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Psychiatry Coding & Reimbursement Alert

CPT® Coding:

Get Set to Incorporate New POS Code for Telehealth Services in 2017

Hint: Note that new changes are only applicable to distant sites.

When your clinician provides covered psychiatric services to a patient in another location using interactive telecommunication systems, you will need to know the codes and modifiers that you must report in order to receive payment for these telehealth services. In addition, you will also need to be informed of a new place of service (POS) code that is coming into effect for telehealth services beginning Jan. 1, 2017.

Background: The Centers for Medicare & Medicaid Services (CMS) will provide Medicare coverage for telehealth services when your clinician performs a telehealth service for patients who are in a rural Health Professional Shortage Area (HPSA) or a county outside of a Metropolitan Statistical Area (MSA). You will receive coverage for a telehealth service only when your clinician is face-to-face with the patient through interactive communication systems. So, both your clinician and the patient should be able to communicate using audio as well as video telecommunications.

“For Medicare telehealth purposes, ‘interactive’ means ‘real-time,’”says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “Asynchronous ‘store and forward’ technology doesn’t count except for federal telemedicine demonstrationsin Alaska or Hawaii,” Moore adds.

Reminder: The use of only audio telecommunication systems will not qualify for telehealth service. Your clinician should be able to see the patient through video facilities, too.

Add New POS Code for Distant Site

When your clinician performs a telehealth service, the patient who is receiving the service should be located in an eligible facility to enable him/ her to receive coverage for this service. So, when you’re billing for your clinician’s services provided through telehealth, the location where the patient is will also bill a facility fee. “The originating site is the location of the patient while the distant site is where the physician is located,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa.

So, the location from which your clinician is performing the service is the distant site while the location where the patient is receiving the service is the originating site. For telehealth services, the originating site should be an eligible facility that is located in a rural HPSA or a county outside of a MSA.

Note that the patient will receive coverage only when the originating site is an eligible facility. The list of eligible originating sites includes:

  • Physician’s or other practitioner’s office
  • Hospitals
  • Critical access hospitals (CAHs)
  • Rural health clinics
  • Federally qualified health centers (FQHCs)
  • Skilled nursing facilities (SNFs)
  • Community mental health centers (CMHCs).

CMS released transmittal #R3586CP on August 12, 2016, through which it has announced change request #CR 9726. According to CR 9726, CMS has created a new place of service code for services provided through telehealth. CMS mentions that this new POS code will be effective from Jan.1, 2017, and any claims for telehealth service (on or after Jan.1, 2017) that do not carry this new POS code will be denied.

“Under the Health Insurance Portability and Accountability Act, non-medical code sets, such as POS, are paid based on what code set was in effect on the date of the transaction, not the date of service,” Moore notes. “So even if the date of service was in 2016, if you initiate the claim on or after Jan. 1, 2017, you should use the new POS code.”

According to the transmittal, you will need to assign the new POS code if you are making claims for the services provided by your clinician through telehealth. If you are the originating site, you will continue to claim for your services in the same manner as before without any changes. The new POS code will not be applicable to the originating site.

If your clinician is providing telehealth services to a patient, you will need to assign the newly created POS code 02 (Telehealth). CMS mentions the descriptor to this newly created POS code as “The location where health services and health related services are provided or received, through telecommunication technology.”

Continue Reporting Telehealth Service with Appropriate Modifiers

When your clinician performs a service through telehealth, you report the appropriate CPT® code for the service. In order to identify that your clinician has provided the service through telehealth, you should report the CPT® code with specific modifiers.

“Modifier GT (Via interactive audio and video telecommunications systems) would need to be appended to the service code selected,” Hauptman says. When you are claiming for your clinician’s service provided as a telehealth service, you will report the appropriate CPT® code along with the modifier GT appended to the code.

You also have the modifier GQ (Via asynchronous telecommunication system) that can be appended if your clinician is performing the service using ‘asynchronous store and forward’ technology.

The CMS transmittal mentions that you will need to continue using modifier GT or modifier GQ along with the CPT® code that you are reporting for the particular service that your clinician is performing. The transmittal mentions that any claims for telehealth services that include the modifier GT or GQ with the CPT® code but does not carry the new POS code will be denied. The transmittal also mentions that any claims after the effective date that carry the new POS code but do not include the modifier GT or GQ will also be denied.

Understand How to Report Originating Site Claims

If you are reporting a facility fee as an originating site for the service provided through telehealth, you will continue to report your claims as before with no changes. As the originating site, your facility will receive the lesser of 80 percent of the actual charge or 80 percent of the originating site fee except in CAHs, according to section 190.5 of chapter 12 of the Medicare Claims Processing Manual. For CAH’s, the payment amount is simply 80 percent of the originating site facility fee.

When billing the facility fee for the originating site, you will not have to report the particular CPT® code that the distant site will be reporting for the service provided through telehealth. Instead, you will only bill one code for claiming the facility fee for the originating site for any service that was provided through telehealth. “There is only one code for the originating site and it is Q3014 (Telehealth originating site facility fee),” Hauptman says.

So, for billing the facility fee as an originating site, you will report Q3014 irrespective of what service was provided by the physician in the distant site. Deductible and coinsurance rules will apply to Q3014.

Example: Your psychiatrist performs an initial psychiatric evaluation of a patient who is suffering from symptoms of depressed mood. The patient is receiving the services from the outpatient department of a hospital located in a rural HPSA. Both your clinician and the patient communicated with each other using interactive video and audio telecommunication systems.

You report 90792 (Psychiatric diagnostic evaluation with medical services) for the evaluation performed by your clinician. To let the payer know that the service is a telehealth service, you report 90792 with the modifier GT appended to 90792. The outpatient department of the hospital will bill the facility fee for their part of the service using Q3014.

Resources: For more information on the new POS code for telehealth services, check the MLN matters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9726.pdf.

For more information on Medicare telehealth services and reimbursement check the guidance manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf and the MLN matters article at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf.