Clarification of Coding for Medicare Advantage

Written by Ted Kyi

May 26, 2020

There have been a lot of questions about appropriate coding for telehealth visits.  (Full disclosure, as new information was coming out, I have offered different coding recommendations, so I may have contributed to the confusion.)  Let’s recap some of the discussion about coding telehealth visits for Medicare:

First, the March 17 FAQ about the section 1135 waiver mentioned the use of POS code “02” for all telehealth encounters.

Q: How does a qualified provider bill for telehealth services?

A: Medicare telehealth services are generally billed as if the service had been furnished in-person. For Medicare telehealth services, the claim should reflect the designated Place of Service (POS) code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site.

Then, the April 10 memo on applicability of diagnoses from telehealth services for risk adjustment offered CPT modifier “95” as a second option:

“In order to report services to the EDS that have been provided via telehealth, use place of service code “02” for telehealth or use the CPT telehealth modifier “95” with any place of service.”

This seems to offer flexibility between using the POS code or using the CPT modifier to designate a telehealth encounter.

The latest Medicare guidance that I’ve read differentiates telehealth allowed before the pandemic from services under the waiver:

“To implement this change on an interim basis, we are instructing physicians and practitioners who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person. This will allow our systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. Given the potential importance of using telehealth services as means of minimizing exposure risks for patients, practitioners, and the community at large, we believe this interim change will maintain overall relativity under the PFS for similar services and eliminate potential financial deterrents to the clinically appropriate use of telehealth. Because we currently use the POS code on the claim to identify Medicare telehealth services, we are finalizing on an interim basis the use of the CPT telehealth modifier, modifier 95, which should be applied to claim lines that describe services furnished via telehealth. We note that we are maintaining the facility payment rate for services billed using the general telehealth POS code 02, should practitioners choose, for whatever reason, to maintain their current billing practices for Medicare telehealth during the PHE for the COVID-19 pandemic.”

(Note that CMS is referring to the Public Health Emergency as “PHE” and abbreviating the Medicare Physician Fee Schedule as “PFS.”) Based on this information, I recommend that only the telehealth services that were allowed prior to the pandemic and the section 1135 waiver should use POS “02.”  Those services always used POS “02,” and they should continue to be coded exactly the same way they used to be coded.

For Medicare services which would have taken place in person, but are now using telehealth under the section 1135 waiver, I recommend the claims use the same CPT and POS codes they would have used if they had taken place in person, with the only change being the addition of the CPT modifier “95.” I haven’t seen anything saying that POS “02” won’t be accepted on EDS submissions, so plans not coding this way do not have to change. It seems that for anyone reviewing or newly implementing coding, the CPT modifier is the safer route.

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Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.