By Tiffany Lauria,

With the rapid expansion of telehealth services nationally, CMS is continuing to broaden the ability of practitioners to perform alternative visits and have these visits recognized and reimbursed.

Effective January 1, 2017, CMS will recognize a new Place of Service Code: P02- Telehealth. The descriptor for this code is: The location where health services and health related services are provided or received, through telecommunication technology.

The professional service that is being provided via a telecommunications system by the physician or practitioner at the distant site will be paid at the current fee schedule amount for the service provided at the facility rate. Payment for an office visit, consultation, individual psychotherapy or pharmacologic management via a telecommunications system will be made at the same facility amount as when these services are furnished without the use of a telecommunications system. Modifiers GT (via interactive audio and video telecommunications systems) and GQ (via an asynchronous telecommunications system) are still required when billing for Medicare Telehealth services.

Medicare Practitioners who may bill for covered telehealth services include Physicians, Nurse Practitioners, and Physician Assistants, among other clinicians and are subject to state law. The Center for Connected Health Policy: The National Telehealth Policy Resource Center is a non-profit organization that has a repository of state telehealth policies located on their website at: Practitioners may find it helpful to review their state laws when deciding to implement telehealth services into their patient care.

For more information, on code P02-Telehealth, please see CMS change request 9726:


New HCPCS Modifiers Define Subsets of the 59 Modifier

By Jose Lopez, Senior Consultant, The Verden Group

As of January 1, 2015 the Centers for Medicare and Medicaid Services (CMS) established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier. The Modifier -59, which is used to designate a “distinct procedural service”, is the most widely used HCPCS modifier. It is defined for use in a wide variety of circumstances and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. In addition, this modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of Modifier -59 and help to improve claims processing for providers. The new modifiers (referred to collectively as -X{EPSU} modifiers) are:

  • XE – Separate Encounter, a service that is distinct because it occurred during a separate encounter.
  • XS – Separate Structure, a service that is distinct because it was performed on a separate organ/structure.
  • XP – Separate Practitioner, a service that is distinct because it was performed by a different practitioner.
  • XU – Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual       components of the main service.

CMS will continue to recognize modifier -59 but may selectively require a more specific -X{EPSU} modifier for billing certain codes that are at high risk for incorrect billing. When a specific –X modifier describes the circumstances for reporting both codes it should be reported in lieu of modifier -59. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X {EPSU} modifiers are more selective versions of modifier -59, so it would be incorrect to include both modifiers on the same line. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. For further instructions and implementation of the HCPCS Modifiers -X{EPSU}, check with your Medicare Administrative Contractors (MACs) or Private Payers.

CMS Resources:

The American Academy of Pediatrics Update on Private Payer Implementation of HCPCS Modifiers -X{EPSU}:

Changes to Coding for Brief Emotional/Behavioral Assessments and Developmental Screenings

By Jose Lopez, Senior Consultant, The Verden Group

Effective January 1, 2015, the 96110 code was revised to distinguish it from a new brief emotional/behavioral assessment code 96127. The revision of 906110 clarifies it as an assessment that is focused on identification of childhood and adolescent developmental levels (e.g., fine and gross motor skills, cognitive level, receptive/expressive and pragmatic language abilities, neuropsychological areas [attention, memory, executive functions] and social interaction abilities), rather than behavioral or emotional status, utilizing a standardized instrument.

The new 96127 code is used for brief emotional/behavioral assessment with scoring and documentation using a standardized instrument. This assessment serves as a mechanism to identify emotional and behavioral conditions that previously may have been underestimated and/or undetected in any age population, such as depression screening and attention-deficit/hyperactivity disorder rating scales. This new code was added to differentiate those instruments that look solely or mainly at behavioral and/or emotional issues from developmental screening which are reported with 96110.

A summary of the revision to 96110 and new descriptor for 96127 is as follows:

  • 96110 – Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.
  • 96127 – Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

A listing of brief emotional/behavioral assessment and developmental screening instruments with their appropriate CPT code is listed in the grid below.