Navigating the Challenges of Medical Billing Codes in Telehealth

The rapid adoption of telehealth during the pandemic has presented new medical billing and coding challenges. With complex and evolving rules around telehealth claims, practices offering remote care services must navigate with caution. According to the good folk over at Find-A-Code.com, accurately assigning medical billing codes and modifiers, meeting requirements, and managing insurance policies around telehealth continues to challenge medical billers. 

Understand Code Set Differentiation

A solid grasp of the codes intended specifically for reporting telehealth is critical. Services like virtual check-ins, e-visits, remote evaluation of pre-recorded data, and telehealth consultation have unique codes that distinguish them from standard office visits. Billers must recognize when a telehealth-specific code is available for the rendered service versus when to use a typical evaluation and management (E/M) code with telehealth modifiers. Mixing up these codes leads to incorrect representation of the service and risks under/overpayment. 

Use Modifiers to Identify Telehealth

For many services, standard CPT E/M codes remain the primary codes even when delivered via telehealth. Nonetheless, to communicate the telehealth delivery and relevant reductions in facility resources, modifiers like 95 or GQ must be appended to denote services that weren’t performed in person. Missing these modifiers could prompt an assumption that the service occurred face-to-face, affecting reimbursement rates. Ensure whoever is assigning diagnosis codes also attaches proper corresponding telehealth modifiers. 

Vet Each Payer’s Telehealth Policies

Billing codes correctly is only half the battle, as every payer has its own telehealth coverage qualifications and restrictions that billers must account for. Medicare telehealth expansion during COVID enabled broader access to codes, but commercial insurers vary widely in reimbursement rules. Most require an established patient-provider relationship and restrict originating sites. When taking on new telehealth patients, immediately vet their insurance to confirm the practice and services qualify. 

Maintain Thorough Medical Documentation

As with all medical billing, comprehensive documentation upholding medical necessity is vital for telehealth claims. Notes should capture relevant history to support assessment/plan of care while also providing a clear picture of the virtual visit specifics. Where policy dependent, accurately showing adherence to patient consent, education, identity verification, and transmission security protocols is critical, if records face scrutiny. Solid documentation helps justify codes assigned and fees for remote services rendered. 

Invest in Technology Infrastructure

Technological infrastructure enabling smooth telehealth visits lays the critical groundwork for accurate billing. Internet connectivity issues, inadequate audio/video, electronic health record (EHR) system lags, or hybrid visit barriers all threaten to reduce telehealth service levels from intended standards of care. Small investments in faster broadband connections, updated devices/peripherals, telehealth software applications integrated with practice EHR systems, and staff training pays dividends for optimal care delivery and thus full billing capture. 

Design Straightforward Consent Forms

Practices must obtain and save affirmative written consent to deliver and charge for virtual visits. Develop telehealth consent forms outlining the care limitations, patient responsibilities, technology specifics, potential risks, emergency protocols, privacy measures, and billing implications associated with remote care. 

Monitor Telehealth Utilization Analytics

Telehealth department profitability and cost efficiencies rely on accurate capture of utilization levels, no show rates, reimbursement success, visit acuity distribution, and other such analytics. Practices venturing into virtual care delivery modes must invest in solutions tracking telehealth-specific visit metrics versus standard face-to-face appointment data. 

Conclusion

As telehealth billing and coding continues to evolve, practices must refine their protocols surrounding telehealth claims submission, payer policy management, technical infrastructure, consent capture, documentation practices, and relevant analytics monitoring. Keeping current with the latest guidance around appropriate codes, modifiers, restrictions, and requirements supports telehealth billing success. Proactively clarifying gray areas and addressing problems through informed analytics reduces delays and revenue leakage. While telehealth coding intricacies pose challenges, concerted organizational focus on billing optimization and adaptation allows for smooth navigation.