Please note that developments related to the COVID-19 pandemic and associated legislative guidelines and payer policies are changing rapidly. Some of the information in this article may have changed since we last updated it on May 29, 2020. While we are doing our best to keep all of our content current, we recommend referencing the original source (e.g., government or payer guidance) whenever possible.

In these tumultuous times, prioritizing the safety of our fellow healthcare workers and patients is of the utmost importance. For that reason, many providers are shaking up their business model and reallocating resources to telehealth—especially now that CMS is reimbursing PTs and OTs for certain teletherapy and remote care services. That said, for those PTs and OTs who decide to bill telehealth in the near future, there are a few crucial facts and processes to understand.

The primary purpose of this informational discussion is to explain how PTs and OTs can bill for telehealth services—not to provide recommendations on technology platforms and services used to deliver telehealth.

Please note that this article covers general teletherapy principles—and that telehealth and remote care coverage and billing requirements vary widely from payer to payer (especially during the current crisis). Refer to the “Coverage” section of this article for more information, including a summary of CMS’s temporary telehealth coverage policy.

Telehealth Terminology and Basic Requirements

In order to successfully navigate the rules and regulations that apply to telehealth and other virtual care services, PTs and OTs must ensure that they’re using the correct terminology.

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Types of Virtual Care Services

“Virtual services” (a.k.a. remote services) is a large umbrella term that can refer to any type of service provided to patients from a different location than where the patient is located. The virtual services umbrella encompasses telehealth—which is a specific type of virtual care service—in addition to other types of long-distance care.

Because of the COVID-19 public health emergency, many payers are allowing PTs and OTs to provide and bill for an array of virtual services, including:

  • Telehealth visits (i.e., when a provider furnishes care to a patient via a live, synchronous video stream);
  • E-visits (i.e., when a provider communicates with a patient and conducts synchronous or asynchronous assessment and case management services through an online patient portal);
  • Virtual check-ins (i.e., when a provider communicates with a patient and conducts asynchronous or synchronous assessment and management services “via a number of communication technology modalities”); and
  • Telephone visits (i.e., when a provider communicates with a patient and conducts assessment and case management services through a telephone call).

Technology Requirements

Telehealth Visits

Telehealth visits require the use of a two-way, HIPAA-compliant, audio and visual technology platform. The platform can be real-time and synchronous (e.g., a live video call) or asynchronous (e.g., transmission of data—like video files—back and forth over a period of time). Many older telehealth platforms include “store-and-forward” capabilities, but states are phasing out this type of telehealth delivery. Phone calls, texts, unencrypted emails, and faxes do not meet the criteria for qualified telehealth delivery technologies. (Learn more here.)

E-Visits, Virtual Check-ins, and Telephone Visits

To successfully administer an e-visit, a provider must use a secure, HIPAA-compliant patient portal; virtual check-ins can occur via a number of different communication technologies, including a secure messaging platform and/or a live video call; and telephone services must be conducted by telephone.

Legality

State Law

Because each state has its own practice act—and many states have made their own telehealth accommodations for the pandemic—telehealth laws vary widely across the country. It is important that you familiarize yourself with your state laws, regulations, and practice act before you begin incorporating telehealth services into your practice. Start by reviewing your state practice act, and contact your state licensing board to confirm that you can provide telehealth or other virtual care services. If you cannot get in touch with a representative, contact your state APTA, AOTA, or ASHA chapter.

Therapists typically must be licensed in the state in which the patient is receiving services, which makes providing telehealth to out-of-state patients difficult. However, the APTA reports that recent Medicare actions “did include temporarily waiving Medicare and Medicaid requirements that out-of-state providers hold licenses in the state where they are providing services.” However, we strongly advise exercising caution and conferring with a legal expert before providing any services across state lines.

HIPAA Compliance

Providers are usually required to use a HIPAA-compliant telecommunications system to deliver telehealth services. However, the HHS Office for Civil Rights (OCR) has stated it will exercise discretion in enforcing that requirement in the face of the COVID-19 health crisis, opening up the potential use of more consumer-friendly platforms—like Skype and FaceTime—for telehealth delivery. Still, we do not recommend using a non-HIPAA-compliant telecommunications system to deliver telehealth, as it jeopardizes patients’ protected health information (PHI).

Additionally, the HHS OCR is only relaxing these requirements for telehealth services—not the full spectrum of virtual care services. Your e-visit and virtual check-in platforms must remain HIPAA-compliant.

Billing

It’s essential that you understand how to accurately represent your services when billing payers for telehealth or other virtual care services.

Sites

When billing for remote therapy services, you typically must notate two “site” locations:

  1. the originating site, and
  2. the distant site.

The originating site is where the patient is located—often indicated on a CMS-1500 claim form by the patient’s personal address. The distant site is where the practitioner is located, and it is indicated through various place of service (POS) codes.

Place of Service (POS) Designation

There are three POS codes that are typically used when billing remote care services:

  • 02 (telehealth)
  • 11 (office), and
  • 12 (home).

When billing Medicare for telehealth visits, virtual visits, e-visits, or telephone visits, therapists should use the place of service code that indicates where they would normally treat the patient. So, therapists should use POS 11 if they would normally treat patients in their office, and POS 12 if they would normally treat patients at the patient’s home. Do not use the 02 modifier when billing Medicare (or any other payers that are providing telehealth payment parity), as this will activate pre-PHE discounts for telehealth services.

Medicaid and other commercial payers may or may not follow this billing protocol, which is why therapists must reach out to individual payers to determine their billing preferences for telehealth and other virtual care services.

Modifiers

In some cases, you’ll need to use a specific modifier with your service codes to designate them as remote care services. Please note that e-visits, virtual check-ins, and telephone visits are designated as “sometimes therapy” codes, which means they will require the appropriate therapy modifier (i.e., GP, GO, or GN) when delivered by a PT, OT, or SLP.

Modifier 95

Modifier 95 indicates that a service was delivered synchronously in real-time using a HIPAA-compliant platform. While this modifier typically doesn’t apply to PT and OT services (as seen in Appendix P of the CPT® 2020 Professional Edition book), the modifier may be used with certain codes as part of the COVID-19 response period.

Medicare requires that this modifier be applied to all codes for services furnished via telehealth—but not e-visits, virtual check-ins, or telephone services.

Modifier GT

Modifier GT indicates that a service was delivered synchronously in real-time using a HIPAA-compliant platform. This code was replaced by modifier 95 in 2017—but some commercial payers still use GT for covered telehealth services.

While this modifier typically does not apply to any codes from the Physical Medicine and Rehabilitation section of the CPT manual, some non-Medicare payers may require therapists to use this modifier to designate telehealth services during the COVID-19 response period.

Modifier GQ

Modifier GQ indicates that a service was delivered asynchronously using a HIPAA-compliant platform. This is considered an “old” modifier (and an old method of delivering telehealth), and it’s slowly getting phased out.

While this modifier typically does not apply to any codes from the Physical Medicine and Rehabilitation section of the CPT manual, some non-Medicare payers may require therapists to use GQ to designate telehealth services during the COVID-19 response period.

Modifier CR

The CR modifier—which indicates that services are catastrophe/disaster-related—is not mandatory when billing Medicare for true telehealth services, e-visits, virtual check-ins, or telephone services. CMS has also clarified that it “will not deny claims due to the presence of the ‘CR’ modifier or ‘DR’ condition code for services/items related to a COVID-19 waiver…or for services/items that are not related to a COVID-19 waiver.” So, rehab therapists should still receive payment for claims that were submitted with CR appended.

Keep in mind that the CR modifier is still required in a small number of unique situations (e.g., if DMEPOS is “lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency”). It’s crucial for rehab therapists to review this CMS guidance before submitting telehealth claims.

Codes

There are several CPT codes providers can use to bill for non-face-to-face, non-physician services. Take a look at the following guidance (much of it from the CPT manual). These guidelines contain specific details regarding the volume and timing of these services.

Telehealth Visits

Telehealth visits are limited to specific CPT codes within the 97000 series codes. Medicare, for instance, covers these codes: 97161–97164, 97165–97168, 97110, 97112, 97116, 97150, 97530, 97535, 97542, 97750, 97755, 97760, and 97761.

However, Medicaid and other payers may or may not cover these or other codes, so you need to reach out to each payer individually to determine the extent of its coverage.

When billing a telehealth visit, simply furnish the covered service (e.g., gait training), select the appropriate CPT code (e.g., 97116), apply the correct POS code and modifier as per the payer’s specifications, and complete the claim as normal.

E-Visits or Online Digital Evaluation and Management (E/M) Services

According to the CPT manual—which, by the way, we recommend reviewing in addition to this post—qualified non-physician healthcare professional online digital evaluation and management services (hereafter referred to as online digital E/M services or e-visits) are “patient-initiated digital services with qualified nonphysician health care professionals that require qualified nonphysician health care professional patient evaluation and decision making to generate an assessment and subsequent management of the patient.” Non-evaluative test result communication, appointment-scheduling, and other non-E/M communications do not fall under this classification.

These patient-initiated services must occur through a HIPAA-compliant, secure platform that allows for digital communication—and while the patient’s problem might be new, the patient should be established. Keep in mind that you must keep and permanently store visit documentation (either electronically or as a hard copy).

Online digital E/M services are billed once during a seven-day period—which begins upon your initial review of the patient’s inquiry—for all the time accumulated therin. The cumulative time for these services encompasses the time you take to:

  • review the initial inquiry,
  • assess the patient’s problem,
  • interact with other healthcare professionals regarding the patient’s problem,
  • develop management plans (including prescription generation or test ordering), and
  • communicate with the patient through HIPAA-supported digital communication tools.

Here are some other key things to know about e-visits per the waiver release:

Medicare requires PTs and OTs to use the HCPCS G-codes to indicate when they provided an online digital E/M service (a.k.a. an e-visit). Other payers (e.g., workers’ compensation or commercial payers) may ask PTs and OTs to use the HCPCS codes or the equivalent 98-series CPT codes.

Medicare Codes

This APTA release directs providers to the CMS Physician Fee Schedule lookup tool to determine the reimbursement rates for G2061-G2063 and notes that the Medicare coinsurance and deductible apply to these services.

  • G2061: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes.
  • G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes.
  • G2063: Qualified non-physician healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.
Equivalent Non-Medicare Payer Codes

Do not bill code 98969 for an online digital E/M service, as it’s been deleted. Instead, bill one of the following codes:

  • 98970: “Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes”
  • 98971: Same service description for “11–20 minutes”
  • 98972: Same service description for 21 or more minutes”
Qualifying Scenarios

If a patient reaches out within seven days of a prior in-office treatment, E/M service, or procedure—and that outreach relates to the same issue addressed during the prior treatment—then you may not bill this as a separate service. However, if the patient reaches out within seven days of a prior, unrelated in-office service, then you may bill this time as its own individual service. And finally, if another, separate E/M service occurred within seven days of your initial review of the patient’s inquiry, then you cannot bill codes G2061–G2063 or 98970–98972 again during that time period.

If, during the seven-day period encompassing an online digital E/M service, the same patient exhibits a new, unrelated issue, then the E/M time you spend on the new problem will be added to the cumulative service time of the currently active online digital E/M service time period.

Billing Caveats

Note the following caveats when billing these codes:

  • Only bill codes G2061–G2063 and 98970–98972 once every seven-day period.
  • Do not bill digital E/M services that last fewer than five minutes.
  • Do not count time as part of codes G2061–G2063 or 98970–98972 when that time is included (and billed) with other services.
  • Do not bill codes 98970 through 98972 for home and outpatient INR monitoring if you’re also billing 93792 or 93793.
  • Do not bill codes 98970 through 98972 if you’re billing one of the following codes for the same communication: 99091, 99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380, 99487, 99489, 99495, or 99496.
Example Scenario

In this news release detailing CMS’s action, Alice Bell, PT, DPT, APTA senior payment specialist, provides this PT-specific example of a situation these codes might cover: “Let’s say that, as a PT, I’ve been seeing a patient for an orthopedic condition and I am progressing the patient’s exercises,” Bell said. “The patient is unable to come into the clinic but calls me to say she’s having difficulty with one of the exercises and that the other two seem to be too easy. I could arrange an e-visit with the patient and discuss her performance of the exercises. And I could then make a determination—maybe I find that the patient is performing one of the exercises incorrectly—and I could direct the patient on the correct performance. Perhaps I also determine that two of the exercises can be progressed because the patient is improving, so I could instruct the patient in the two new exercises. After that I could advise the patient to contact me for a follow-up e-visit as needed until the patient can return to the clinic.”

Virtual Check-Ins

According to CMS, virtual check-ins are “short patient-initiated communications with a healthcare practitioner” that are intended to allow patients to communicate with their healthcare provider while avoiding unnecessary trips into the clinic.

These patient-initiated services can occur through a number of communication technologies including (but not limited to) “synchronous discussion over a telephone or exchange of information through video or image…The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.”

As with e-visits, the patient’s problem might be new, but the patient must be established prior to the check-in. Additionally, you must permanently store visit documentation (either electronically or as a hard copy).

Codes
  • G2012: “Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.”
  • G2010: “Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.”
Qualifying Scenarios

You may bill these codes if an existing patient wants to communicate with his or her provider, and the communication is not related to a previous medical visit that occurred within the last seven days and does not lead to a visit within 24 hours (or to the soonest available appointment). Additionally, the patient must verbally consent to participate in a virtual check-in.

Telephone Services

According to the CPT manual, Telephone Visits are “non-face-to-face assessment and management services provided by a qualified health care professional to a patient using the telephone.” Special rules apply to the codes that fall under this classification. If, for example, you and a patient determine during a telephone service that he or she needs to schedule an urgent in-person visit with you within the next 24 hours (or during the next open urgent visit slot), then you would not bill the telephone code. Instead, that session’s time would count as “preservice work” for the office visit that followed.

Additionally, if the subject of the call relates to a service that you performed and reported within the past week (or within its post-op period), then the telephone service would become part of the previous service—regardless whether you called the patient, or the patient decided to call you.

Codes
  • 98966: “Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion”
  • 98967: Same service description for “11–20 minutes of medical discussion”
  • 98968: Same service description for “21–30 minutes of medical discussion”
Billing Caveats

Note the following caveats when billing these codes:

  • Do not report CPT codes 98966 through 98968 if you’ve reported these same codes during the previous seven days;
  • Do not report 98966 through 98968 the same month you report codes 99487 through 99489;
  • Do not report 98966 through 98968 if they’re performed at the same service time as transitional care management services (99495 and 99496); and
  • Do not report codes 98966 through 98968 in conjunction with 93792 or 93793.

Coverage

On March 17, 2020, CMS relaxed its remote care services requirements in response to COVID-19. Per those updates, Medicare began reimbursing PTs, OTs, and SLPs for e-visits, virtual check-ins, and telephone visits that occurred on March 6 or later. On April 30, 2020, CMS relaxed its telehealth policies and added PTs, OTs, and SLPs to the list of qualified telehealth providers, retroactive to March 1, 2020. As such, rehab therapists can now bill Medicare for traditional telehealth services.

These updates did not apply to Medicaid or commercial insurances—however, many Medicaid programs and commercial payers have loosened their own remote care coverage policies and now allow PTs, OTs, and SLPs to administer some form of remote care. Reach out to your payers and verify whether or not they cover remote services for rehab therapy—and what those services are. If your payers do not cover virtual care, you will likely need to look to your patients to pay for these services.

Cash-Pay

As with all medically necessary services, third-party payer coverage is only part of the patient’s decision process. Consider dry needling: non-coverage in that case creates an opportunity to discuss the benefits of the service.

If a service is not covered by a payer for which you are a preferred provider, you may collect payment directly from patients at the time of service. However, before you do this:

  1. set a fee schedule for your telehealth services, and
  2. create a transparent billing process for your patients.

Notify these patients (in writing) that telehealth services are not covered by their payer, and clearly establish the projected cost as well as when you expect payment. If you are not a preferred provider, you are not bound by the payer’s noncoverage of your services.

Remember, because Medicare now covers all of the remote care services discussed above, Medicare beneficiaries may not pay for these services out-of-pocket.

Payer Policy Restrictions

Be sure to check payers’ medical policies to ensure they do not classify telehealth therapy services as “not medically necessary” or “effectiveness not established.” If either of these classifications apply, then you cannot balance bill the patient for telehealth services. If you proceed and bill these services to that payer, then it will assign the balance to the practice or individual therapist—not the patient. And remember, if you’re a preferred provider for a commercial plan, your contract likely requires you to bill all services to that payer so it can determine the patient’s liability—meaning you cannot simply collect cash from the patient upfront to bypass submitting a claim to the payer.

Evolving Standards

Until the emergence of the COVID-19 health crisis, there was very limited payer coverage for PT and OT telehealth or remote monitoring. However, the current situation is fluid—and many payers (including Medicare) currently allow telehealth practice in light of COVID-19’s public health implications. Stay informed about the evolving situation (and consume accurate information) by subscribing to updates from:


To help rehab therapists during this time of crisis, WebPT has provided a wealth of information about telehealth and business continuity. If you would like to learn more about these topics, I urge you to review our resources in addition to those provided by CMS, the APTA, the AOTA, and your payers.