Telemedicine Codes – A Quick Guide on CPT and CMS Codes

The telemedicine sector had already been climbing steadily over the last couple of years, but the pandemic caused sudden and widespread adoption. In 2020, the global telemedicine market size was $55.9 billion and is expected to grow at a CAGR of 22.4% between 2021 and 2028. There’s no longer any doubt. Telemedicine is here to stay.
But of course, many issues need solving. Despite the increase in telemedicine adoption, the challenge of healthcare expense reimbursement haunts many. Given the multitude of insurance players in the market, the numerous policies being offered, and the fluid rules that change from payer to payer, the onus is on healthcare providers to adopt efficient ways to bill telehealth patients and maximize their chances of full and timely reimbursement.

What are telemedicine codes?

Billing patients for telemedicine services can be tricky. Especially as the volume of patients opting for these services grows, it can be hard to keep up. Although the guidelines around telemedicine billing are still evolving, telemedicine codes make it easy for healthcare providers to ensure maximum reimbursement.
Telemedicine codes make the process of claiming insurance seamless and error-free. These codes pave the way for putting in place apt guidelines for billing patients for virtual care – just as they would have been billed for a normal face-to-face office visit – albeit with certain changes to maximize the amount of coverage received.
Current Procedural Terminology (CPT) and Centers for Medicare and Medicaid Services (CMS) are two of the most popular telemedicine codes that are recognized by both private and public payers. Since telemedicine services need to be billed based on where the patient is located and what services he/she received, these codes outline the different coding and billing requirements.

  • CPT codes, also known as service codes, are universally recognized as the medical procedures offered to patients via telemedicine. These five-digit codes are uniquely specific to the treatment that was provided and indicate the service healthcare providers are billing for. They are the primary billing code and do not identify or mention the diagnosis.
  • CMS requires the inclusion of both – the originating site where the patient was located at the time of telemedicine encounter as well as the distant site where the physician or licensed practitioner delivering the service was located. Accordingly, a telemedicine facility fee is paid to the originating site and claims should be submitted using the appropriate code.
Why are they necessary?

Although telemedicine helps healthcare providers deliver timely, high-quality care to patients in the comfort of their homes, a major obstacle has always been (and remains) the complexity in reimbursement. Since the industry as a whole has been slow to implement formal policies around telemedicine compensation, misconceptions around reimbursements at a reduced rate are rife – which makes telemedicine economically unattractive to providers.
As the pandemic continues to wreak havoc across the world, here’s why telemedicine codes like CPT and CMS are a blessing for healthcare providers:

  • Telemedicine codes simplify the coverage and eligibility of telehealth services, making it easy for healthcare providers to reimburse healthcare payments, often at the same rate as in-person service.
  • These codes help ease the financial burden of healthcare services, especially at a time when healthcare providers are already under immense strain and stress, treating and taking care of the constant slew of COVID-19 patients.
  • Today, many new and upcoming services are included in these codes, making even reimbursements for medical nutrition therapy, cognitive and speech impairment, mental health disorders, and physical therapy and occupational therapy possible and frictionless.
  • Telemedicine codes make it easy for providers to cover costs – irrespective of the services provided, where the patient was located, or how new or established the public or private provider is.

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Challenges (and solutions) with integrating them into the healthcare model

Although CPT and CMS codes aid providers (and patients) receive decent reimbursement for the telehealth services provided to patients in a pandemic era, some issues need to be looked into

  1. Which code to use when: Given the massive number of telehealth services offered and the presence of just as many codes, you might find it challenging to determine which code to use when. This issue can be overcome by speaking to the payer to learn about their policies for telemedicine
  2. Updating the database: The rapidly changing nature of telemedicine reimbursement policies is also a challenge you need to overcome. This can be done by investing in a scalable, automated database that takes into account the variations between payers as well as policy changes that happen over time. Using automated rules, the database will take note of changes and automatically push them to respective patients for optimal reimbursement.
  3. Ensuring vast coverage: When it comes to telemedicine, a large number of payers continue to offer reimbursement only for critical health issues. But as the number of psychological, cognitive, and mental health issues continue to surge, to ensure full reimbursement, providers must reach an amicable middle ground with payers and have a common understanding of the services that will be covered under telemedicine – with the option of expanding coverage as the pandemic worsens.

As telehealth continues to gain widespread adoption, telemedicine codes like CPT and CMS make it easy for healthcare providers to get reimbursements for healthcare services provided remotely to patients. With new rules coming out every day, these codes make it easy for providers to keep up with changing policies and apply codes as applicable for timely and optimal reimbursement.

Common Medicare Telemedicine Services – CPT Codes Summary by Type of Patient”
Mandar Gadre | Director of Engineering – Healthcare & Manufacturing

Mandar Gadre serves as Director of Engineering – Healthcare & Manufacturing for GS Lab. Mandar holds B.Tech from IIT Bombay, and a Ph.D. in engineering from Arizona State University, USA. He brings deep expertise and experience in crafting industrial solutions, leading technology teams, while contributing technically to sensor technology, hardware and control solutions, and data analytics. Mandar has helped numerous organizations implement IIoT and delivered results that have shaped new business models for those organizations.