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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.

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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

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Billing and coding Medicare Fee-for-Service claims

Read the latest guidance on billing and coding Medicare Fee-for-Service (FFS) telehealth claims.

On this page:

Telehealth codes covered by medicare, coding claims, common telehealth billing mistakes, more information about ffs billing.

Medicare added over one hundred CPT and HCPCS codes to the list of telehealth services .

Telephone visits and audio-only telehealth

Medicare is temporarily waiving the audio-video requirement for many telehealth services. Codes that have audio-only waivers are noted in the list of telehealth services .

Place of Service codes

When billing telehealth claims, it is important to understand the place of service (POS) codes as it affects reimbursement.

The POS code (PDF) explains where the provider and patient are located during the telehealth encounter. There are currently two POS codes:

• POS 02: Telehealth provided other than in patient's home. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
• POS 10: Telehealth provided in patient's home. 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.

Avoiding mistakes in the reimbursement process can help implementing telehealth into your practice a smoother experience.

Incorrect billing codes

More than 100 telehealth services are covered under Medicare. However, some CPT and HCPCS codes are only covered temporarily.

Using the wrong code can delay your reimbursement. This can happen for a variety of reasons, such as a misunderstanding of what code applies to what service or input error.

Stay up to date on the latest Medicare billing codes  for telehealth to keep your practice running smoothly.

Documentation

Post-visit documentation must be as thorough as possible to ensure prompt reimbursement.

While there are many similarities between documenting in-person visits and telehealth visits, there are some key factors to keep in mind.

Patient consent

Make a note of whether the patient gave you verbal or written consent to conduct a virtual appointment.

Code categories

Telephone codes are required for audio-only appointments, while office codes are for audio and video visits.

Time of visit

A common mistake made by health care providers is billing time a patient spent with clinical staff. Providers should only bill for the time that they spent with the patient.

Store-and-forward

Many states require telehealth services to be delivered in “real-time”, which means that store-and-forward activities are unlikely to be reimbursed. You can find information about store-and-forward rules in your state here  .

Originating sites and distant sites

Learn about eligible sites as well as telehealth policies specific to Federally Qualified Health Centers and Rural Health Clinics.

If you are looking for detailed guidance on what is covered and how to bill Medicare FFS claims, see:

• Billing for Telehealth Encounters: An Introductory Guide on Fee-for-Service  (PDF) – from the National Policy Center - Center for Connected Health Policy

Medicaid and Medicare billing for asynchronous telehealth

Learn how to bill for asynchronous telehealth, often called “store and forward".

Billing Medicare as a safety-net provider

Medicare billing and coding guidelines on telehealth for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).

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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2024 Telehealth CPT Codes: Cheat Sheet

Charika Wilcox-Lee, VP, Revenue Cycle Management

Keeping track of telehealth reimbursements accurately directly impacts your healthcare organization’s bottom line. We’ve compiled a list of telehealth CPT codes to help you better navigate telehealth billing for your care program.

Source: American Academy of Sleep Medicine (AASM)

CMS Telehealth & RPM Billing Guidelines [PDF]

In recent years, the Centers for Medicare & Medicaid Services (CMS) have released the physician fee schedule with expanded reimbursement for remote patient monitoring (RPM). The guidelines notably increase reimbursement for other services like remote therapeutic care and chronic care management, while making slight adjustments to allowances for RPM.

Top 4 Common Telehealth Billing Mistakes—And How to Avoid Them

The surge of telehealth adoption in recent years has led to regulatory changes and telemedicine coverage expansion that greatly benefits healthcare providers—if reimbursement is done correctly. Here are the top four common mistakes when billing for telehealth, and how you can avoid them.

Mistake #1: Not keeping up with the correct billing codes

As Medicare regulations change in response to public healthcare needs, the billing codes that you’re already familiar with could change as well. Submitting claims with the wrong code could result in delayed reimbursement and in some worst cases, be flagged for abuse.

Avoid by : Staying up to date with additions or deletions to the list of Medicare telehealth services .

Mistake #2: Not maintaining post-visit documentation

Ensuring that you document the right information during telehealth visits is key to getting prompt payment. For a start, touch base with your administrative team to understand the type of information you should be keeping a record of.

Avoid by : Creating a checklist that you can go over before the telehealth visit for cross-checking purposes.

Mistake #3: Not training your team on telehealth billing processes

Your team already has to keep track of thousands of CPT codes on a daily basis. With the new batch of telehealth CPT codes added to the mix, things can easily get very complicated for your team.

Avoid by : Training your team on the types of codes, processes, and all things reimbursement.

Mistake #4: Not checking with the patient’s insurance beforehand

While most major private payers provide coverage for telemedicine, it’s prudent to call up the payer and confirm if the services offered are covered. The good news is, that you’ll only need to verify this once for that particular policy.

Avoid by : Being more diligent about checking insurance coverage before the patient’s first telehealth visit. Use an insurance verification form to log the call and make sure you’re asking the right questions.

8 Key Updates to Telehealth Reimbursement in 2024

CMS has   released its final rule   for Medicare payments under the Physician Fee Schedule (PFS), introducing significant changes that will impact healthcare providers across the country. To help you stay informed and prepared, we've compiled the eight key updates you need to know.

Telehealth Reimbursement Resources & Expert Support

At Health Recovery Solutions, we provide a host of resources on reimbursement and telehealth billing modeled after best practices that we established from working with our healthcare partners—and we’re ready to help. Whether you're in the early stages of researching the benefits of telehealth and remote patient monitoring for your patients or you have an existing program in place and you're considering options to maximize the value of RPM, our team of experts is here to support you. 

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April 27, 2024

Coding Telehealth Visits: Place of Service

Information in this article was updated July 2023, based on the 2024 Proposed Physician Fee Schedule Rule.

Coding telehealth visits changes faster than the weather here in New England. The resources on the site relate to Medicare policy and CPT codes and rules. Unfortunately, they don’t address individual commercial payer policies.

• There are two new POS codes for coding telehealth visits, but don’t start using them for Medicare.
• Place of service codes determine if the encounter is paid at the facility or non-facility rate. The non-facility rate is a higher rate of reimbursemnet.
• Congress passed a law 12/20/2020 that allows behavioral health services to continue to be billed via telehealth after the end of the public health emergency.
• The Consolidated Appropriates Act, 2023 extended certain telehealth flexibilities through Dec. 31, 2024. These are described in another article on CodingIntel.

CMS is proposing that beginning in CY 024, claims submitted with POS 10 will be paid at the higher, non-facility rate.

Beginning January 1, 2024, claims submitted with POS 02 will be pad at the lower, facility rate.

POS 02 : Telehealth Provided Other than in Patient’s Home

Description: 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.  (Effective January 1, 2017) (Description change effective January 1, 2022, and applicable for Medicare April 1, 2022.)

POS 10: Telehealth Provided in Patient’s Home

Description: 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.)

See CMS’s MedLearn Matters article describing the new POS code. It seems to indicate we shouldn’t use it!  Here is what they say:

“ Medicare hasn’t identified a need for new POS code 10. Our MACs will instruct their providers to continue to use the Medicare billing instructions for Telehealth claims in Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190 .”

This policy is confirmed in the 2023  Physician Fee Schedule Final Rule.

“As such, we are finalizing that we will continue to allow for payment be made for Medicare telehealth services at the place of service for telehealth services that ordinarily would have been paid under the PFS, if the services were furnished in-person, through the latter of the end of the of CY 2023 or the end of the calendar year in which the PHE ends. For those services furnished in a facility as an originating site, POS 02 may be used, and the corresponding facility fee can be billed, per pre-PHE policy, beginning the 152nd day after the end of the PHE.” page 197

Continue to use the place of service in which the service would have been provided until Dec. 31, 2024.

What about a patient in their car? 

From the 2023 Final Rule, p. 193. “ We remind readers that we defined “home” in our CY 2022 PFS final rule (86 FR 65059)to include, as: “both in general and for this purpose, a beneficiary’s home can include temporary lodging, such as hotels and homeless shelters. We also clarified that for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth service, the service is still considered to be furnished ‘in the home of an individual’ for purposes of section 1834(m)(4)(C)(ii)(X) of the Act.”

Use POS 10 in this situation.

POS “10” – Telehealth Provided in Patient’s Home

One MAC, NGS posted a question about this, which is linked below.

https://www.ngsmedicare.com/web/ngs/news-article-details?lob=96664&state=97224&rgion=93623&selectedArticleId=3794814

And, here is a link to the Family Practice Management journal article that describes the policies of two other payers.

Coding telehealth visits

• Telemedicine and COVID-19 FAQ
• Telemedicine in RHCs and FQHCs
• Is it or isn’t it a telehealth service
• Telemedicine | Webinar
• Payment for telephone calls
• Overview of Medicare telehealth services
• Interprofessional Internet Consultations
• CPT® codes (99421-99423) – and payment for – online digital evaluation and management (E/M) services
• Virtual communication: two new HCPCS codes G2010 and G2012
• Should we begin using the new CPT modifier -93
• Modifier 95
• Modifier CS
• Medicare changes telehealth rules, again

Telehealth source documents you can download

• CMS list of telehealth
• AMA coding advice
• CMS interim rule – March 30, 2020
• CMS interim rule – April 30, 2020
• CMS enrollment COVID-19PEHotline
• Aledade guide to getting started with telehealth

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Last revised April 8, 2024 - Betsy Nicoletti Tags: telehealth

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A virtual visit algorithm: how to differentiate and code telehealth visits, e-visits, and virtual check-ins

Virtual visits have quickly become vital in the primary care setting as a way to continue providing care while reducing exposure during the COVID-19 national public health emergency. The Centers for Medicare & Medicaid Services (CMS) has temporarily relaxed certain requirements for Medicare telehealth visits to make them more widely available, even through the use of basic tools such as Facetime, Skype, and Zoom. Some private payers are also expanding their coverage of virtual visits, but the American Academy of Family Physicians is calling on all payers to do the same.

There are four types of virtual visits:

• 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 (which are not covered by Medicare but may be covered by some private payers).

The following algorithm, developed by James Dom Dera, MD, FAAFP, provides a quick way for physicians to tell these services apart and to assign proper codes for reimbursement.

Note: On March 30, CMS announced another broad expansion of telehealth capabilities, including audio-only telephones. You can read more about it here . The list of specific codes covered can be found here . For more information on the other types of virtual visits, CMS has put together a toolkit for primary care practices .

Virtual visit algorithm

Click for full-size version.

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Telehealth Coding Billing CPT codes for Video, Virtual and e-visit

Types of virtual services.

• Medicare telehealth visit
• virtual check-ins 

Telehealth Coding Billing CPT codes for Video, Virtual, and e-visit

Telehealth visits, virtual check-ins, post a comment.

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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.

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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

View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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