As a physician, are you curious about beginning telehealth services but aren’t sure how the reimbursement procedure will work? A critical component of getting timely, comprehensive reimbursement is accurately coding health insurance claim forms for telehealth services you’ve rendered. However, for many providers understanding what CPT and HCPCS codes to use for appointments conducted on a telehealth platform can be challenging.
To help clear up any confusion, let’s dive into common telemedicine CPT codes. We’ll also take a look at what CPT and HCPCS codes are, and what the most common codes are for telehealth services that you’ll need to know.
What is a CPT code?
CPT stands for Current Procedural Terminology. The CPT coding system was developed by the American Medical Association (AMA) to create a clear and consistent system through which healthcare providers could describe healthcare services they have provided through billing codes. The system was first developed in 1966 and underwent significant revisions following the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996.1
What is a CPT Code Used For?
CPT is a coding system that is used by health care providers to communicate medical services that have been rendered to third-party payers. These third-party payers include private insurers, and the public health programs Medicare and Medicaid.2
The CPT manual changes regularly, so as a physician it’s necessary to always stay up-to-date on correct coding for your services. Providers must use the most current version of the CPT manual available for accurate reimbursement. Not only can accuracy impact reimbursement, but an inaccurate CPT code can result in penalties for an inappropriate claim.3
While this coding may seem obscure and unnecessarily confusing from the outside, it allows for the concise transmission of descriptions for agreed-upon services. It also creates consistency between healthcare providers, who might otherwise describe services rendered in different ways.
CPT codes can best be thought of as one important part of how healthcare services are described in billing and claims. CPT codes are considered a Level I code and primarily describe outpatient professional services that have been provided to the patient. But how are these different from HCPCS codes, and do you need both? Understanding how CPT and HCPCS codes interact is essential for accurate billing purposes.
What are HCPCS Codes?
The Healthcare Common Procedure Coding System (HCPCS) was developed by the Centers for Medicare and Medicaid Services (CMS) in 1983. The goal of the HCPCS level codes is simple: to create a set of codes that represent different goods or services supplied to patients during treatment. These billing codes are used to describe services that have been provided to individuals who have Medicare and Medicaid, as well as for people with private insurance. HCPCS codes are also used to identify products, supplies, or other material provided to individuals as part of their medical treatment.
HCPCS codes are maintained, updated, and distributed by CMS regularly. CMS was tasked with this responsibility following the passage of HIPAA and delegation of authority from the Secretary of Health and Human Services (HHS). Rest assured, Beam ensures telehealth HIPAA compliance for virtual visits between patient and physician to ensure all confidential information is secured.
HCPCS, pronounced as “hick-picks”, is a two-part coding system which includes CPT codes that are broken into two levels. Let’s take a look at the two levels of HCPCS:
- Level I : The first level of HCPCS codes includes CPT codes that are developed by the AMA. These codes are used in outpatient settings for professional services that have been provided to patients.
- Level II : The second level of HCPCS Codes is known as National Codes. These codes are used to describe items and services that are not included in Level I codes. Common examples of products or services with Level II codes are ambulance services, prosthetics, and drugs. Level II codes are in a 5-character alphanumeric format and are revised quarterly by an Alpha-Numeric Workgroup that includes CMS, the Health Insurance Association of America, Blue Cross, and Blue Shield.4
What are HCPCS Codes Used For?
These codes are used to describe services or medical equipment that aren’t covered by CPT codes. Using CPT codes alone for billing would leave gaps for services or items that don’t have an assigned CPT code. For example, there are no CPT codes for drugs, prosthetics, or durable medical equipment, all of which are commonly used in treatment. HCPCS codes allow for more comprehensive, detailed, and accurate billing for services rendered.
When is an HCPCS Code Used?
National Codes are required any time you submit a claim with Medicare and Medicaid. Because of their wide use in these public health programs, many third-party payers also prefer or require the use of National Codes on claim submissions for non-Medicare patients. The idea behind this is that standardized use of HCPCS codes provides more granular and uniform health service data and greater continuity between Medicare and non-Medicare patients.
But what are HCPCS codes not used for? It is important to note that HCPCS National Codes are not used to code services provided in an inpatient setting. Inpatient health facilities assign codes from the ICD-10-PCS, not HCPCS. Rather, HCPCS and CPT codes are used in an outpatient setting. The key difference is that within an inpatient setting, providers use the diagnosis as the basis of payment, while in an outpatient setting the service provided is the basis for payment. Within an outpatient setting, the diagnosis codes are used to establish medical necessity for treatment.
Common Telemedicine CPT Codes
Guidance on current CPT codes provided by CMS can be found readily available online. Note that the current telehealth services covered for the COVID-19 public health emergency are different than what is normally covered.
It should be kept in mind that state law determines what can be reimbursed for telehealth services. Some states have parity laws, where in-person and telehealth services are billed and treated the same. Other states do not, and many states have laws that have different rules for reimbursement under Medicare, Medicaid, and private insurers. Navigating these overlapping rules can be challenging, but our support staff at Beam are here to help! We’ll walk you through coverage in each of the states you are operating in, giving you insights into what’s covered and what isn’t.
Here are a few common CPT telemedicine codes:5
Service HCPCS/CPT Code
|Office or Outpatient Visit||99201-99215|
|Telehealth consultations, initial input, emergency department||G0425-G0427|
|Health and Behavior Assessment (Individual and Group)||96150-96154|
|Telehealth Pharmacologic Management||G0459|
|Psychiatric diagnostic interview examination||90791-90792|
|Medical Nutrition Therapy (Individual and Group)||G0270, 97802-97804|
|Advanced Care Planning (30 minutes)||99497|
|Annual Wellness Visit including a personalized prevention plan of service (PPPS)||G0438 (first visit)|
G0439 (subsequent visits)
|Health Risk Assessment||96160, 96161|
This list is not meant to be exhaustive, and since it changes frequently it is worthwhile for healthcare providers to maintain a current, up-to-date list of CPT and HCPCS codes for services that they provide. What is important is whether a service is using an HCPCS code or a CPT code. HCPCS codes are a five-digit alphanumeric code, such as G0459 for Telehealth Pharmacologic Management. While many services will have either a CPT or an HCPCS code, some services have both.
Alongside the service code, providers must also include a few additional pieces of information. These include:
- Place of Service (POS) 02 – The POS (02) code was implemented in 2017 by CMS to indicate when telemedicine services have been provided.
- 95 Modifier – This modifier is used to signify that telehealth services were provided using synchronous technology, meaning technology that allows for real-time interaction between the patient and provider.
- GQ Modifier – The GQ modifier is used by providers in specific federal telemedicine programs in Alaska or Hawaii that use asynchronous technology.
- GT Modifier – This modifier has been replaced with the Place of Service 02 Code, but remains in use in some situations.6
Gaining an in-depth understanding of medical coding for telehealth services may be challenging, but it’s necessary to get timely reimbursement and avoid any inaccurate claims. The HCPCS coding system contains two levels that you’ll need to be aware of. CPT codes are developed by the American Medical Association and are used for professional services provided in an outpatient setting. Under the HCPCS system, these are considered Level I codes.
HCPCS codes, also called National Codes, are used for services or products that aren’t generally covered by CPT codes. These include things like ambulance services, drugs, and durable medical equipment which don’t have a CPT code. While HCPCS codes were developed for use by providers for services rendered for Medicaid and Medicare patients, many private payers also require providers to submit both CPT and HCPCS codes for all claims.
Understanding which CPT and HCPCS codes to use for telehealth services can be challenging depending on what state you are in. While some states offer policy parity between in-person and telehealth services, others do not. If your practice is ready to begin offering a telehealth component but you aren’t sure how billing and medicare or medicaid reimbursement will work in your state, speak with one of our knowledgeable staff at Beam today.
Our expert staff has a deep understanding of telehealth coverage on a state-by-state basis. We can give you the insights you need to confidently begin submitting claims. And with the Beam platform, offering telemedicine services to your patients has never been easier! Our intuitive platform is easy-to-use, offers robust end-to-end encryption, and doesn’t cost providers anything! To learn more, contact Beam today.
- Carol J. Buck and Jackie L. Koesterman, Bucks 2020 Step-by-Step Medical Coding (St. Louis, MO: Elsevier, 2020), p.197)
- Buck and Koesterman, Bucks 2020 Step-by-Step Medical Coding, 195.
- Buck and Koesterman, Bucks 2020 Step-by-Step Medical Coding, 221.