Use of New Audio-Only Telemedicine Claim Modifiers


Contact: Johnathan Staloff, MD, MSc



COVID-19 spurred a rapid uptake of telemedicine in the US. This adoption was enabled in part by responses to pandemic circumstances, including policy changes by Medicare and other insurers to reimburse for telemedicine services at parity to in-person services.1 Such changes included coverage and payment parity for audio-only telemedicine services that enabled patients and clinicians to connect synchronously via telephone.

However, audio-only telemedicine use has been difficult to characterize. At the beginning of the COVID-19 pandemic, audio-only telemedicine services were intended to be coded with specific Current Procedural Terminology (CPT) codes 99441 to 99443 (evaluation and management [E/M] telephone visits conducted with physicians) and 98966 to 98968 (telephone visits conducted with nonphysician health care professionals) in contrast to audiovisual services, which were denoted by CPT code modifiers 95 or GT.2 However, additional types of services denoted by other CPT codes were increasingly permitted to be offered via audio-only telemedicine over the course of the pandemic3 and difficult to capture due to a lack of specific modifiers.

Furthermore, among patients who self-reported having an audio-only service in a survey in fall 2020, only 20% had a matching corresponding claim.4 In comparison, among those reporting an audiovisual service, 96% had an audiovisual service claim. The reasons for this difference are unclear and may be due to discrepancies in billing (eg, clinician billing for audio-only services as audiovisual services) or perceptions (eg, differences in patients’ and clinicians’ definitions of audio-only services). Data discrepancies undercut the ability to accurately identify and understand utilization of audio-only telemedicine services.

This problem is particularly worrisome because of what is at stake. From a financial perspective, reimbursement for audio-only telemedicine is new, with ongoing debates about whether and how to continue reimbursement. This is, in part, due to the limited evidence regarding the clinical effectiveness of audio-only telemedicine and despite the lack of firmly established evidence, assumptions about the superiority of audiovisual telemedicine.5,6 In reality, some patients may prefer audio-only telemedicine when offered a choice.7

Audio-only telemedicine also poses important equity implications with historically disadvantaged groups potentially relying more heavily on audio-only modalities to access telemedicine. Specifically, use of audiovisual vs audio-only services has been lower among older, non-English speaking patients, racial and ethnic minority individuals, and individuals living in areas with low broadband access.8,9 This utilization gap may reflect access to, knowledge of, and comfort with the use of audiovisual-enabled devices, as well as practice and health care professional assumptions of who may be willing and able to conduct audiovisual services.

New CPT code modifiers 93 and FQ were created in 2022 to address these issues and more reliably identify situations in which audio-only medicine is used for any reason and specifically for behavioral health services, respectively. However, there is a dearth of data about the use of these codes, and the types of care they reflect. In this analysis, we aimed to address this knowledge gap and use new code modifiers to describe early trends in audio-only telemedicine.

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