Written by the AOA’s Coding & Reimbursement Committee.
Excerpted from page 46 of the November/December 2022 edition of AOA Focus.
Beginning April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) allowed payment for audio-only telephone evaluation and management (E/M) visits (CPT codes 99441-99443). CMS made this policy change, noting that some Medicare beneficiaries do not have access to the interactive audio-video technology required for qualified Medicare telehealth services or they choose not to use it.
The audio-only codes are described as follows:
99441 – Telephone evaluation and management service by a physician or other qualified health care professional who may report E/M services provided to an established patient, parent or guardian 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
99442 – 11-20 minutes of medical discussion
99443 – 21-30 minutes of medical discussion
While these codes have been reimbursed under Medicare for the past few years, changes may be coming. In early July, CMS released its proposed coverage policy changes that impact the calendar year 2023 Physician Fee Schedule. Among other things, while recognizing the increased benefits of telehealth services for Medicare beneficiaries, CMS indicated it does not intend to permanently add audio-only telehealth services (CPT codes 99441-99443) to the Medicare Telehealth Services List. Instead, 151 days after the COVID-19 public health emergency (PHE) expires, these services will revert to their pre-PHE “bundled” status under Medicare (i.e., covered but not separately payable). If CMS does indeed end reimbursement for audio-only telehealth services, doctors of optometry will no longer receive separate reimbursement. This is because, per CMS, telehealth services must be analogous with in-person care. Audio-only telehealth services, according to CMS, fail to meet this standard. If this provision remains in the final rule (expected to be released later this year), it will become effective on Jan. 1, 2023 (ending coverage 151 days after the end of the public health emergency).
Federal legislation also could impact the reimbursement for audio-only services in the future. H.R. 4040 would make permanent several telehealth flexibilities under Medicare that were initially authorized during the public health emergency relating to COVID-19. The bill would permanently allow audio-only telehealth under Medicare. At time of publication, the legislation had passed the House and was in the Senate. Look for future updates from the AOA on Congressional action on Medicare and telehealth.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.