How to Deliver, Document, and Bill for Different Types of Remote and Virtual Rehab Therapy

Disclaimer: Information on remote rehab therapy is changing rapidly. So while we are doing our best to provide the most accurate information we can, it is ultimately up to you to monitor updates from CMS, your state and national professional associations, and your payers. What follows should not be construed as legal advice.

In response to the COVID-19 pandemic, regulations are changing and loosening to help facilitate the delivery of remote rehab therapy services. That way, patients can continue to receive the care they need while simultaneously limiting the spread of the virus. Compliance expert Rick Gawenda, PT,  joined WebPT Co-founder and Chief Clinical Officer Heidi Jannenga, PT, DPT, ATC, on April 8, 2020, to present the latest information on how to deliver, document, and bill for these services. If you haven’t watched the webinar yet, we highly recommend you do so—and check out our ever-expanding telehealth and business continuity FAQ here. 

In the meantime, we’ve put together a brief overview of what Gawenda and Jannenga shared—as well as what the APTA is recommending per its latest guidelines—particularly with respect to Medicare beneficiaries. While some commercial payers have adopted these guidelines, not all have, so you’ll want to discuss the specifics with your individual payers prior to billing for any remote care or telehealth services. Furthermore, it’s essential to note that all Medicare-covered remote rehab therapy sessions must be patient-initiated, which means patients must request to connect with you. That said, providers may share that these services are available, and following the patient’s request, providers may be the one to contact the patient to begin the session. 

Now, without further ado, let’s get to it:

Virtual Services

As it stands, there are four main types of virtual services available to patients, each with its own parameters and guidelines:

1. Telehealth Visits: The patient and provider connect over a telecommunication platform for treatment that would otherwise occur in person. As of the publication date of this article, PTs, OTs, and SLPs are not authorized to provide true telehealth services to Medicare beneficiaries unless they are billing incident to a physician. However, if a Medicare patient would like to receive telehealth rehab therapy services, then you may charge that beneficiary out-of-pocket (and we strongly recommend issuing a voluntary advance beneficiary notice of noncoverage [ABN]). Telehealth services should be conducted using a real-time, two-way video platform that meets all payer and HIPAA security criteria. Private payers may have specific CPT codes eligible for reimbursement when services are provided via telehealth. When providing cash-pay telehealth services, use your best clinical judgement to determine which services—and associated tests or measures—you can safely and realistically perform in a telehealth treatment environment. Because there is so much variation in billing requirements for true telehealth services, this article focuses on Medicare’s requirements for billing non-telehealth remote care services.
2. E-Visits: An established patient and provider may connect virtually via an approved online patient portal, such as WebPT’s HEP. E-visits are designed mainly for asynchronous (i.e., non-real time) assessment and management services that are supplemental to in-person visits.
3. Virtual Check-Ins/Remote Evaluations of Images and Recorded Video: An established patient and provider may connect briefly to discuss the patient’s care. These visits may include both asynchronous information exchange (i.e., sending images and videos via secure messaging or email) as well as synchronous phone calls to briefly discuss that information. These visits are designed for assessment and management services that are supplemental to in-person visits. 
4. Telephone Visits: An established patient and provider may connect via a real-time telephone call to discuss the patient's care. Telephone visits are designed mainly for synchronous assessment and management services that are supplemental to in-person visits. They do not account for technology use beyond the telephone.

E-Visits

The Codes

• G2061: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes. 
• G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes.
• G2063: Qualified non-physician healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

The Modifiers

Per CMS, as of March 30, 2020, these codes are considered “sometimes therapy codes.” This means that—in addition to the CR modifier that must be used for the duration of the COVID-19 crisis—you must affix the GP, GO, or GN therapy modifier when billing these services. CMS has not stated whether it will pay for these services when billed by institutions on a UB-04 claim form.

The Payout

As we explain in this blog post, “You can use CMS’s physician fee schedule search tool to find information specific to your location. That being said the non-facility national payment amount averages are as follows:

• G2061: $12.27
• G2062: $21.65
• G2063: $33.92”

Example

A Medicare patient calls his physical therapist to cancel an upcoming appointment due to the need to shelter in place. The therapist informs the patient that he can stay in contact with the therapist—and continue receiving instruction and guidance on his home exercises and other home care elements—by initiating an e-visit. The patient agrees to do this. The therapist documents the patient’s initiation of the service as well as his consent to receive it. The therapist sets the patient up with access to a secure patient portal that allows him to send and receive messages and other materials—like exercise videos and images. The patient uses the portal to tell the therapist that he is having trouble replicating some of the exercises at home due to lack of equipment. The therapist makes suggestions on how he can adapt the exercises using household items and sends recorded videos to demonstrate those suggestions. The therapist spends 30 minutes thinking about how to adapt the exercises, preparing the materials, and sending them to the patient. The therapist does not provide any other services over the course of the seven-day period, so she bills one unit of G2063.   

Virtual Check-Ins/Remote Evaluations of Images and Recorded Video

The Codes

• G2012: Brief communication technology-based service (e.g., virtual check-in), by a physician or other qualified healthcare professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
• G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

The Modifiers

Per CMS guidance issued on March 30, 2020, these codes are considered “sometimes therapy codes,” which means that—in addition to the CR modifier that must be used for the duration of the COVID-19 crisis—you must affix the GP, GO, or GN modifier when performing and billing these services. CMS has not stated whether it will pay for these services when billed by institutions on a UB-04 claim form.

The Payout

According to CMS’s physician fee schedule search tool, the non-facility national payment amount averages are:

• G2010: $12.27
• G2012: $14.80

Example

Let’s assume that, similar to the e-visit example, the Medicare patient has initiated and consented to receiving a remote evaluation service. The patient isn’t sure he is performing a particular exercise correctly, because it is making him very sore afterwards. He records a video of himself performing the exercise and sends it to the therapist for review via email. The therapist receives the video, watches it, and immediately calls the patient on the telephone to provide instruction on how to correct his form so that he is performing the exercise correctly and thus, reducing the amount of soreness he feels afterwards. The therapist may bill one unit of G2010 to account for this service.  

Telephone Visits

The Codes

• 98966: Telephone assessment and management services provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian, not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management procedure within next 24 hours of soonest available appointment; 5-10 minutes of medical discussion.
• 98967: Telephone assessment and management services provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian, not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management procedure within next 24 hours of soonest available appointment; 11-20 minutes of medical discussion.
• 98968: Telephone assessment and management services provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian, not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management procedure within next 24 hours of soonest available appointment; 21-30 minutes of medical discussion.

The Modifiers

According to CMS, these three codes also require the GN, GO, or GP modifier. Gawenda believes they also require the CR modifier; however, we’re still waiting for confirmation from CMS. Speaking of confirmation, we’re also waiting on confirmation on whether CMS will pay for these codes when institutions bill them on UB-04 claim forms.

The Payout

Because Medicare did not previously cover these services at all, they are not included in the most recent version of physician fee schedule, meaning there is no payment information for them.

Examples

1. A 64-year-old woman had a right knee arthroplasty 12 days ago. She is an established patient at your PT practice and contacts you to tell you that after completing her home exercises today, she is experiencing increased soreness and pain around her right knee. You ask her a few questions to gather more information about which exercise she was performing and whether she did anything to remedy the pain at home. As a result, you learn that the patient walked on her StairMaster for 15 minutes prior to completing her home exercise program, and she did not ice her knee afterwards as you had previously instructed. You remind the patient to lie supine for 10 to 15 minutes following any exercise with her right leg elevated and ice on her knee. You also encourage her to skip the rest of her exercises for the day and resume them tomorrow, assuming the pain and swelling subside.

This phone call lasts 6 minutes, so you would bill one unit of 98966 with the GP and—most likely—CR modifiers, depending on what we learn from CMS. 

2. Now, if you are an OT, and an established patient reaches out to you to discuss, say, the wearing schedule and fit of her orthosis, and you spend 16 minutes discussing techniques for ensuring a proper fit and comfort, then you would bill one unit of 98967 with the GO and—most likely—CR modifiers.
3. Finally, if you are an SLP, and the husband of an established patient contacts you because his wife with stroke-induced dysphagia is having coughing fits while eating, and you spend 28 minutes asking questions to ascertain what might be causing the problem and providing instructions for safe feeding strategies, then you would bill one unit of 98968 with the GN—and most likely—CR modifiers.

Please note that these codes are not speciality-specific and instead depend solely on the time spent with each patient.

Place of Service Codes

As we discussed in this blog post, whenever providers bill for remote therapy services, they must denote two site location codes:

1. The site where the patient is located (a.k.a. the originating site) 
2. The site where the practitioner is located (a.k.a. the distance site)

As a reminder, for Medicare services, those place of service codes (POS) are:

• POS 11: Clinic
• POS 12: Home

According to Gawenda, for all services conducted during the current pandemic, Medicare will accept the patient’s residence as the originating site. We are currently recommending that providers use POS 11 when they provide services from their clinic and POS 12 when they provide services from their home.

Additionally, when billing true telehealth services to commercial payers (remember, Medicare does not cover true telehealth), you will typically use POS 02, which indicates the services were furnished via telemedicine. 

Documentation

The documentation requirements for all remote therapy services are the same as those for in-person visits. Thus, you’ll want to adhere to all Medicare guidelines for defensible documentation. Per Gawenda, you’ll also need to note that the patient initiated and consented to conducting a remote therapy session. Note that some—though not all—states and payers require therapists to record their telehealth visits. If you plan to record sessions, you must also document your patient’s consent to being recorded and having that recording saved. Furthermore, all “telehealth service providers must read their state practice act, all applicable administrative telehealth rules, and payer’s telehealth policies—and adhere to any additional documentation requirements” as outlined.

Want more details on conducting and billing for telehealth, e-visits, and other remote care services for both Medicare and commercial payers? Watch the WebPT webinar in full. Want help documenting patient consent, establishing best practices for conducting and billing for remote therapy services, and choosing the best secure video platform? Check out the webinar Gawenda recently hosted with his colleague Mark Milligan, PT, DPT.