronic Health Record (EHR) system to automate documentation and billing.
Take Billing Software and Services into Account: Take into account using specialized medical billing software or contracting with a billing service that has experience with telehealth to minimize errors and maximize payments.
Speak with Patients: Tell patients billing rules and possible charges for telehealth visits clearly in advance. By understanding the specific billing rules and coding for telehealth services, primary care practices can successfully integrate virtual care into their practice and receive payment accurately and in a timely fashion. Keeping up to date with the changing rules of telehealth and payer policies is highly essential to controlling this changing part of healthcare.