Medicare e-visits occur between a doctor, Notice of Privacy Practices (NPP), various other provider types and a patient. These e-visits were designed to occur through an online portal but with more recent laxities based upon the COVID-19 pandemic, Medicare is allowing additional provider types to provide telehealth and virtual visits. This has occurred as a result of the current national emergency and states applying for waiver 1135 relief. Many states are waiving co-pays and prior authorization processes for many but not all services. This action also allowed for physical, occupational and speech language pathologists to be added to provider types who can provide e-visits. 

How Do I Code an E-Visit?

This is a little more complicated and is based upon your provider type. There are provider type codes for physicians and non-physician providers. Unfortunately, it is different by payers as well. The Centers for Medicare & Medicaid Services (CMS) has its own codes by provider types, which in many cases do not match CIGNA, AETNA, BC/BS, UHC, Workers Compensation, etc. It is recommended you develop a check list of questions to ask when verifying e-visit payment coverage. 

Here are a few questions to consider:

  • What provider types are currently considered qualified or eligible providers within membership?
  • Are there differences for in-network vs. out-of-network providers?
  • If the payer is not reimbursing for coverage, what is your Advanced Beneficiary Notice (ABN) process?
  • Does the payer consider e-visits the same as telehealth? If so:
    • What is the definition of “Originating Site”?
    • What is the definition of “Distant Site”?
  • What Place of Services (POS) are allowable to be used by provider type (keep in mind UB-04s do not require POS)?
  • What are the payer’s expectations on documenting and maintaining consent for non-face-to-face encounters?
  • What modifiers should be reported, for which types of visits and which provider types?
  • Are you requiring the CR Modifier to be reported, acknowledging visits in compliance with wavier 1135?

Due to the increased number of virtual visits, American Academy of Family Physicians (AAFP) published an algorithm, developed by James Dom Dera, MD, FAAFP, to determine the appropriate code to use for services performed in a virtual setting. These services include:

  • Telehealth visits (real-time audio and video)
  • E-visits (online E/M visits)
  • Virtual check-ins (assessments by telephone or other telecommunication device to determine whether an in-office encounter is needed for the patient’s concern)
  • Telephone E/M visits

You can access the algorithm on the AAFP website.

To determine the appropriate e-visit code, ask the following questions:

  • Will video be utilized? If yes, your patient interaction is not an e-visit.
  • Is there communication to determine if an office E/M service is necessary?
  • What online patient portal will be utilized?

What Providers Need to Know About E-Visits? 

For an encounter to be considered an e-visit, the following must apply:

  • The practice must have an established relationship with the patient.
  • The patient must generate the communication request and consent to the e-visit.
  • There must be non-face-to-face patient initiated digital communication (patient portals are examples).
  • The patient must not have been seen in the past 7 days for an office visit (physician or therapy) for the same clinical issue.
  • E-visits can only be reported every 7 days.
  • E-visits are not typical therapy treatment visits.

Documentation requirements for e-visits must include:

  • The total time documented over the 7-day period to support the billable service.
  • Record of the patient’s consent, captured in the clinical note, supported by a signed consent. The signed consent can be in the form of a document scanned into the e-visit software platform. Some systems may have electronic signature capability.
  • A chief complaint with all E/M services.
  • The specifics of the conversation, including the treatment, management, evaluation, and/or assessment of diagnoses or symptoms.

Available CPT Codes Requiring Providers to Follow Payer Policies

The online digital evaluation service (e-visit) codes for physicians being utilized is complex, and are as follows: 

  • 99421 (online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes);
  • 99422 (online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes); and
  • 99423 (online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes).

The online digital evaluation service (e-visit) HCPCS codes and descriptors being utilized by Medicare for qualified non-physician professionals are as follows:

  • G2061 (qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes);
  • G2062 (qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes); and
  • G2061 (qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes).

The online digital evaluation service (e-visit) CPT codes and descriptors being utilized by many private payers and workers compensation are as follows:

  • 98970 (qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes);
  • 98971 (qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes); and
  • 98972 (qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes).

Resources:

  1. AHIMA. Telemedicine Toolkit. (2017). Retrieved from https://healthsectorcouncil.org/wp-content/uploads/2018/08/AHIMA-Telemedicine-Toolkit.pdf
  2. An Introductory Guide on Fee-For-Service. (n.d.). Retrieved from https://www.cchpca.org/sites/default/files/2020-01/Billing%20Guide%20for%20Telehealth%20Encounters_FINAL.pdf
  3. E-visits. (n.d.). Retrieved from https://www.medicare.gov/coverage/e-visits
  4. Gardner, K. (n.d.). APTA Quick Reference to Using E-Visits for Physical Therapist Services. Retrieved from http://www.apta.org/COVID-19/E-Visit/QuickReference/
  5. Telemedicine Glossary. (2018). Retrieved from http://thesource.americantelemed.org/resources/telemedicine-glossary
  6. Telemedicine and Telehealth. (2017, September 28). Retrieved from https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth