Telemedicine: How to Maximize Your Reimbursement

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By Teri Thurston
Billing & Coding Advisor, PECAA

July 22, 2020

Telemedicine gained tremendous traction during the recent practice shutdowns, in which only emergency eyecare was permitted to be provided in-person. Now, many patients, who had never experienced this new way of visiting the doctor, may be open to continuing to do so. Some may even expect the continuation of remote access to their eye doctor. Here are key points to keep in mind to ensure you receive maximum reimbursement for services delivered via telemedicine.

Telemedicine Codes to Know

Here are key resources to guide you in coding for services delivered via telemedicine:

• There is a lot of information available on the American Medical Association web site.

• A complete list of covered Telemedicine and Telehealth codes can be found on the CMS web site.

AOA guide to telehealth-based care during COVID-19

PECAA COVID-19 Optometry Resource web page

Telemedicine is Here to Stay
The most common misconception about telemedicine is that it doesn’t have a lasting place in the OD practice, and is not profitable enough to implement. Through the current health crisis, we’ve seen physicians and patients find benefit in accessing care through telemedicine services. Long-term, telemedicine has the potential in optometry to offer an additional revenue stream by expanding options for care delivery.

These days who hasn’t had a telemedicine visit! Patients are experiencing telemedicine visits with various specialties in all types of clinical settings and becoming familiar with the process. The Public Health Emergency (PHE) has opened up an opportunity for optometrists to try telemedicine services with relaxed restrictions, taking some of the pressure off providers.

Implementing telemedicine services during this time has allowed physicians to really see what works and what doesn’t, and how patients respond to virtual visits. Not only have some barriers of delivering care been lifted, but we have also seen an increase in reimbursements for telemedicine services.

Getting Started: Basic Points to Know About Reimbursement
Telemedicine rules and regulation vary by state and by individual contracted insurance payer. Making sure physicians meet both requirements will be a key step in implementing telemedicine. The state rules depend on where the patient is being seen, rather than where the physician is providing care. During the Public Health Emergency 1135 Waiver, however, this state-to-state restriction has been temporarily lifted to allow greater access to care.

Each telemedicine and telehealth CPT code is based on how care is delivered, either by:

Real-time audio video communications allowing for face-to-face interactions (synchronous)


Through technologies that collect and store images or data to transmit and interpret later, or simply audio communications. Think non face-to-face communications (asynchronous), such as patient portals, or smartphones, for example.

Utilizing a HIPAA compliant platform, like Eyecare Live, will be necessary in implementing telemedicine services, especially once the PHE 1135 Waiver is no longer in place.

It will be important for physicians and billers to understand the coding guidelines for each of the Telemedicine Evaluation and Management CPT codes. For example, when billing Medicare for face-to-face (synchronous) Telemedicine services (99201 – 99205, 99211 – 99215) append modifier 95, defined as “telehealth” to the service line. Generally, the place of service code would be changed from “11” for in-office to “02” to indicate telemedicine services were performed.

However, Medicare is currently allowing the place of service code to remain as “11” for in-office while the PHE 1135 waiver is in place. Determining the specific billing requirements for each contacted insurance plan, and verifying the patient’s coverage and benefits, will be important factors for successful reimbursement outcomes.

Be Careful: Not All Payers Have Relaxed Requirements for Reimbursement
The majority of insurance plans have followed CMS recommendations following the 1135 Waiver expansion. However, not all insurance plans are following CMS/Medicare billing guidelines or reimbursing on the same telemedicine and virtual care codes. The billing requirements for telemedicine E/M services can vary by individual insurance plan. Most payers have published on their web sites these billing requirements. By reviewing a payer’s medical policies or COVID-19 webpages, you’ll generally find this information.

For example, Medicare may not reimburse for Online Digital Evaluation and Management services (99421 -99423), but you may find your local Blue Cross Blue Shield does. If you are receiving a denial for non-covered services, double-check the payer’s telemedicine/telehealth medical policy or their COVID-19 resources for a list of codes that are covered. Other denials may be received around invalid place of services codes, or improper use of modifiers due to changes made by CMS from March until now.

Going back and reviewing these changes may be beneficial if you are receiving a number of denials. Making the necessary corrections, and resubmitting the claims following the payer’s preferences for claim correction, should get denials resolved.

Resources to Help You Maximize Telemedicine Profitability
On the PECAA web site, under COVID-19 Optometry Resource webpage, you will find telemedicine billing information. In addition, PECAA offers billing and coding education and support to both physicians and staff through reference guides, webinars and billing and coding workshops. Members also have access to one-on-one support in troubleshooting issues and process implementation within the revenue cycle.

The public health emergency of the pandemic has shone a spotlight on virtual services, highlighting what is working and what is not, and CMS is paying attention to physician input. Over the last few months we’ve seen an increase in reimbursement rates in telemedicine and an expedited need for virtual services during the public health emergency.

As optometry moves forward reviewing opportunities for practice growth, telemedicine may prove beneficial. Even if you determine it’s not a good fit today, it may be worth revisiting in the future.

Teri Thurston is the Billing & Coding Advisor for PECAA. To learn more about PECAA’s Billing & Coding program, please call 503-670-9200 or e-mail:



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