March 15, 2020

March 15, posted on NANOSnet


Dear NANOS members,

As the worldwide response to COVID-19 continues to evolve, there is a growing demand for telemedicine options to minimize in-person exposure (1,2). While some of the discussion is geared towards applying telemedicine practices for screening for COVID-19, questions have also been raised about how this applies to the way we've practiced medicine (3). Specifically for neuro-ophthalmology, is there an appropriate context for us to safely provide high-quality care using telemedicine to reduce the risk of exposure, and how can we get paid for these services?

While it may or may not be possible to implement new telemedicine technologies this late, we want to support our members who are considering utilizing telemedicine services where possible during this pandemic. Some of you may be working closely with your institutions to craft telemedicine solutions. Obviously, telemedicine does not replace the in-person exam, but it may allow us to make appropriate medical decisions in patients where in-person examination is not required. In neuro-ophthalmology, some possible cases may include:

  • Stable myasthenia gravis patients with no symptoms
  • Resolved microvascular ischemic cranial nerve palsies
  • Stable MS patients with no visual symptoms
  • Stable visual pathway tumors (the patient may have a local ophthalmologist who can perform ancillary testing)

We encourage you to use your best judgment when it comes to determining what patients may be good candidates for telemedicine care. Given our recent Telemedicine Symposium at the NANOS 2020 Annual Meeting, We wanted to summarize some basic ideas and strategies for you to consider as you decide what works best for your practice. Resources and references have been linked at the bottom of this message.

For those who may end up or currently are participating in the screening and triage efforts for COVID-19, CPT just released a new code for the lab testing:  87635.

Telemedicine of Interest to Neuro-Ophthalmology

Live Synchronous ("Real-Time Video")

  • You are talking with the patient in real-time with video through a privacy-compliant application.
  • While some electronic medical record (EMR) programs already have this feature available, others do not but this type of encounter can still be achieved through 3rd-party vendors.
  • The medical history is collected in the same manner; depending on the technology, equipment, and technician services available where the patient is located, some elements of the physical exam may also be available for interpretation.
  • You document your encounter in the typical "SOAP" (Subjective-Objective-Assessment-Plan) fashion.
  • Time spent on call may be helpful if billing based on time.
  • You counsel the patient live as you would in person.
  • If billing Medicare/Medicaid, the patient must be located in a healthcare provider shortage area ( Other plans may be more flexible, including Medicare Advantage plans (see below).

"Virtual Check-In"

  • This is either a phone call or video chat with an ESTABLISHED patient.
  • The communication is initiated by the patient.
  • The goal of this type of encounter is to determine whether or not the patient needs to be seen in clinic for a NEW problem or CHANGE to existing problem.
  • Documentation includes nature of the visit, medical decision making (including whether or not the patient needs to be seen), and time spent on call.
  • Non-qualified calls:  calls related to follow-up of recent visit diagnoses (within the last 7 days) including test result updates, calls that result in scheduling urgent evaluation (within 24 hours or next available appointment)

Review/Interpretation of Remote Patient Data

  • An ESTABLISHED patient securely messages you photos/videos of their condition, which you review, interpret, and then call the patient back to discuss management.
  • Documentation includes interpretation, phone discussion summary, and time spent on evaluation.
  • Non-qualified calls:  evaluation related to recent visit diagnoses (within the last 7 days), test evaluation prompts urgent evaluation (within 24 hours or next available appointment).

Online Patient Portal Communication

  • An ESTABLISHED patient securely messages you through patient portal. The back-and forth conversation may involve medical decision making, but may be an exchange of information (patient questions).
  • The communications can take place over a 7-day period.
  • Documentation is through the message exchange, and total time spent during entire exchange (provided it is within a 7-day period) is used as billing reference.

Interprofessional Consult ("E-Consult")

  • NEW patient or ESTABLISHED patient with NEW or CHANGE in existing condition
  • Initiated by a doctor or APP to consultant
  • Verbal or written request
  • Written report (+/- verbal summary to consultant) summarizing data review and recommendations, as well as time spent (data review and summary are considered separately for time)
  • Non-qualified calls:  calls related to recent visit to consultant (within 14 days), calls prompt evaluation by consultant within 14 days, patient is still at referring doctor's office, patient had similar E-consult within last 7 days

Billing for Telemedicine Services (U.S.)

We recognize that many of our non-U.S. members will have different rules regarding the billing of telemedicine services. Within the U.S., Medicare and Medicaid have some rules regarding billing that may or may not be recognized by other insurers. While cash payment (concierge-type services) is the most direct method for payment, not all patients will choose to use this route. While the focus of this section is geared towards some of the specific billing/coding regulations in the U.S., we hope that this discussion will also be useful in other contexts.

With the declaration of a national emergency in the U.S., many of the restrictions previously placed on telemedicine services have been temporarily lifted, including restrictions on requiring separate state licenses if a physician is remotely treating a patient located in a different state (4). Some private insurers have announced measures to also aid in telemedicine services, though the scope of these waivers remains variable and may be limited to COVID-19-related visits (5).

The Centers for Medicare and Medicaid Services (CMS) has several articles on their website addressing implementing and utilizing telemedicine services that may be helpful:

The CDC also has many resources listed on their website.

There have been several press releases discussing the recent emergency funding laws and the broad language that is designed to waive restrictions on telemedicine care for Medicare and Medicaid patients (6, 7). Unfortunately, the details of what specific restrictions were waived and how to apply for those waivers (if necessary) were not readily apparent on the CMS website.

Based on previous articles from CMS regarding the use of telemedicine services prior to the COVID-19 outbreak, Medicare and Medicaid patients can receive telemedicine services of the types listed above, and Medicare/Medicaid can be billed for those services. The patient must provide verbal or written consent for the service and billing their insurance (documented in the chart) prior to the service, as they may be responsible for a co-pay. Some private insurers will also reimburse for the same codes (dependent on state parity laws or other emergency policies).

Live Synchronous ("Real-Time Video")

  • Coding is dependent on where the patient is located (office, hospital, ER, etc.).
  • Standard E&M codes are used for billing (99201-99205/99211-99215 for outpatient office visits, etc.). Criteria for E&M coding is the same as that of an in-person visit.
  • On the claim the place of service should be changed to 02 to reflect telemedicine (typically 11 signifies office visit, 21 for hospital, etc.).
  • Reimbursement per Medicare/Medicaid is the same as that for an in-person visit.
  • Traditional Medicare and Medicaid require that the patient be located in an Healthcare Provider Shortage Area.
  • Medicare Advantage allows telehealth services in any geographic location, "INCLUDING IN BENEFICIARIES HOMES" (emphasis mine).

"Virtual Check-In"

  • G2012 is the CPT code used (place of service is still generally 11).
  • The 2020 National CMS Reimbursement is listed at $14.80.

Review/Interpretation of Remote Patient Data

  • G2010 is the CPT code used (place of service is still generally 11).
  • The 2020 National CMS Reimbursement is listed at $12.27.

Online Patient Portal Communication

  • 99421-99423 are the CPT codes used for these types of communication; they are time-based codes.
    • 99421 (5-10 minutes) reimburses $15.52
    • 99422 (11-20 minutes) reimburses $31.04
    • 99423 (≥21 minutes) reimburses $50.16

Interprofessional Consult ("E-Consult")

  • 99451 is the CPT code typically used for written-only consults >5 minutes. It reimburses $37.53 in 2020.
  • 99446-99449 are time-based codes and require both a verbal and written report to the referring provider.
    • 99446 (5-10 minutes) reimburses $18.41
    • 99447 (11-20 minutes) reimburses $37.17
    • 99448 (21-30 minutes) reimburses $55.58
    • 99449 (≥31 minutes) reimburses $73.98
  • The time counted is for summary and verbal consultation only, not for data review. If >30 minutes was spent in data review, 99358-99359 (non-face-to-face) codes can be used (99358 = $113.68, 99359 is billed for >74 minutes with 99358 = $113.68 + $55.58 = $169.26).


We want to support and encourage all providers during this challenging situation. One of the ways we may be able to help serve our patients better is to start considering new methods of delivering care without compromising quality. We welcome additional ideas and considerations as we work together as a community to innovate and adapt. We hope everyone stays safe and healthy!


  1. Shah A. "Coronavirus prompts hospitals to fast-track telemedicine projects." The Wall Street Journal. 13 March 2020.
  2. Ducharme J. "The Coronavirus outbreak could finally make telemedicine mainstream in the U.S." Time. 3 March 2020.
  3. Hollander JE, Carr GB. Virtually Perfect? Telemedicine for Covid-19. 11 March 2020. DOI: 10.1056/NEJMp2003539.
  4. Cohrs R. "Trump declares COVID-19 emergency, asks hospitals to activate emergency plans." Modern Healthcare. 13 March 2020.
  5. Chauvin Y. "Horizon Blue Cross Blue Shield waives costs for telemedicine." New Jersey 101.5. 13 March 2020.
  6. O'Brien J. "President Trump signs $8.3B coronavirus funding bill, telehealth restrictions waived." HealthLeaders. 6 March 2020.
  7. Wicklund E. "Coronavirus scare gives telehealth an opening to redefine healthcare." mHealthIntelligence. 5 March 2020.


Kevin E. Lai, M.D. on behalf of NANOS and the Practice Support Committee

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Attention future neuro-ophthalmologists! Applications for 2024-25 neuro-ophthalmology fellowship positions will be coordinated through the SF-Match Ophthalmology Fellowship match.