Procedure code 99441, 99442, 99443 , 98966 - telephone consult

Procedure code 77427: Radiation treatment management, 5 treatments

Procedure code 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

Procedure code 98967: 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; 11-20 minutes of medical discussion

Procedure code 98968: 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; 21-30 minutes of medical discussion

Procedure code 99441: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian 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

Procedure code 99442: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian 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; 11-20 minutes of medical discussion

Procedure code 99443: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian 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; 21-30 minutes of medical discussion

Telephone Calls 

Telephone calls are payable to the attending provider, consultant, psychologist or other provider only when they personally participate in the call. These services are payable when discussing or coordinating care or treatment with:

• The worker
• L&I staff
• Vocational rehabilitation counselors
• Nurse case managers
• Health services coordinators (COHE)
• L&I medical consultants
• Other physicians
• Other providers
• TPAs
• Employers


The insurer will pay for telephone calls if the provider leaves a detailed message for the recipient and meets all of the documentation requirements

Duration procedure code (Physicians) procedure code (Nonphysicians)

1-10 minutes 99441 98966
11-20 minutes 99442 98967
21-30 minutes 99443 98968


Documentation Requirements 

Documentation for case management services (team conferences and telephone calls) must include:
• The date, and
• The participants and their titles, and
• The length of the call or visit, and
• The nature of the call or visit, and
• All medical, vocational or return to work decisions made.

Psychiatrists and clinical psychologists may only bill for these services when also providing consultation or evaluation.

Team conference documentation must also include a goal-oriented, time-limited treatment plan covering:
• Medical,
• Surgical,
• Vocational or return to work activities, or
• Objective measures of function

Coding Question: If a radiation oncologist provides E/M services to his/her patients via telephone, can they bill 99441, 99442 and 99443? Also, can a Medicare Provider bill these Procedure codes and, if so, where can the pricing be found on the Medicare Fee Schedule? Can this kind of phone service be billed under any other E/M billing code that is on the Medicare Fee Schedule?

Coding Response:
  Procedure codes 99441 - 99443 describe telephone evaluation and management services provided by a physician to an established patient. The patient or patient’s parent/guardian must initiate the contact as these codes may not be used for calls initiated by a provider. The codes are differentiated according to the length of the medical discussion with the patient. These codes are used only for services personally performed by a physician. Procedure codes 98966-98968 describe telephone services performed by qualified non-physician health care professionals. Medicare has designated all telephone evaluation management codes with a status indicator “N” which indicates the service is not covered by Medicare.  It should be noted that relative value units (RVUs) are listed for these codes in the Medicare Physician Fee Schedule. Therefore, while Medicare does not cover these services, some private payers could potentially cover these services and use the RVUs assigned by Medicare to set payment rates. ASTRO recommends you review the current policies of your major payers to determine their coverage policies regarding telephone evaluation management services. Phone calls during treatment are included in the work captured in Procedure code 77427 which includes a 90-day global period after treatment is completed.


OVERVIEW

This policy describes reimbursement for Telemedicine and Telehealth services, which are services where the physician or other healthcare professional and the patient are not at the same site. Examples of such services are those that are delivered over the phone, via the Internet or using other communication devices. This policy does not address care plan oversight services (see the Care Plan Oversight).


REIMBURSEMENT GUIDELINES

Telehealth Services

The Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes that describe a Telehealth service (a physician-patient encounter from one site to another) are generally the same codes that describe an encounter when the physician and patient are at the same site.

The modifiers below describe the technology used to facilitate a Telehealth encounter. One of these modifiers should be reported when performing a service via Telehealth to indicate the type of technology used and to differentiate a Telehealth encounter from an encounter when the physician and patient are at the same site. For more information, see the Definitions section below.

Modifier Description

GQ Via Asynchronous Telecommunications systems

GT Via Interactive Audio and Video Telecommunications systems

The Centers for Medicare and Medicaid Services (CMS) have authorized specific Originating Sites as “eligible” for furnishing a Telehealth service. When reporting modifier GT, the physician, hospital, ambulatory surgical center, or qualified healthcare professional is certifying that they are rendering services to a patient located in an eligible Originating Site via an Interactive Audio and Visual Telecommunications system.

In accordance with CMS the eligible Originating Sites are listed below:

* The office of a physician or practitioner;

* A hospital (inpatient or outpatient);

* A critical access hospital (CAH);

* A rural health clinic (RHC);

* A federally qualified health center (FQHC);

* A hospital-based or critical access hospital-based renal dialysis center (including satellites);

* A skilled nursing facility (SNF); and

* A community mental health center (CMHC)

CMS has also authorized which practitioners may be reimbursed for Telehealth services. In accordance with CMS these practitioners are listed below:

* Physician

* Nurse practitioner

* Physician assistant

* Nurse-midwife

* Clinical nurse specialist

* Clinical psychologist

* Clinical social worker

* Certified Registered Nurse Anesthetists

* Registered dietitian or nutrition professional

Note: Clinical psychologists (CP) and clinical social workers (CSW) cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.

The use of modifier GT indicates a Telehealth service was performed by an eligible practitioner via an Interactive Audio-Visual Telecommunications system and the patient was present at an eligible Originating Site. Oxford will reimburse for Telehealth services which are recognized by CMS when reported with modifier GT (Interactive Telecommunications). In addition, Oxford recognizes that medical genetics and genetic counseling services (CPT code 96040), education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum (CPT codes 98960-98962), and alcohol and/or substance abuse screening and brief intervention services (CPT codes 99408-99409) can be effectively performed via Interactive Audio and Video Telecommunications systems; these codes will be allowed for reimbursement when reported with modifier GT. Oxford will also reimburse CPT codes 0188T and 0189T when these codes are reported with or without a modifier GT, since the description for these codes indicates a Telehealth service and the technology used. Any other service reported with a modifier GT that is not recognized by CMS will not be reimbursed. For a complete list of codes that Oxford recognizes when reported with modifier GT refer to Codes Recognized with Modifier GT.



HCPCS Code Description

Non-Reimbursable HCPCS Code (regardless of appended modifier)


T1014 Telehealth transmission, per minute, professional services bill separately


QUESTIONS AND ANSWERS

1 Q: How does Oxford reimburse for phone calls to patients that are not associated with any other service ?

For example, a pediatrician receives a call from a mother at 2 A.M. regarding an asthmatic child having difficulty breathing. The physician is able to handle the situation over the phone without requiring the child to be seen in an emergency room. On what basis will the visit be denied*

A: Oxford will not reimburse for this service (99441-99443 or 98966-98968) since it did not require direct, in-person patient contact. This service is considered included in the overall management of the patient.


2 Q: A physician makes daily telephone calls to an unstable diabetic patient to check on the status of his condition. These services are in lieu of clinic visits. Will Oxford reimburse the physician for these telephone services ?

A: No, Oxford will not reimburse telephone services (99441-99443 or 98966-98968) since they do not involve direct, in-person patient contact. These services are considered included in the overall management of the patient.


3 Q: Does Oxford reimburse website charges for physician groups if their website provides patient education material ?

A: No, Oxford will not reimburse for Internet charges since there is no direct, in-person patient contact.


4 Q: What is the difference between Telehealth services and telephone calls ?

A: Telehealth services are live Interactive Audio and Visual Transmissions of a physician-patient encounter from one site to another, using telecommunications technologies. Telephone calls are non-face to face medical discussions, between a physician or other healthcare professional and a patient, that do not require direct, in person contact.

5 Q: If a provider renders the professional component for a diagnostic service, at a distant site from the patient, should modifier GT be reported ?

A: No. Modifier GT indicates a face-to-face encounter utilizing interactive audio-visual communication technology. Therefore, it is not appropriate to report modifier GT in this scenario since this does not represent a face-to-face encounter. However, use of modifier 26 would be appropriate to designate that the professional component of the diagnostic service was provided.

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