Virtual Care II

By: Kerry Luciani, Business Intelligence Manager, Healthcare Resource Group Inc.


This year, Medicare (CMS), began paying for virtual care visits under the Medicare Physician Fee Schedule. As recently published in the fee schedule regulations, this is what we know:


  • Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care 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.
  • Includes 5-10 minutes of medical discussion.

Supplementary information, is as follows:

  • Technology usage: Audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions enhanced with video or other kinds of data transmission, is included (only allowed between the patient and the billing practitioner).
  • Pricing: It is priced at a rate lower than current E/M in-person visits to reflect the low work time and intensity, and to account for the resource costs and efficiencies associated with the use of communication technology. The office based national rate per visit is approximately $14.78 per visit.
  • Beneficiary payment responsibility: Cannot be waived due to statute, so any co-insurance/co-pay responsibility will be owing from the beneficiary.
  • Consent: Verbal consent by the patient must occur and be noted in the medical record for each service.
  • Clinician Type: This set of codes is only reportable by those that can furnish E/M services. Though similar beneficial check-ins may be provided by nurses/other clinical staff, they are not allowed to bill for this new service.
  • Caregiver setting: This is not consistent with the existing Telehealth Distant site location policy.
  • Coverage: Applicable to traditional Medicare only. Varying degrees of adoption will occur with other non-governmental carriers (including Medicare Advantage plans).
  • Utilization: Concerns exist that this new service may be over-utilized. However, CMS will not implement a frequency limitation at this time, but will monitor adoption of the new service.
  • CMS also introduced one other service, HCPCS G2010. This code acknowledges remote evaluation of recorded video and/or images submitted by an established patient.

Please note this proposal is not to be confused with Medicare’s Telehealth program and reimbursement policy. Distinct differences to that program do exist.

Lastly, it is never too late to be operationally ready for such changes. Under this final rule, Medicare anticipates the new service will mitigate the need for potentially unnecessary office visits, and fewer billable services.

About the author:

Kerry has over 30 years of healthcare revenue cycle management experience on both the payer and provider side. Over the course of his career, Kerry has developed an abundance of expertise in Medicare Part B reimbursement and has published several comments in the Federal Register.


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