Introduction to Telemedicine Terminology and Coding with Cheat Sheet

More eyecare providers than ever are embracing telemedicine to deliver high-quality care with enhanced accessibility and patient satisfaction while maximizing efficiency.

Digital engagement with patients through telemedicine is rapidly evolving, and the healthcare landscape is shifting to adopt a broader use of this technology for patient care.

Brief introduction to telemedicine in eyecare

The terms telemedicine and telehealth are frequently used interchangeably, yet they hold distinct meanings. Telehealth encompasses a wider scope of digital technology utilization to enhance healthcare, while telemedicine specifically refers to utilizing this technology to deliver healthcare services, falling within the realm of telehealth.

According to the American Academy of Ophthalmology (AAO), telemedicine is described as the remote diagnosis and treatment of patients by means of telecommunications technology.¹ This encompasses the virtual provision of care, allowing practitioners to provide non-emergency services to patients without an in-person visit.²

The American Optometric Association (AOA) suggests that telemedicine may have potential applications in the following areas:³

Triage
Data acquisition
Patient communication
Non-emergency follow-up appointments
- Confirmation of expected therapeutic results
- Confirmation of stability or homeostasis
Chronic disease monitoring
Straight-forward medical decision-making clinical cases
Some cases of initial diagnosis

Download the Telemedicine Coding & Billing Cheat Sheet here

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Telemedicine Coding & Billing Cheat Sheet

Use this cheat sheet with a list of relevant telemedicine CPT codes to optimize billing and coding for virtual services.

Glossary of key telehealth terms^4,5

Augmented intelligence: Artificial intelligence that was developed to play an assistive role, emphasizing that its design enhances human intelligence rather than replacing it.
Asynchronous (“store and forward”): Telemedicine services where the patient-provider encounter occurs with a time delay. Clinical data is collected at the originating site of service and transmitted to the doctor for review. Once reviewed, the doctor provides a consultative report to the patient or referring clinician at a later point in time.
Coverage parity: A policy that requires telehealth services to be covered the same as it would be in person.
Communication technology-based service (CTBS): A set of Centers for Medicare and Medicaid Services (CMS) billable codes that are required by IL, NC, OH, SC, and UT to bill for store and forward telemedicine claims.
Federally qualified health centers (FQHCs): Health centers that qualify for funding under Section 330 of the Public Health Service Act and enhanced reimbursement from Medicare and Medicaid to serve an underserved area or population with a sliding fee scale.⁶
Originating site: The location of the patient who is receiving telemedicine services.
Payment parity: A policy that requires telehealth services to be reimbursed at the same payment rate as an in-person service.
Remote patient monitoring (RPM): Personal health and medical patient data collected in one location and transmitted to a provider in a different location for continued care and related support. This is used when the patient-doctor relationship has already been established previously.
RPM device: The device that gathers patient data. In eyecare, examples could include home-based tonometry, perimetry, and photography.⁷
Remote site: The location of the physician who is providing telemedicine services.
Rural health clinics (RHCs): A Medicare-approved clinic in a non-urbanized area (as designated by the US Census Bureau) that serves health professional shortage areas (HPSAs) or medically underserved areas (MUAs), designated or certified by the Secretary of the Department of Health and Human Services.
Safety net provider (SNP): Those providers that organize and deliver a significant level of healthcare and other needed services to uninsured, Medicaid, and other vulnerable patients, as defined by the Institute of Medicine (IOM).
Synchronous: Telemedicine services where the patient-provider encounter occurs primarily through videoconferencing, where participants are separated by distance but interact in real-time.

Telemedicine credentialing, policies, and coverage

Medicare

Providers currently eligible to bill Medicare for professional services will be reimbursed for telemedicine services as well. Many of the flexibilities related to telemedicine enacted by the post-pandemic emergency waiver have been extended through December 31, 2024.

These telemedicine rules include:^8,9

Location: No geographic restrictions for patients or providers
Eligible Services: CMS has expanded the list of services eligible for telehealth. The most common eligible primary care optometric services are:
- 92002-92005 Evaluation/management for new patient–office or other outpatient visit (determined by physician time or medical decision making [MDM])
- 99211-99215: Evaluation/management for established patient–office or other outpatient visit.(determined by physician time or medical decision making [MDM])
- 99421-99423: Online digital evaluation and management service, for an established patient for up to 7 days (determined by cumulative physician time within 7 days)
- 99441-99443: Telephone evaluation and management services (determined by physician time)
- G0406-G0408: Follow-up inpatient telehealth consultation (Medicare)
- G0425-G0427: Emergency or initial inpatient telehealth consultation services via telehealth. (Medicare)
Modality: Audio-only coverage for approved services

Providers must be licensed in the state where they are located as well as in the state where the patient is located,⁹ and verbal or written patient consent is required in most states.

Asynchronous (store and forward)

Asynchronous healthcare allows providers and patients to share information directly with each other before or after telehealth appointments. Federal law limits Medicare asynchronous telehealth coverage to certain projects located in Alaska or Hawaii.⁸

Fee-for-service

Medicare’s List of Telehealth Services (2024) is an up-to-date list of the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that are telehealth eligible. Additionally, there is a temporary waiver of the audio-video requirement for some telehealth services, which is also noted in the list.⁸

Claims should include a place of service (POS) code to indicate the provider and patient location during the telehealth encounter. These affect reimbursement.

There are currently two POS codes used for telehealth:

POS 02: Patient is not located in their home when receiving health/health-related services through telecommunication technology.
POS 10: Patient is located in their home when receiving health/health-related services through telecommunication technology.

Safety net

RHCs and FQHCs can bill Medicare for telehealth services as distant site providers, and patients can receive telehealth services in their homes. Virtual communication services are covered, including online digital evaluation and management (i.e., digital communications that are patient-initiated using a secure patient portal), but are reimbursed at a different rate since they are not defined as telehealth services by CMS.^8,9

Remote patient monitoring/Remote physiologic monitoring (RPM)

Medicare covers RPM for established patients with consent. Practitioners eligible to bill for E/M services may bill for RPM services

Private insurance companies

Most insurance companies offer coverage for some telehealth services. It is recommended to reach out to your affiliated insurance plans about licensure requirements and telehealth service reimbursement to ensure eligibility and understand their specific policies.^8.9

Patients should also confirm coverage prior to their appointment, as telehealth coverage and regulations differ state-by-state.

Check out the Telemedicine Coding & Billing Cheat Sheet for a comprehensive list of relevant codes!

Telehealth coverage trends in the United States

Figure 1: Illustration of reimbursement policies for live video services, audio-only services, store-and-forward services, remote monitoring, and transmission/facility fees in the United States.

^{Figure 1: Data adapted from the Center for Connected Health Policy.}

Live video: 50 states and DC reimburse live-video services.
- VI and PR do not.
Audio only: 43 states and DC cover audio-only services.
- DE, FL, MS, NJ, RI, VI, WY, WV, and PR do not.
Store and forward: 33 states reimburse store-and-forward services.
- IL, NC, OH, SC, and UT require CTBS billing.
- AL, AR, CO, CT, DC, DE, ID, IN, KS, LA, MS, NE, NH, NJ, OK, PA, PR, TN, VI, and WY do not.
Remote monitoring: 37 states reimburse remote monitoring services.
- CA, HI, MA, and WV require CTBS billing
- CT, DE, GA, MT, NH, NJ, NM, NV, PA, PR, RI, SD, TN, VI, and WY do not.
Transmission fees: 35 states reimburse transmission and facility fees.
- AK, AZ, CT, DC, FL, ID, LA, MA, MD, MN, NH, NJ, OH, OK, PR, RI, UT, VI, do not.

Telehealth regulation trends

Figure 2: Illustration of which states have private payer laws, originating site restrictions, and consent requirements.

^{Figure 2: Data adapted from the Center for Connected Health Policy.}

Private payer laws: 43 states, DC, and VI have private payer laws.
- AL, ID, NC, PA, PR, SC, WI, and WY do not.
- AZ, CA, CO, CT, DE, GA, HI, IA, IL, KY, LA, MA, MD, NM, NV, NY, OK, RI, UT, VT, WA, WI, and WV have payment parity for some specialties.
Originating site restrictions: 17 states and DC restrict originating sites
- AK, AR, AZ, CA, CO, CT, FL, GA, ID, IL, IN, KS, KY, LA, MA, ME, MO, MT, NE, NH, NJ, NC, ND, OH, OK, OR, PA, PR, RI, SD, TX, UT, VT, VI, and VA do not.
Consent requirements: 45 states, DC, and PR have consent requirements
- FL, IL, SC, SD, and VI do not.

Use the CCHP Policy Finder to stay up-to-date on policies in your state.

5 common telemedicine coding/billing mistakes

1. Miscoding

Incorrect coding can lead to delayed reimbursement. Ensure a thorough understanding of which services each code represents and input them accurately. Stay updated on the latest Medicare billing codes for telehealth to maintain smooth practice operations.

2. Not understanding payers

Familiarize yourself with various insurance plans and other payers in order to ensure claims adhere to their specific requirements. Always confirm insurance coverage for specific telehealth services with patients before the appointment.

3. Undercoding/Upcoding

Code services accurately based on provided services, supported by thorough documentation. Be vigilant in staying informed about policies like bundled services, etc.

4. Improper modifier

Modifiers indicate the nature and location of services rendered and influence reimbursement. Understand modifiers and their appropriate usage. For instance, modifier 95 applies to synchronous telecommunication with audio and video, not asynchronous services or in-person visits.

5. Out-of-network billing

Out-of-network billing often results in a higher cost to patients and lacks pricing transparency. Verify coverage and obtain pre-authorization if required by the insurance plan.

5 tips for telemedicine coding/billing success

1. Do your research

Understand eligibility criteria and reimbursement requirements outlined in the current guidelines from your affiliated insurance companies and government programs, as they may vary.

2. Start slow

Implement a small set of easily executable telehealth services and straightforward codes to help gain proficiency and navigate potential challenges. Expand telehealth services gradually as both your team and patients become more accustomed to the process.

3. Provide staff training

Provide comprehensive staff training to ensure familiarity with telehealth coding and billing policies, promoting accuracy and adherence to regulations.

4. Document thoroughly

Telemedicine visit documentation should mirror the level of detail required for in-person examinations, covering chief complaint(s), patient history and discussions, relevant findings, diagnoses, treatments, and patient instructions.

5. Stay up-to-date

Stay informed about the evolving regulations and guidelines—as the landscape shifts rapidly—to uphold accuracy and compliance, thereby maximizing reimbursement.

Helpful resources for telemedicine coding and billing

In conclusion

As telemedicine continues to reshape the eyecare delivery landscape, it's imperative for providers to understand the complexities of billing and coding to ensure successful implementation and reimbursement.

With the right knowledge and resources, eyecare professionals can embrace telemedicine confidently, enriching patient care experiences while adapting to the evolving healthcare terrain.

Don't forget to download the Telemedicine Coding & Coding Cheat Sheet before you go!

This article was updated on September 23, 2024 to reflect the latest telemedicine codes.