Making Sense of Telephone CPT Code Modifiers: FQ, 93 & the 99441 CPT Code

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HERE IS HOW

Given the official ambiguity about the official termination of the COVID-related Public Health Emergency (PHE), it may be time to discuss using the “FQ” telephone CPT code and available resources for provider groups and individuals delivering telephone-based services. Some of the key facts include the following:

• The FQ modifier code was approved in 2022 for when a service is rendered using audio-only technology. The technology allows for two-way, real-time communication behavioral health services (counseling and therapy),1 although it was reportedly effective 1-1-2022.
• However, providers are not allowed to bill using this code until after the end of the PHE, as per the WPS Government Health Administrators (WPSGHA) publication of the Modifier FQ Fact Sheet.
• The use of the new code appears to have been postponed until the end of the PHE for many providers.
• However, it is worthy of note that some private insurers, such as  OPTUM of Alaska, began requiring the use of the FQ audio-only modifier code in April of 2022.

What Is the Difference Between CPT Procedure Codes and Modifier Codes?

CPT (Current Procedural Terminology) codes are the foundational elements of a worldwide diagnostic and procedure coding system for reimbursement of healthcare services based on the International Classification of Diseases, 10th Revision (ICD-10). This was endorsed by the World Health Organization (WHO) in 1990 and adopted in the United States on October 1, 2015. These distinctions may help:

• CPT Codes. Five-digit CPT codes correspond to the type of service supplied or action taken by licensed professionals. For example, the code 90834 corresponds to “Psychotherapy. 45 minutes.” 
• Modifier Codes. CPT modifiers provide extra details concerning a procedure or service without changing the definition of the CPT code. In the case of the FQ code, the 90843 would be augmented to read: 90843-FQ to signify that the psychotherapy service was delivered by telephone rather than in-person.
• Another way to differentiate a CPT code from its modifier is that when coded on a 1500 form, CPT Codes are always five numbers, while CPT modifiers are always two characters, numeric or alphanumeric, and added to the end of CPT codes with a hyphen. 

Why Have a Specific Telephone CPT Code or Modifier?

To justify the continued reimbursement of audio-only telehealth, careful research must substantiate the efficacy of telephone telehealth services. The issue is that CMS has required the same modifier code for video telehealth and telephone telehealth, the -95. The sharing of this code for both services has made it difficult to conduct the needed research for long-term reimbursement of telehealth services across the continuum of care. This deficit in appropriate coding led to a public recommendation by the Government Accountability Office (GAO) that the Centers for Medicare and Medicaid Services (CMS) data regarding audio-only versus video telehealth visits should be improved. More accurate data collection will allow policymakers to make informed decisions using audio-only telehealth.

The provision of audio-only healthcare has many benefits but also has risks. These include the possibility that it may be inappropriately used. Unscrupulous people may use the telephone CPT modifier code to over-charge payers. Clinicians may not be trained or understand evidence-based protocols for maximally effective telephone interventions. The modifier adds transparency to reimbursement claims, which can help mitigate these risks.

The telephone CPT modifier codes may also help to standardize healthcare data collection and storage, allowing policymakers to compare data in states where policies differ to measure the effects of the different approaches. Adding a modifier to the existing codes rather than allowing other payers to create new codes has simplified data collection and storage. The new CPT telephone code offers researchers the coded data that could take the country closer to a more equitable healthcare system for all. 

Why Not Use 99441 CPT Code rather than the CPT Modifier FQ?

In its November 1, 2022, release of the 2023 Medicare Physician Fee Schedule (PFS) rule, CMS has announced the discontinuation of reimbursement for telephone (audio-only) evaluation and management (E/M) services at the end of PHE. While telephone telehealth was billed as CPT code 99441 during COVID, it was not universally accepted as a substitute for in-person care, as has video-based telehealth. Therefore, the telephone E/M CPT codes 99441, 99442, and 99443 will be removed from the Medicare Telehealth Services List and assigned a bundled status. 

Being assigned a bundled status refers to including a non-billable service with a billed service, such as an in-person session. Being given a bundled status means the provider will be paid for the in-person session at a flat rate, and phone calls will not be reimbursed unless otherwise coded using an acceptable code. For behavioral professionals, that code will reportedly be “FQ.”

What about the 93 Modifier?

At its September 2021 meeting, the CPT® Editorial Panel of the American Medical Association accepted the addition of Modifier 93 to allow for the reporting of medical services provided via real-time interaction between the physician or other qualified healthcare professional and a patient through audio-only technology. The use of this modifier was effective on January 1, 2022. 

The 93 descriptor was intended to apply to synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system.² Readers are encouraged to stand by to see how this code will be used by the AMA now that the Physician Fee Schedule has discontinued Medicare reimbursement for physician audio-only services 151 days after the PHE expires.

Telehealth.HHS.gov

Before the reader gets too excited about using the FQ code for telebehavioral telephone services, it is important to note that different government websites may or may not be current. For example, the September 28, 2022 update of the Telehealth.HHS.gov website dedicated to billing for telebehavioral health states:

Although Medicare reimburses for audio and video telehealth services, reimbursement for audio-only telehealth services is currently only covered during the COVID-19 public health emergency.

Conclusion

Given that the PHE isn’t over yet, and that the proposed start date is 151 days (five months) after the official end of the PHE, there is time for telephone CPT code-related questions to be answered about the 99441 CPT Code and the FQ or 93 CPT Modifier Code. Readers are encouraged to contact individual health plans to determine which code to use, as health plans often have the autonomy to ask for various possible codes. As for Medicare and Medicaid, a wait-and-see approach is advised.

While discrepancies abound, you can be sure that Telehealth.org will keep you posted. One thing is certain: reimbursement for telephone services for specific mental health services is assured by CMS.

_{¹For details, see MLN Matters Number MM12549
²CPT® Appendix A Modifier 93}

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