modifier for video visit

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Video Visits Billing, Coding and Regulations Information

Many patients have utilized telemedicine for medical care during the COVID pandemic and will continue to seek this option going forward. These resources will help refine and improve your delivery of virtual care, and practical implementation tips are offered below.

E/M and Other Medicare Allowed Services

This is a list of eligible CPT/HCPCS codes .

• Use POS code 10 for telehealth services provided in the patient's home - The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology. (This code is effective January 1, 2022, and available to Medicare April 1, 2022.)
• Use POS 02 for telehealth services provided other than in patient's home - The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.  (Description change effective January 1, 2022, and applicable for Medicare April 1, 2022.)
• Modifier -95 should not be used with virtual check-ins (G2012) or the digital evaluations (99421-99423). It is for use with all other telehealth codes that use synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.
• During the current PHE, telehealth E/M levels can be based on Medical Decision Making (MDM) OR time (total time associated with the E/M on the day of the encounter). Likewise, CMS has also removed any requirements regarding documentation of history and/or physical exam in the medical record for Telehealth visits.
• -GQ: Clinicians participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system.”
• -GO: Use of telehealth for purposes of diagnosing stroke.
• Note:  Medicare stopped the use of modifier -GT in 2017 when the place of service code 02 (telehealth) was introduced.  However, private payer may still be using the modifier -GT.

Virtual Check-In

This is a set of telehealth-specific codes for the following use-cases:

• Any chronic patient who needs to be assessed as to whether an office visit is needed. 
• Patients being treated for opioid and other substance-use disorders.
• Can be any real-time audio (telephone), or "2-way audio interactions that are enhanced with video or other kinds of data transmission."
• Nurse or other staff member cannot provide this service. It must be a clinician who can bill E&M services.
• If an E&M service is provided within the defined time frames, then the virtual check-in is bundled in that E&M service. It would be considered pre- or post-visit time of the associated E&M service and thus not separately billable.
• Should be initiated by the patient since a copay is required. Verbal consent to bill and documentation is required.
• No modifier needed as these are technology based codes.

Online Digital Evaluation and Management (E/M)

Telehealth-specific codes for the following use-cases:

• Given the temporary approval of E/M visits via telehealth, these online codes would primarily be used for patient interactions via a portal.
• Can be done synchronously and asynchronously and audio/video phone can be used (but not a traditional telephone).
• The patient can initiate a virtual check-in, the practice can let the patient know about their options. If the patient calls back within 7 days, then the time from the virtual check-in can be added to the digital E/M code and only the digital E/M code is billed.
• If the patient initiates a call to the physician office this would qualify for the remote check-in code (G2012), the time for the remote (virtual) check-in can be counted toward 99421-3 only if and when the patient calls back, so it is important to document the time. (See CPT book for further details regarding when the 7 days begins, how to count time, which “qualified non-physician health professionals” it applies to, and other documentation requirements.)
• Must be patient initiated.
• Cost sharing applies.
• Use only once per 7-day period. If the patient presents a new, unrelated problem during the 7-day period of an online digital E/M service, then the time is added to the cumulative service time for that 7-day period.
• Clinical staff time is not calculated as part of cumulative time.
• Service time must be more than 5 minutes.
• Do not count time otherwise reported with other services.
• Do not report on a day when the physician or other qualified health care professional reports other E/M services.
• Do not report when billing remote monitoring, CCM, TCM, care plan oversight, and codes for supervision of patient in home, domiciliary or rest home etc. for the same communication[s]).
• Do not report for home and outpatient INR monitoring when reporting 93792, 93793.

Private Payer and State Policies

Many states have issued their own public health emergencies, and some have ended theirs, which results in changes to Medicaid, private payer, and licensure for telehealth.  

• The Center for Connected Health Policy (CCHP) is an excellent resource to keep up with state regulations and has two toolkits that track COVID-19 Telehealth Coverage Policies and COVID-19 Related State Actions , which include Medicaid clarification, waivers, and telehealth guidance, prescription and consent waivers, private payer requirements, and cross-state licensing.
• The Alliance for Connected Care also has a chart showing state changes to licensure, coverage, and other changes during COVID-19.
• Full listing of all blanket waivers and flexibilities related to provider enrollment, telehealth, 1135 waivers, and other changes resulting from the COVID-19 public health emergency.

Other Resources

Many Medicare restrictions related to virtual visits have been lifted during the COVID public health emergency. ACP will update this information when the federal PHE ends.  Some states have already ended their PHE.

Medicare policies during the emergency:

• Patients can be at home and non-HIPAA compliant communication technology is allowed.
• Practices are allowed to waive cost sharing (copays and deductibles) for all telehealth services All E/M and other services that are currently eligible under the Medicare telehealth reimbursement policies are included in this waiver. This is a list of eligible CPT/HCPCS codes , including which codes are allowed to use audio-only telephone.
• New or established patients.
• Rural and site limitations are removed.
• CMS has issued additional guidance regarding flexibilities specific to FQHCs and RHCs.
• Informed Consent for Telehealth: Although it is not always required, it is important that patients understand the risks and benefits of using telehealth. AHRQ has a simple, customizable consent form and how-to guidance for clinicians on how to explain telehealth. Document verbal consent prior to each telehealth visit until you can receive a signed consent (either digitally or on paper) from the patient.   

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Telemedicine Codes

Telemedicine and telehealth are used interchangeably throughout the United States healthcare system, in reference to the exchange of medical information from one site to another through electronic communication. Reporting of telemedicine/telehealth services varies by payer and state regulations.

AASM Telemedicine/Telehealth Resources

• AASM Coding FAQs
• AASM Telemedicine Video Library

CMS Telemedicine/Telehealth Codes

The codes below are commonly reported for Medicare patients:

CMS finalized the creation of two additional G codes that can be billed by practitioners who cannot independently bill for E/M services. G2250 and G2251 are billable by certain non-physician practitioners, consistent with the scope of these practitioners’ benefit categories.

CPT Telemedicine Codes

Modifier 95 indicates a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system. The 2020 CPT® manual includes Appendix P, which lists a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.

HCPCS LEVEL II CODES

There are also HCPCS Level II codes that describe telemedicine services.

Place of Service (POS) Code for Telemedicine

On January 1, 2017 the Center for Medicare and Medicaid Services (CMS) introduced place of service (POS) code 02 to identify telemedicine services. The descriptor for POS code 02 is “The location where health services and health related services are provided or received, through telecommunication technology.” Use of the telehealth POS code certifies that the service meets all of the telehealth requirements. Many private payers have also begun requiring use of POS code 02 for telemedicine services.

GT/GQ Modifiers

Medicare previously required providers to submit claims for telehealth services using the appropriate procedure code along with the telehealth GT modifier (“via interactive audio and video telecommunications systems”) or GQ modifier (“via an asynchronous (delayed communications) telecommunications system”). As of January 1, 2018, the GT modifier is only allowed on institutional claims billed under Critical Access Hospital (CAH) Method II since institutional claims do not use a POS code. If the GT modifier is billed by other provider types, the claim line will be rejected. The GQ modifier is still required when applicable (e.g., for those providers participating in the Alaska or Hawaii federal telemedicine demonstration programs).

Additional CMS Telemedicine/Telehealth Resources

• Complete list of CMS Telehealth Services
• General Provider Telehealth and Telemedicine Toolkit
• Medicare Telehealth Frequently Asked Questions (FAQs)
• Medicare Telehealth Services

Note: CPT Copyright 2021 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Coding Q&A: Coding telehealth services and virtual visits

by Stephanie Dybul, MBA, RT, FSIR

July 12, 2020

What are the CPT codes for a virtual video telehealth visit?

A virtual video visit is reported with the same CPT codes that you would use for in-person visits ( 99201 – 99205   new patient visit ;  99211 – 99215   established patient visit ; or  99241 – 99245   consultation visit  [not recognized by CMS, see G-codes]). The service should be reported with a - 95  modifier (confirm your local payer rules). There must be a synchronous two-way audio and visual component to the visit in order to report using these standard codes. Additionally, it should be noted that the place of service (POS) listed on the claim should match wherever the intended POS would have been in normal circumstances. For example, if you typically perform your clinic visit in an on-campus, OP hospital setting, report  POS 22  for  facility  or  POS 11  for  nonfacility/office setting . Currently, telehealth services are reimbursed under the CMS Physician Fee Schedule at the same amount as in-person services.

Are there any special documentation requirements for virtual video visit?

You should document all of the same elements that you would normally, with consideration of what is possible for you to achieve via the video connection. Typical elements of past medical history can be taken, limited examinations can be performed and documentation of your medical decision making (MDM) or time spent counseling should be clearly stated. However, CMS is removing requirements regarding documentation of history and/or physical exam in the medical record. Additionally, it should be noted that, on an interim basis, CMS is revising their policy to specify that the outpatient E&M level selection for these services when furnished via telehealth can be based on MDM or time, with time defined as all of the time associated with the E&M on the day of the encounter. It remains CMS’ expectation that providers will document E&M visits as necessary to ensure quality and continuity of care. These policy changes only apply to office/outpatient visits furnished via Medicare telehealth, and only during the Public Health Emergency (PHE) for the COVID-19 pandemic. It is strongly recommended to work with your coding/compliance team to ensure that language required by all payers is included in the documentation to ensure timely payment.

Can I bill an E&M service for telephone calls to patients?

Yes, there are CPT codes to support telephone E&M service, with the understanding that two-way audio-visual technology may not be available. Briefly, they are described as follows (see CPT® for full descriptors):

99441 :  Telephone E&M, for an established patient, 5–10 minutes

99442 :  Telephone E&M, for an established patient, 11–20 minutes

99443 :  Telephone E&M, for an established patient, over 21 minutes

These codes are only reportable when providing E&M services to an established patient and cannot be reported within 7 days of a previously provided E&M service or within 24 hours of a procedure. During the PHE, CMS has established that these codes can be used for new patients.

Is responding to a patient’s electronic message billable?

Yes, CPT codes  99421 – 99423  can be used when a provider responds to a  patient generated  electronic inquiry. These E&M services do not use interactive audio or visual. As with other non-face-to-face E&M services, the codes are time based and are cumulative over a 7-day period; which begins when the provider reviews the initial patient generated inquiry. The time includes review of patient’s medical records, the time to perform medical decision-making, develop a plan and place orders, as well as the time for communication back to the patient. Permanent documentation should support the time and effort taken, including documentation of the time in minutes spent performing these activities. The codes may not be used for work done by clinical staff and should not be billed if/when other E&M services are provided within the past 7 days. During the PHE, these codes can be used for new patients or established patients. 

99421 :  Online digital E&M service, for an established patient, for up to 7 days cumulative time during the 7 days; 5 – 10 minutes

99422 :  Online digital E&M service, for an established patient, for up to 7 days cumulative time during the 7 days; 11 – 20 minutes

99423 :  Online digital E&M service, for an established patient, for up to 7 days cumulative time during the 7 days; 21 or more minutes

Disclaimer:  SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2020/CPT ® ). It is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service.

Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.

*The content and guidance described in this article was current at the time it was written. Due to the nature of the recent PHE,  payment policy is likely to change rapidly and may vary geographically.  Members should continue to follow and consult local/national payer guidelines for most up-to-date guidance. Also refer to SIR’s telehealth information within the COVID-19 Toolkit:  bit.ly/2YcQz4u .

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Coding Telemedicine Visits for Proper Reimbursement

Gary n. gross.

Internal Medicine, Southwestern Medical Center, University of Texas, Dallas, TX USA

Purpose of Review

Coding for patient visits and monitoring via telehealth have expanded over the past years with a wide acceptance of telemedicine as a consequence of the coronavirus pandemic. Coding topics of interest to the allergist/immunologist in regard to services provided via telemedicine will be of increasing importance in the coming years.

Recent Findings

CPT coding for telephone as well as synchronous face-to-face telehealth visits has changed over the past few years. With the need for distancing and patient protection during the coronavirus pandemic, telehealth services have increased dramatically. The introduction of newer devices to remotely monitor patients will increase and be incorporated into patient care.

This review will summarize current codes available for designating what services have been provided. The area of telemedicine is changing and will continue to evolve as other platforms for visits are designed and other methods of monitoring patients become available. Coding for these services will be an ongoing need for the provider.

Introduction

Current procedural terminology (CPT) has recognized the need for designations of procedures done using technology. Although initial codes focused primarily on telephone visits, in 2017, CPT recognized a new place-of-service (POS) code designating “The location where health services and health related services are provided or received, through a telecommunication system.” This POS “02” was a step forward in awareness of the need for distant patient encounters and procedures. Further codes for both monitoring and evaluating via telehealth will be discussed. Table ​ Table1 1 lists current CPT codes available for designating services provided.

Current CPT codes [ 1 ]

Telehealth Coding

Two words must be remembered whenever coding is discussed. The two words, “it depends,” define the lack of consistency in coding throughout the industry. Coding is generally driven by The Centers for Medicare & Medicaid Services (CMS) and CPT (although they do not always align). CPT codes exist for procedures, but some carriers may not recognize or reimburse for the codes [ 2 ]. Some carriers may create their own limits on reimbursing for codes, arbitrarily considering procedures bundled with evaluation and maintenance (E&M) visits. Codes may be paid for certain disease states but not for others. Insurers vary with regard to expectations of what place-of-service to use or how to bill for some procedures. New modifiers for telehealth visits further complicate billing. The modifiers –GT and -95 are used by some carriers for telehealth visits and vary depending on the insurer. Similarly, place of service may be either “02,” the telecommunication POS mentioned above, or remain “11” which designates the office location. Therefore, one must be flexible and informed. Keeping track of each carrier’s latest provider information and appealing denials with alternative codes may be necessary.

As with conventional patient encounters, documentation is key. For telehealth visits, there is also the need to document the patient’s consent for the encounter via telehealth. Most of the telehealth codes are for providers who could bill for evaluation and management (E/M) services such as physicians, physician assistants (PAs), and nurse practitioners (NPs). These providers are considered qualified healthcare providers (QHP).

Non-face-to-face Telehealth Patient Visits

Telephone services (99441–99443).

These codes are non-face-to-face E/M services used by QHP. They are designed for telephone calls initiated by an established patient and have certain restrictions. If the call includes the decision to see the patient in the next 24 h or next available urgent appointment, it cannot be billed. Similarly, if the call refers to an E/M service reported by the QHP within the past 7 days, the telephone codes cannot be used. Thus, these calls are initiated by the patient or guardian of the patient and stand apart from other E/M visits as described.

• 99441 - 5–10 min of medical discussion
• 99442 - 11–20 min of medical discussion
• 99442 - 11–30 min of medical discussion

An established patient, who has not been seen in the past month, calls the office because of a recent ant bite. The patient wants to speak to the physician since the physician also treats the son for anaphylaxis to wasps and the patient is concerned. The physician talks to the patient about the kinds of reactions that might occur and notifies him of what symptoms he should be aware of. Out of an abundance of caution, the physician reminds the patient about using an epinephrine autoinjector. The conversation takes 25 min. The staff calls in the autoinjector to the pharmacy and is on the phone for 15 min waiting for the pharmacist.

The patient is billed 99443 for the physician time. The staff time would not enter into the total time. The note in the chart would document that the visit was via telephone and that the patient called the clinic about the problem. The discussion would be documented and the note would indicate the patient had not been seen and no E/M visit was anticipated. The note would also indicate that 25 min was spent in discussion.

Online Digital Evaluation and Management Services (99421–99423)

These codes are electronic communication codes. The problem may be new to the physician or QHP but the patient must be established. These services are patient-initiated through HIPAA-compliant secure platforms or portals.

These services include evaluation, assessment, and management of the patient.

These services are reported once during a 7-day period and therefore time is cumulative.

The time includes (1) review of the initial inquiry, (2) review of patient records or data pertinent to assessment of the patient’s problem, (3) interaction with clinical staff focused on the patient’s problem and development of management plans, (4) physician or other QHP generation of prescriptions or ordering of tests, and (5) subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service.

These services require permanent documentation storage (electronic or hard copy) of the encounter.

If within 7 days of the initial patient-initiated contact a separate E/M visit (in person or synchronous telemedicine) occurs, then the Online Digital visit is not billed but the time is incorporated into the subsequent E/M visit. If the Online Digital visit is initiated within 7 days of a previous E/M visit for the same or related problem, the Online Digital visit is not reported. If a new or different problem is being addressed in the Online Digital visit, then the visit is billable and should be reported.

• 99421-5–10 min (over a 7-day period)
• 99422-11–20 min (over a 7-day period)
• 99423-21 or more minutes (over a 7-day period)

Remember that only physician or other QHP time is used in the calculation. Staff time is not included.

An established patient who was seen 3 days ago for allergic rhinitis wakes up with hives. She uses the practice’s HIPAA compliant portal to message her doctor about the hives. The PA responds to the message and gathers information about the hives, the patient’s activities, and ultimately prescribes an antihistamine. The encounter takes 10 min. Two days later, the patient messages again saying the hives are better but not gone. She wants stronger medicine. The PA responds to the message and offers to prescribe a short course of corticosteroids. The PA describes the possible side effects of the steroids and also tells the patient what should be done if the hives do not clear. The PA spends 12 min with the encounter. The patient does not call back and does not come to the office for the hives. The PA bills the patient 99423 since the sum of the two encounters was 22 min within a 7-day period and the hives were not related to the allergic rhinitis the patient had been seen for 3 days before the hives.

The chart would document that the patient contacted the clinic for a new problem. All time spent by the PA would be documented to support the total time billed. It would be documented that no E/M visit was anticipated for this new problem.

Healthcare Common Procedure Coding System (HCPCS) have 2 levels of commonly used codes. Level 1 codes are CPT codes and level 2 codes are alphanumeric codes. One group of HCPCS codes are “G codes.” The G codes are used to identify professional healthcare procedures and services that would otherwise be coded in CPT but for which there are no CPT codes. Two “G codes” are relevant to telehealth and do not yet have matching CPT codes [ 3 ].

was in the 2019 physician fee schedule and is used for remote evaluation of established patient’s submitted videos or still images. The purpose of the evaluation is to determine whether or not an E/M visit is necessary. It may be billed if the evaluation does not lead to an E/M visit and does not occur within 7 days of a previous E/M visit. To bill for the evaluation, the physician or other QHP must evaluate the image within 24 business hours and follow-up with the patient in the form of a 5–10 min discussion with the patient.

An established patient develops a rash and is uncertain about its cause. The patient sends the physician a picture of the rash. The physician evaluates the photo and determines it is a hive. The physician calls the patient and tells him that these are common and if they last more than 6 weeks or get worse he can check back, but that he does not need to have an E/M visit.

Documentation of this remote evaluation would include the picture in the chart and the provider’s note that the picture was viewed and that no visit would be necessary unless the hives lasted more than 6 weeks. The presumed diagnosis of acute urticaria would also be included.

was also included in the 2019 physician fee schedule. It has been referred to as a “virtual check-in.” It is considered to be a call or video check in to see if an E/M visit is needed. Similar to some other e-codes, it cannot be billed if there was a related E/M service within the previous 7 days or it leads to an E/M visit within the next 24 h or soonest available appointment. The code is used for established patients having direct interaction with the billing practitioner (not the staff). The service must be medically reasonable and necessary but there is no limitation on frequency. The code assumes 5–10 min of medical discussion.

An established patient calls the nurse practitioner and describes a large, local reaction they have from a mosquito bite. The patient wants to know if they need to come in or go to the ER. The nurse practitioner informs the patient about the type of reaction and tells the patient they only need to come in if they have trouble breathing or if the reaction spreads. The patient is reassured and watches the reaction as it gradually goes away. The practitioner can bill G2012.

The documentation for this virtual check in would include the main points of discussion including the bite and the likely diagnosis as well as the 5+ min the provider is on the platform talking with the patient.

Face-to-face Telehealth Patient Visits

The Centers for Medicare & Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient. These are visits commonly considered “office visits” but delivered via synchronous audio and video contact with the patient. The usual E/M visit codes (99201–99215) would apply.

Prior to 2021, these E/M visits level of service was determined by history, physical exam, and medical decision-making as documented in the CPT book each year. If more than 50% of the face-to-face time with the patient and/or family was used in counseling and/or coordination of care, time becomes the key factor in determining level of service.

Beginning with CPT 2021, time alone may be used to select the appropriate level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). This “time” requires a face-to-face encounter with the physician or other QHP. Time spent with staff such as registering in the office or making future appointments is not used in the calculation of time. Also, note that the new patient level one code (99201) has been deleted.

Medical decision-making (MDM) includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Beginning in 2021, MDM may be used independently in establishing a level of service (without consideration of history or physical exam as was required previously). These changes were designed to reduce duplication and unnecessary, repetitious documentation, and should also make coding for telehealth E/M visits easier.

The telemedicine E/M visits are coded just as an in-office E/M visit would be but possibly with the addition of a modifier or a different place of service code depending on the insurance company. Some provisions for telemedicine have been waived during the pandemic to allow more patients access to medical care and to avoid exposure to others in waiting rooms and offices. The telemedicine waivers include evaluation of new patients via telehealth, beneficiaries living in any geographic area and accessing telemedicine from their homes, and use of smartphones and audio only connections for some services. Whether all these waivers will remain in place following the pandemic is unknown.

An established patient calls the office to set up an appointment and is offered a telemedicine option. The patient finds this attractive since it will save him time in traffic and reduce his time away from work. It is for a follow-up to see how he is doing after starting immunotherapy a month ago. The patient signs into the doctor’s telehealth platform and gives verbal consent for the visit. They discuss symptoms, reactions to injections, medications, and concerns of the patient regarding future injections if he goes on vacation. The face-to-face time with the physician is 22 min and the code billed is 99213 (less than the minutes currently typical for 99214 and within the 20–29 min designated for 2021).

These telemedicine visits will require documentation similar to in-person visits. They will include the notation that the patient consents to the telehealth visit. Since the visits for new patients require physical examinations, the best way to document and bill these visits will be based on time. Until 2021, the notation that over 50% of the time with the patient was related to counseling and/or coordination of care is also needed. For follow-up visits before 2021, only two major components of the E/M visit are necessary, so history and medical decision-making with documentation could be used. It may be easier since most telemedicine visits are largely counseling and coordination of care, to base these encounters on total time also and indicate that greater than 50% was devoted to counseling/coordination of care. Typical documentation will include the consent for the visit, the discussion with the patient, the differential diagnosis, the plan of care, and the total “face-to-face” time spent on the visit. The further notation that > 50% of the time was related to counseling and coordination of care (assuming it was) should also be documented.

Remote Monitoring

In addition to patient encounters whether non-face-to-face or face-to-face, the allergist/immunologist may also do remote monitoring of the patient. The 2020 CPT book lists the following codes for remote patient monitoring (RPM). Although some requirements for telehealth services have been modified during the pandemic, RPM services have never been limited by geography to rural or medically underserved areas, nor is there any “originating site” restriction for RPM services. In fact, RPM services can be provided anywhere the patient is located, including at the patient’s home.

• 99453 Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
• 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days (provided monitoring occurs at least 16 days during the 30-day period)
• 99457 Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 min.
• 99458 Each additional 20 min

As more devices become available to monitor asthma and other diseases treated by the allergist/immunologist, these codes will become more widely used just as blood pressure monitoring and diabetes monitoring are today.

An established patient is in the office and has poorly controlled, moderately severe persistent asthma. You provide the patient with a home spirometer that will transmit the FEV1 and FVC to your office. The patient is instructed on how to set up and use the device. He provides data via the portal for 20 days of the next month and you and your staff retrieve the data and analyze it. The time involved in retrieving and analyzing the information is 18 min. You modify the patient’s treatment program and describe the new treatment program during a telemedicine visit.

Billing would be 99453, 99454, and 99457 (each one unit). The E/M visit would be billed based on the time spent with the patient in describing the new treatment plan.

The documentation for these services might include a statement such as “we have provided this patient a remote spirometer and taught the patient its proper use. The patient has used it and transmitted information to us 20 days this month and the staff and I have spent 18 min total in the monitoring and responding to this patient in regard to asthma management based on results of the information transmitted.”

An older CPT code used for remote patient monitoring is 99091. This older code requires 30 min to bill based on a 30-day period. It is also limited to physicians and QHPs. There must be a face-to-face visit within 1 year and consent must be given and documented. The platform used must both collect and transmit data in real time or near real time to be eligible.

Another set of spirometry codes (94014, 94015, 94016) relate to patient-initiated remote spirometry, transmission of tracings, and review and interpretation by a physician or QHP. The second code (94015) does not include review and interpretation by a physician or other QHP whereas the third code (94016) is the review and interpretation by the provider. 94014 is an inclusive code of the latter two.

Interprofessional Telephone/Internet/Electronic Health Record Consultations

Codes 99446, 99447, 99448, 99449, and 99451/99452 are used to report a consultation when there is an interprofessional electronic consultation regarding assessment and management of a patient who is not seen face-to-face by the consulting provider. The patient may be a new patient to the consultant or an established patient with a new problem. The patient should not have been seen by the consultant for a face-to-face encounter in the past 14 days. Similarly, there should not be a transfer of care or a face-to-face encounter within the following 14 days of the consultation. Greater than 50% of the time for service must be devoted to the verbal or internet discussion. These codes should not be reported more than once within a 7-day interval. The consulting provider delivers a written or verbal report to the patient’s treating provider. The patient or family must give verbal consent (documented in the record) for the consult.

• 99446 reported by the consulting provider for 5–10 min of consultative discussion/review
• 99447 11–20 min
• 99448 21–30 min
• 99449 31 min or more

Code 99451 is reported by the consultant for 5 min or more time but does not require that more than 50% of the time be consultative time as opposed to data review. Furthermore, 99451 requires a written report.

Code 99452 is billed by the treating/requesting provider. This code is for time spent in preparing the consult and/or time communicating with the consultant for 16 min or more time.

Conclusions

Telemedicine will continue to be a significant part of the allergy/immunology practice even after the pandemic. Both Medicare and commercial insurance companies have made special provisions for telehealth during the pandemic in order to make medical care more readily available for patients who are concerned about their symptoms and also concerned about possible exposure to illness in a healthcare facility. Such provisions as allowing telephone calls (without video) to be sufficient for a “face-to-face” telemedicine visit for patients who do not have access to computers or other means of communicating via video connections will probably not continue after the pandemic [ 3 , 4 ]. The leniency on what platforms can be used by practices for telehealth visits will also likely change after the pandemic. These possible changes will likely be rolled out at different times for different carriers so it will be critical to review EOBs and look at insurers’ websites and newsletters.

It will be important to learn the codes and understand what codes different insurers require in order to be properly reimbursed for your work. Remembering to get consent for visits, to document what was done, to adhere to procedures that are medically necessary, and to code correctly will help practices receive payment for these services. It would be helpful to medicine in general if the commercial insurance companies and CMS provided a uniform approach and guideline for telemedicine coding. Until such time that these stakeholders provide a consistent and uniform coding guide to telemedicine, remember that “it depends” as you select the appropriate code, modifier, and place of service for telemedicine encounters.

Compliance with Ethics Guidelines

The authors declare no conflicts of interest relevant to this manuscript.

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Telemedicine and Technology

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Telehealth for behavioral health care

Billing for telebehavioral health.

The federal government, state Medicaid programs, and private insurers have expanded coverage for telebehavioral and telemental health during the COVID-19 public health emergency.

Medicare and some Medicaid programs will continue to cover telebehavioral health through December 31, 2024. Information on Medicaid reimbursement for telehealth by state is available at the Center for Connected Health Policy with live policy trend maps .

Tip:  If a patient has private insurance, verify coverage via the insurance provider policy or request the patient to confirm coverage before each appointment.

On this page:

Medicare billing guidance, private insurance.

The following Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes are used to bill for telebehavioral and telemental health services and have been codified into the current Medicare Physician Fee Schedule (PFS) . See the complete list of telehealth services  covered by Medicare from the Centers for Medicare & Medicaid Services through to December 31, 2024.

Telebehavioral health requirements with safety-net providers  (PDF) – from the Centers for Medicare & Medicaid Services

Telehealth codes for Medicare reimbursement for telebehavioral health

Although Medicare reimburses for audio and video telehealth services, reimbursement for audio-only telehealth services is currently only covered through December 31, 2024.

Non-covered services

These telebehavioral health services are not Medicare reimbursable.

Health care billing code changes initiated during the COVID-19 public health emergency cover telehealth and include specific information for audio-only or video-only visits. It is important to note that most states distinguish between reimbursement standards for permanent telehealth policies and temporary COVID-19 reimbursement policies. For tips on coding private insurance claims, see:

• Current State Laws & Reimbursement Policies  (Private Payer Laws) — from the National Policy Center - Center for Connected Health Policy
• Coding Scenarios for telehealth visits  (by payer policy) — from the American Academy of Family Physicians

Have a question?

Contact the staff at the regional telehealth resource center  closest to you for help setting up billing and reimbursement for a new telehealth service.

For more details about billing and reimbursement, including telehealth coding, watch Behavioral Health Billing & Coding 101: How to Get Paid  (video) — from the American Medical Association (AMA)

While each state is different, many have expanded coverage for telebehavioral and telemental health during the COVID-19 public health emergency. Many states currently match Medicare’s telebehavioral and telemental health coverage.

To see which telebehavioral and telemental health services Medicaid covers, check your state’s current laws and reimbursement policies .

Frequently Asked Questions on Telehealth and COVID-19

Frequently Asked Telehealth Questions

Telehealth and telemedicine can be confusing to navigate, especially during the COVID-19 pandemic. We have gathered our top questions to get you the exact information you need to bill and code telehealth correctly.

• What does it mean to say that geographic and originating site restrictions have been waived?
• What is the HIPAA Enforcement Discretion?
• What diagnosis code should I use?
• Which services qualify for a cost-sharing waiver?
• What is considered a COVID-related visit?
• What if a patient doesn't have access to an audio-video connection?
• What type of visit do I bill if the video connection drops in the middle of the visit?
• Are there additional codes I should use if a telephone E/M visit lasts more than 30 minutes?
• Are telemedicine visits paid the same as in-person visits?
• If cost-sharing is waived, will my payment be reduced?
• When do the cost-sharing waivers expire?
• What do I do if cost-sharing wasn't applied appropriately or I wasn't paid at parity?
• What place of service and modifier should I use?
• Can I provide the Welcome to Medicare and Annual Wellness Visit (AWV) via telehealth?
• Can I provide chronic care management (CCM) or transitional care management (TCM) using telehealth?
• Can I count the time my staff spends getting a patient set up for a telemedicine visit toward total visit time?
• What about the services of teaching physicians that involve residents?
• Can I bill for phone calls between clinical staff (e.g., nurse) and patients under Medicare's "incident-to" rules using code G2012?
• Can I provide direct supervision virtually?
• Can Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) bill for telehealth and virtual services?
• Are there cost-sharing waivers for treatment related to COVID-19?
• Are prior authorization requirements waived?
• Do I still need to collect data for the Merit-based Incentive Payment System (MIPS) or Medicare Shared Savings Program (MSSP)?

1. What does it mean to say that geographic and originating site restrictions have been waived?

The originating site is where a patient is located when they receive telehealth services. These normally must be clinical settings, such as physician offices and hospitals. Additionally, the originating site normally must be in a county located outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract to be eligible for telehealth services.

For the duration of the public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) is waiving the geographic and originating site restrictions. Patients may receive telehealth services in any setting, including their homes.

2. What is the HIPAA Enforcement Discretion?

The Department of Health and Human Services (HHS) Office for Civil Rights will waive penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care professionals  serving patients in good faith  via nonpublic-facing everyday communication technologies, such as FaceTime or Skype, during the COVID-19 PHE.

3. What diagnosis code should I use?

Download diagnosis coding guidance from CMS »

4. Which services qualify for a cost-sharing waiver?

For the duration of the PHE, Medicare is waiving and will cover  cost-sharing  for COVID-19 diagnostic tests and visits related to COVID-19 testing. Additionally, physicians may voluntarily waive cost-sharing for non-COVID-19-related telehealth and virtual/digital services. However, Medicare will not pay any cost-sharing waived at a physician’s discretion. Read the coding and reporting guidelines from CMS  here .

Cost-sharing policies for private payers vary by payer. For more specific guidance, see  this release  from CMS. Review the  Private Payer FAQ  or contact your provider relations representative for additional information.

Note:  Self-funded plans may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state level and may differ from national policies.

5. What is considered a COVID-related visit?

The Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Families First Coronavirus Response Act require Medicare and group health plans to cover diagnostic testing related to COVID-19 at no cost to patients for the duration of the PHE. As defined by the laws, COVID-related services include:

• an in vitro diagnostic test for the detection of SARS-CoV-2 or the diagnosis of COVID-19; the test must be approved, or the developer has requested or intends to request emergency use authorization under the Federal Food, Drug, and Cosmetic Act;
• a test that is developed in and authorized by a state that has notified the secretary of HHS of its intention to review tests intended to diagnose COVID-19;
• other tests the secretary of HHS determines appropriate in guidance; and
• terms and services furnished to an individual through office visits (in person and telehealth), urgent care center visits, and emergency room visits that result in an order for or administration of a COVID-19 test; items and services must be related to the furnishing or administration of the test or to the evaluation of the patient for the purposes of determining the need for a COVID-19 test.

Please see the  Private Payer FAQ     for additional information on coding COVID-19-related visits.

6. What if a patient doesn't have access to an audio-video connection?

For the duration of the PHE, CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443). For Medicare patients, on an interim basis, the relative value units and payment amounts will align as follows: 99441 will align with 99212, 99442 will align with 99213, and 99443 will align with 99214.

Additionally, a select group of services can be provided using an audio-only connection. However, the audio-video requirement remains in place for most services, such as office visit E/M services. An updated list of telehealth services that shows which services may be provided using audio-only can be found  on this CMS webpage .

Private payers also cover telephone E/M services. Their policies on audio-only office visit E/M services vary. More information can be found in the  Private Payer FAQ  or by contacting your provider relations representatives to verify policies.

7. What type of visit do I bill if the video connection drops in the middle of the visit?

Physicians should bill the visit that most appropriately describes the service. If the visit is conducted primarily via audio, it would be appropriate to use the applicable telephone E/M code (CPT codes 99441-99443).

8. Are there additional codes I should use if a telephone E/M visit lasts more than 30 minutes?

No. If a telephone visit lasts more than 30 minutes, physicians should bill the CPT code 99443.

9. Are telemedicine visits paid the same as in-person visits?

Yes — if they are coded correctly. Visits must be coded according to each payer’s guidance. Visits that are not coded correctly may be denied or paid at a lower rate. For the duration of the PHE, CMS will pay office visit/outpatient E/M services provided via telehealth at the same rate as an in-person office visit. Additionally, CMS will pay telephone E/M services (CPT codes 99441-99443) at parity with office visit E/M codes of comparable length. Payment will range from $56 to $130.

Please see the  Private Payer FAQ   for additional information.  

To ensure proper payment, the AAFP recommends that practices update their billing system's allowable amounts to reflect the updated payment rates. Claims submitted with the previous, lower amounts may not be paid the full amount, since payers often pay the lesser of the allowed amount and the actual charge.

10. If cost-sharing is waived, will my payment be reduced?

Medicare is waiving patient cost-sharing for services related to COVID-19 testing during the PHE. Medicare will pay 100% of the allowable, so physician payment is effectively not reduced. Physicians should use the CS modifier on the claim lines for services related to COVID-19 testing. Physicians may waive cost-sharing for non-COVID-related telehealth services and telephone E/M services (CPT codes 99441-99443). However, Medicare will not pay any cost-sharing voluntarily waived by the physician at their discretion.

Private payer policies vary. Review the  Private Payer FAQ  or contact your provider relations representative for additional information.

Note:  The HHS Office of Inspector General has said it’s permissible for physicians to routinely waive Medicare cost-sharing for telehealth services during the PHE, even if they are not COVID-19-related. In that case, it’s the physician’s choice, and if they waive the cost-sharing, that would represent lost revenue, since Medicare will pay only its portion.

11. When do the cost-sharing waivers expire?

Medicare’s cost-sharing waivers are in effect until the end of the PHE. The PHE is currently set to expire April 20, 2021.

Expiration dates for private payers vary. Please review the  Private Payer FAQ   for additional information.

12. What do I do if cost-sharing wasn't applied appropriately or I wasn't paid at parity?

Verify that the claim was coded according to the payer’s requirements. Common causes of reduced payment or missing cost-sharing waivers include incorrect place of service and missing modifiers. Additionally, self-funded plans may opt out of a payer’s national policy. If the claim appears to be coded correctly, contact your provider relations representative.

Note:  Resolving claim-level issues often requires the physician’s NPI and information from the claim. The quickest way to resolve a claim-level issue is through your provider relations representative. The AAFP monitors policy trends and is in regular contact with national payers.

13. What place of service and modifier should I use?

The billing and coding requirements for telehealth and virtual/digital services vary by payer. Please review the  Private Payer FAQ   for additional information.

14. Can I provide the Welcome to Medicare and Annual Wellness Visit (AWV) via telehealth?

The Medicare AWV codes (HCPCS codes G0438 and G0439) are on the list of approved Medicare telemedicine services.  CMS states that self-reported vitals  may be used when a beneficiary is at home and has access to the types of equipment they would need to self-report vitals. The visit must also meet all other requirements.  

The Welcome to Medicare visit (code G0402, “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment”) is not on the list of approved Medicare telemedicine services.

Commercial and private payers may have different policies. Please check with your provider relations representatives for additional guidance.

15. Can I provide chronic care management (CCM) or transitional care management (TCM) using telehealth?

Yes. CCM is already considered a non-face-to-face service. Patient consent is required. Verbal consent is sufficient and must be documented in the patient medical record. Patients who have not been seen in the office in the past 12 months must have an initiating visit, such as an office visit. The initiating visit may be provided via telehealth.

TCM is on Medicare’s list of covered telehealth services. Per Current Procedural Terminology (CPT), CPT codes 99495 and 99496 include one face-to-face (but not necessarily in-person) visit that is not separately reportable. CMS has not specifically addressed this question but is otherwise covering such visits as stand-alone services.

To date, CMS is not considering a phone (audio-only) visit equivalent to a telehealth visit involving audio and visual technology. Given that CPT describes the visit included in TCM as “face-to-face,” we do not advise conducting that visit as a telephone (audio-only) visit.

The requirements for  CCM  and  TCM  can be found on the AAFP website.

Telephone E/M (CPT codes 99441-99443) and e-visits (CPT codes 99421-99423) should not be billed during the same month as CCM or during the same service period as TCM.

16. Can I count the time my staff spends getting a patient set up for a telemedicine visit toward total visit time?

No. Per  CPT , total time for purposes of reporting the level of service for an office/outpatient visit evaluation and management code includes the face-to-face and non-face-to-face time spent by the physician and/or other qualified health care professional on the date of service and does not include time for services normally performed by clinical staff.

17. What about the services of teaching physicians that involve residents?

For the duration of the PHE, CMS has amended the teaching physician regulations to allow supervision by interactive telecommunications technology (i.e., real-time audio and video) to satisfy the requirement for the presence of a teaching physician for the key portion of the service. The medical record must reflect whether the teaching physician was physically or virtually present for the key portion of the service, including the specific portion of the service for which the teaching physician was present through interactive, audio/visual real-time technology. CMS will also allow teaching physicians to review the services provided with the resident during, or immediately after, the visit through interactive telecommunications technology. This exception is in place through the later of the end of the calendar year in which the PHE ends or December 31, 2021. All other policies continue to apply.

CMS will also temporarily allow all levels of office visit E/M services (CPT codes 99202-99205 and 99211-99215) furnished in a primary care center to be provided under direct supervision of the teaching physician by interactive telecommunications technology.

For the duration of the PHE, CMS will allow the following additional services under the primary care exception:

• telephone E/M services (CPT codes 99441-99443),
• transitional care management (CPT codes 99495-99496),
• e-visits (CPT codes 99421-99423),
• interprofessional telephone/internet/EHR referral service(s) (CPT code 99452), and
• virtual check-ins (HCPCS codes G2010 and G2012).

18. Can I bill for phone calls between clinical staff (e.g., nurse) and patients under Medicare's "incident-to" rules using code G2012?

No. In its recent  Interim Final Rule , CMS stated it believes virtual check-ins (HCPCS codes G2012 and G2010) are reportable only by physicians and practitioners (e.g., nurse practitioner or physician assistant), who can provide evaluation and management services as the service describes a check-in “directly with the billing [physician or] practitioner to assess whether an office visit is needed.”

As such, G2012 cannot involve only clinical staff (e.g., a nurse who is not a nurse practitioner) and be reported “incident-to.” Thus, the only way to capture phone calls between nurses who are not nurse practitioners and patients for Medicare billing purposes is to count the time toward an appropriate chronic care management code or transitional care management code.

19. Can I provide direct supervision virtually?

Yes. Physicians and nonphysician providers may provide direct supervision via real-time, interactive audio/visual technology through the later of the end of the year in which the PHE ends or December 31, 2021.

20. Can Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) bill for telehealth and virtual services?

Yes. For the duration of the PHE, CMS is allowing FQHCs and RHCs to provide distant-site telehealth services. Telehealth services can be provided by any practitioner working for the FQHC or RHC within their scope of services, and there are no restrictions on where the service is provided, meaning physicians or practitioners may provide the service from their homes.

For distant-site services provided between July 1, 2020, and the end of the COVID-19 PHE, FQHCs and RHCs should use HCPCS code G2025 to identify the services furnished via telehealth.

CMS is waiving cost-sharing for services related to COVID-19 testing; FQHCs and RHCs should append the -CS modifier to claims related to COVID-19 testing. Coinsurance should not be collected from beneficiaries when cost-sharing is waived.

Additional information can be found in  this Getting Paid blog post .

Read the full announcement from CMS »

21. Are there cost-sharing waivers for treatment related to COVID-19?

For the duration of the PHE, CMS will cover monoclonal antibody treatments for beneficiaries who meet the following requirements:

• tested positive for COVID-19,
• have a mild to moderate case of COVID-19,
• are at high-risk of progressing to a severe case of COVID-19 and/or are at high-risk for requiring hospitalization.

People with Medicare pay no cost-sharing for COVID-19 monoclonal antibody infusion therapy.

Private payers’ policies vary. Review the  Private Payer FAQ  or contact your provider relations representative..

22. Are prior authorization requirements waived?

Yes. The Families First Coronavirus Response Act   prohibits plans from imposing prior authorization requirements on COVID-19 testing for the duration of the PHE. Private payers are offering additional prior authorization flexibilities. Contact your provider relations representatives for their policies.

23. Do I still need to collect data for the Merit-based Incentive Payment System (MIPS) or Medicare Shared Savings Program (MSSP)?

CMS will automatically apply the extreme and uncontrollable circumstances for the 2020 MIPS performance year. Additional information can be found on the Quality Payment Program  website . CMS has not indicated whether the extreme and uncontrollable circumstances policy will apply to the 2021 MIPS performance year.

CMS  will  apply the MSSP extreme and uncontrollable circumstances to accountable care organizations (ACOs) for the 2020 performance year. Since the PHE was still in effect December 2020, shared losses for the 2020 performance year will be mitigated. The policy is also in effect for the 2021 performance year. CMS may make additional changes through future rulemaking. Please check with your ACO’s administration for additional information on quality reporting requirements.

Access additional telehealth resources and download a free copy of the AAFP Telehealth Toolkit , created in partnership with Manatt Health.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Medicare Wellness Visits Back to MLN Print November 2023 Updates

What’s Changed?

• Added information about monthly chronic pain management and treatment services
• Added information about checking for cognitive impairment during annual wellness visits
• Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits

Quick Start

The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.

Medicare Physical Exam Coverage

Initial Preventive Physical Exam (IPPE)

Review of medical and social health history and preventive services education.

✔ New Medicare patients within 12 months of starting Part B coverage

✔ Patients pay nothing (if provider accepts assignment)

Annual Wellness Visit (AWV)

Visit to develop or update a personalized prevention plan and perform a health risk assessment.

✔ Covered once every 12 months

Routine Physical Exam

Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.

✘ Medicare doesn’t cover a routine physical

✘ Patients pay 100% out-of-pocket

Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :

• Health Equity Technical Assistance Program
• Disparities Impact Statement

Communication Avoids Confusion

As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.

Initial Preventive Physical Exam

The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.

1. Review the patient’s medical and social history

At a minimum, collect this information:

• Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
• Current medications, supplements, and other substances the person may be using
• Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
• Physical activities
• Social activities and engagement
• Alcohol, tobacco, and illegal drug use history

Learn information about Medicare’s substance use disorder (SUD) services coverage .

2. Review the patient’s potential depression risk factors

Depression risk factors include:

• Current or past experiences with depression
• Other mood disorders

Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.

3. Review the patient’s functional ability and safety level

Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:

• Ability to perform activities of daily living (ADLs)
• Hearing impairment
• Home and community safety, including driving when appropriate

Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
• Visual acuity screen
• Other factors deemed appropriate based on medical and social history and current clinical standards

5. End-of-life planning, upon patient agreement

End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:

• Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
• If you agree to follow their advance directive
• This includes psychiatric advance directives

6. Review current opioid prescriptions

For a patient with a current opioid prescription:

• Review any potential opioid use disorder (OUD) risk factors
• Evaluate their pain severity and current treatment plan
• Provide information about non-opiod treatment options
• Refer to a specialist, as appropriate

The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .

7. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

8. Educate, counsel, and refer based on previous components

Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.

9. Educate, counsel, and refer for other preventive services

Include a brief written plan, like a checklist, for the patient to get:

• A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
• Appropriate screenings and other covered preventive services

Use these HCPCS codes to file IPPE and ECG screening claims:

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report

Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination

Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination

Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv

* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.

Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an IPPE when performed by a:

• Physician (doctor of medicine or osteopathy)
• Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)

When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

CPT only copyright 2022 American Medical Association. All rights reserved.

IPPE Resources

• 42 CFR 410.16
• Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
• Section 80 of the Medicare Claims Processing Manual, Chapter 18
• U.S. Preventive Services Task Force Recommendations

No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.

No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.

No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).

A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.

We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .

Annual Wellness Visit Health Risk Assessment

The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.

Perform an HRA

• You or the patient can update the HRA before or during the AWV
• Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
• Demographic data
• Health status self-assessment
• Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
• Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
• Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances

1. Establish the patient’s medical and family history

At a minimum, document:

• Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
• Use of, or exposure to, medications, supplements, and other substances the person may be using

2. Establish a current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.

• Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
• Other routine measurements deemed appropriate based on medical and family history

4. Detect any cognitive impairments the patient may have

Check for cognitive impairment as part of the first AWV.

Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.

5. Review the patient’s potential depression risk factors

6. Review the patient’s functional ability and level of safety

• Ability to perform ADLs

7. Establish an appropriate patient written screening schedule

Base the written screening schedule on the:

• Checklist for the next 5–10 years
• United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
• Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover

8. Establish the patient’s list of risk factors and conditions

• A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
• Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
• IPPE risk factors or identified conditions
• Treatment options and associated risks and benefits

9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs

Include referrals to educational and counseling services or programs aimed at:

• Fall prevention
• Physical activity
• Tobacco-use cessation
• Social engagement
• Weight loss

10. Provide advance care planning (ACP) services at the patient’s discretion

ACP is a discussion between you and the patient about:

• Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
• Future care decisions they might need or want to make
• How they can let others know about their care preferences
• Caregiver identification
• Advance directive elements, which may involve completing standard forms

Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.

We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.

11. Review current opioid prescriptions

• Review any potential OUD risk factors
• Provide information about non-opioid treatment options

12. Screen for potential SUDs

Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .

13. Social Determinants of Health (SDOH) Risk Assessment

Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.

1. Review and update the HRA

2. Update the patient’s medical and family history

At a minimum, document updates to:

3. Update current providers and suppliers list

Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.

• Weight (or waist circumference, if appropriate) and blood pressure

5. Detect any cognitive impairments patients may have

Check for cognitive impairment as part of the subsequent AWV.

6. Update the patient’s written screening schedule

Base written screening schedule on the:

7. Update the patient’s list of risk factors and conditions

• Mental health conditions, including depression, substance use disorders , and cognitive impairments
• Risk factors or identified conditions

8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs

9. Provide advance care planning (ACP) services at the patient’s discretion

10. Review current opioid prescriptions

11. Screen for potential substance use disorders (SUDs)

12. Social Determinants of Health (SDOH) Risk Assessment

Preparing Eligible Patients for their AWV

Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:

• Medical records, including immunization records
• Detailed family health history
• Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
• Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists

Use these HCPCS codes to file AWV claims:

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.

Part B covers an AWV if performed by a:

• Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician

When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.

You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.

Medicare telehealth includes HCPCS codes G0438 and G0439.

ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.

Use these CPT codes to file ACP claims as an optional AWV element:

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

We waive both the Part B ACP coinsurance and deductible when it’s:

• Provided on the same day as the covered AWV
• Provided by the same provider as the covered AWV
• Billed with modifier 33 (Preventive Service)
• Billed on the same claim as the AWV

We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .

We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.

SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.

Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:

Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes

Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.

The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:

We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.

If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.

AWV Resources

• 42 CFR 410.15
• Section 140 of the Medicare Claims Processing Manual, Chapter 18

No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.

No. We waive the coinsurance, copayment, and Part B deductible for the AWV.

We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.

Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.

You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.

Know the Differences

An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .

• We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
• We pay IPPE costs if the provider accepts assignment

An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.

• We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
• We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
• We pay AWV costs if the provider accepts assignment

A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.

• We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
• Patients pay 100% out of pocket

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