Full text
Department of Health and Human Services
Office of Inspector General
Office of Audit Services
April 2026 | A-05-23-00001
CMS Could Strengthen Medicare
Program Safeguards To Prevent and
Detect Potentially Improper
Payments for Virtual Check-in and
E-visit Services
OIG.HHS.GOV
HHS Office of Inspector General
REPORT
HIGHLIGHTS
April 2026 | A-05-23-00001
CMS Could Strengthen Medicare Program Safeguards To Prevent and
Detect Potentially Improper Payments for Virtual Check-in and E-visit
Services
Why OIG Did This Audit
•
CMS has sought to improve access to virtual care by introducing communication technology-based services, such
as virtual check-in services and electronic visit services (e-visits). One of the benefits of virtual care is the ability
to provide services to Medicare enrollees when access to in-person care is limited.
•
We conducted this audit to determine whether there are vulnerabilities that might result in improper payments
for virtual care services and opportunities to reduce the risk of improper payments.
What OIG Found
CMS paid providers for virtual check-in and e-visit services during our audit period that may not have complied with
Medicare requirements. Specifically:
•
CMS made $1,964,125 in potential improper payments for 173,287 virtual check-in services that occurred within
7 days after or 24 hours (1 day) prior to an evaluation and management (E/M) service having the same diagnosis
code for the same enrollee. Of these, 120,316 E/M services were also billed and paid with an unnecessary
modifier.
•
CMS made $298,200 in potential improper payments for 10,237 e-visit services because the services were
provided within 7 days of another e-visit having the same diagnosis code for the same enrollee.
Medicare made potentially unallowable payments to providers for virtual check-ins and e-visit services because CMS and
Medicare Administrative Contractors did not have system edits in place to detect certain payments at risk for
noncompliance; nor did CMS educate providers on the proper billing requirements for virtual check-in and e-visit
services.
What OIG Recommends
We made three recommendations to CMS, including that it develop system edits for billing communication technology-
based services that could have saved the Medicare program up to $2.3 million during our audit period, strengthen the
Healthcare Common Procedure Coding System code descriptions for virtual check-ins in the Physician Fee Schedule, and
further educate providers on the proper billing requirements for virtual and e-visit services. The full recommendations
are in the report.
CMS concurred with our first and third recommendations and described corrective actions it planned to take, or has
already taken, to address the recommendations. CMS did not concur with our second recommendation.
OIG.HHS.GOV
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................... 1
Why We Did This Audit ....................................................................................................... 1
Objective ............................................................................................................................. 1
Background ......................................................................................................................... 1
The Medicare Program ........................................................................................... 1
Communication Technology-Based Services .......................................................... 1
Medicare Requirements for Evaluation and Management Services ...................... 4
Provider Submission of Medicare Claims for Part B Services ................................. 5
CMS and Medicare Administrative Contractor Claim Processing System Edits ..... 5
How We Conducted this Audit............................................................................................ 6
FINDINGS ......................................................................................................................................... 7
Virtual Check-in Service Payments May Not Have Met Federal Requirements ................. 7
Medicare Requirements ......................................................................................... 7
Claims for Virtual Check-in Services With Same Diagnosis Code as a Recent
Evaluation and Management Service .................................................................. 8
Inappropriate Use of Modifiers With Evaluation and Management Services ........ 8
E-Visit Service Payments May Not Have Met Federal Requirements .............................. 10
System Edits Not Developed To Identify Potentially Improper Payments ....................... 11
RECOMMENDATIONS ................................................................................................................... 11
CMS COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ........................................... 12
CMS Comments ................................................................................................................. 12
Office of Inspector General Response .............................................................................. 12
APPENDICES
A: Audit Scope and Methodology .................................................................................... 13
B: Medicare Requirements for Coverage of Communication Technology-Based
Services .................................................................................................................... 15
C: CMS Comments ............................................................................................................ 17
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INTRODUCTION
WHY WE DID THIS AUDIT
The Centers for Medicare & Medicaid Services (CMS) has sought to improve access to virtual
care by introducing communication technology-based services, such as virtual check-in services
and electronic visit services (e-visits). One of the benefits of virtual care is the ability to provide
services to Medicare enrollees when access to in-person care is limited. We conducted this
audit to determine whether there are vulnerabilities that might result in improper payments for
virtual care services and opportunities to reduce the risk of improper payments.
OBJECTIVE
The objective of our audit was to determine whether providers that received payments for
virtual check-in and e-visit services complied with Medicare requirements.
BACKGROUND
The Medicare Program
The Medicare program provides health insurance coverage to people aged 65 years and older,
people with disabilities, and people with end-stage renal disease. Medicare Part B provides
supplementary medical insurance for medical and other health services, including
communication technology-based services. CMS administers Part B and contracts with
Medicare Administrative Contractors (MACs) to, among other things, determine payment rate
amounts and pay claims, conduct audits, safeguard against fraud and abuse, and educate
providers about Medicare billing requirements.
MACs submit Medicare Part B provider claims that they received from providers to CMS’s
centralized Common Working File (CWF) system for prepayment validation. As part of the
validation process, the CWF performs a series of automated system edits that make a claim
approval, adjustment, or rejection determination. This can include checking for modifiers such
as those for separately billable services.
Communication Technology-Based Services
In 2019, CMS began to increase Medicare enrollees’ access to physicians’ services via
communication technology by recognizing a discrete set of services defined by and inherently
involving the use of communication technology. These services include certain kinds of remote
patient monitoring (either as separate services or as parts of bundled services) and
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interpretations of diagnostic tests (when furnished remotely). CMS introduced virtual check-in
services in its calendar year (CY) 2019 Physician Fee Schedule (PFS)1 and e-visit services in its
CY 2020 PFS.2
Virtual Check-in Services
Medicare pays for virtual check-in services for enrollees to communicate with providers and
avoid unnecessary trips to providers’ offices. These services are for enrollees with an
established (or existing) relationship with a provider and for which the communication is not
originating from a related evaluation and management (E/M) service within the previous 7 days
and does not lead to an E/M service or procedure within the next 24 hours (or soonest
appointment available).
Medicare virtual check-in services may only be delivered and billed by providers authorized to
furnish E/M services and are furnished through several communication technology modalities,
i.e., telephone, audio/video, secure text messaging, email, or use of a patient portal.3 Providers
bill for the services using one of two Healthcare Common Procedure Coding System (HCPCS)
codes:4
• HCPCS code G2010 is billed when the provider remotely evaluates a captured video or
image provided by the enrollee.
• HCPCS code G2012 is billed when the provider responds to an enrollee’s concern
initiated via audio-only telephone interactions, in addition to synchronous, two-way
audio interactions that are enhanced with video or other kinds of data transmission.
This service is often used to determine whether an in-person appointment is required.5
Figure 1 on the next page shows the amounts that CMS paid for virtual check-in services from
2019 through 2022.
1 83 Fed. Reg. 59452, 59483 (Nov. 23, 2018).
2 84 Fed. Reg. 62568, 62797 (Nov. 15, 2019).
3 Medicare E/M services are visits covered under Medicare Part B and performed by physicians and nonphysician
practitioners (hereinafter, collectively referred to as providers) to assess and manage an enrollee’s health (42 CFR
Part 410.20).
4 On Aug. 17, 2000, 45 CFR § 162.1002 established the HCPCS Level II codes as part of the regulation to implement
the Health Insurance Portability and Accountability Act requirement for standardized coding systems. HCPCS
codes are used to report medical procedures and services to Medicare, Medicaid, and other health insurance
programs.
5 As of Jan. 1, 2025, CMS CY2025 PFS - 89 FR 97710, 97791 (Dec. 9, 2024), HCPCS code G2012 has been replaced by
CPT code 98016. The descriptor for this new code mirrors that for G2012.
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Figure 1: Medicare Virtual Check-in Service Payments, 2019 Through 2022
E-Visit Services
Medicare enrollees may initiate e-visit services by using online patient portals.6 The enrollee
must generate the initial inquiry, and the communications can occur over a 7-day period. Also,
the patient must, on an annual basis, consent to receive e-visit services.
CMS added three Current Procedural Technology (CPT®) codes for e-visit services for providers
billing under the PFS.7, 8 These codes are used to describe patient-initiated digital
communication that requires a clinical decision that would otherwise have been provided in an
office. An e-visit service should be billed on a claim using a CPT code reflective of the
cumulative communication time spent with the patient over 7 days. Figure 2 on the next page
shows the e-visit service CPT codes and the associated cumulative communication time over
6 An online patient portal is a secure online website that gives patients 24-hour access to personal health
information from anywhere, by using a secure username and password.
7 CPT copyright 2019, 2020, 2021 and 2022 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are
not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice
medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
8 U.S. Government End Users. CPT is commercial technical data, which was developed exclusively at private
expense by the American Medical Association (AMA), 330 North Wabash Avenue, Chicago, Illinois 60611. Use of
CPT in connection with this product shall not be construed to grant the Federal Government a direct license to use
CPT based on FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items).
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
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7 days. For example, CPT code 99422 is billed for 11 to 20 minutes of time the provider spent
for the visit, or visits, during a 7-day period.
Figure 2: CPT Codes and Cumulative Communication Time Over 7 Days
CPT Code9
Cumulative Communication Time Over 7 Days
99421
5−10 minutes
99422
11−20 minutes
99423
21 or more minutes
Figure 3 depicts the amount that CMS paid for e-visit services from 2020 through 2022.
Figure 3: Medicare E-Visit Service Payments, 2020 Through 2022
Medicare Requirements for Evaluation and Management Services
E/M services are cognitive services in which physicians or other qualified health care
professionals diagnose and treat illness or injury.10 Medicare covers E/M services when they
are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve
9 CPT copyright 2019 American Medical Association. All rights reserved.
10 Physicians’ cognitive services involve the application, based on relevant knowledge and experience, of such skills
as data gathering and analysis, planning, management, decision making, and judgment relating to the prevention,
diagnosis, and treatment of health problems, and communication of such information to the patient.
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the functioning of a malformed body member, and the services are documented in the
patient’s medical record.11
Provider Submission of Medicare Claims for Part B Services
Under Medicare Part B, procedure codes and modifiers are used for reporting provider
services.12 Payment rates for provider services are based primarily on CMS’s Medicare PFS.
Additional rate adjustments may be made or restricted based on the presence of certain
modifiers. To receive Medicare Part B payments, a provider must bill for each service
performed using the correct procedure code and, if required, append any applicable modifiers.
Three modifiers commonly used in billing for health care services are: (1) Modifier 25:
significant, separately identifiable E/M service by the same provider or other qualified health
care professional on the same day of the procedure or other service; (2) Modifier 95:
synchronous telemedicine service rendered via a real-time interactive audio and video
telecommunications system;13 and (3) Modifier GT: service rendered via interactive audio and
video telecommunications systems.
CMS and Medicare Administrative Contractor Claim Processing System Edits
The MACs submit Medicare Part B physician claims that they receive from providers to CMS’s
centralized CWF system for prepayment validation. As part of the validation process, the CWF
uses edits that check for modifiers such as telehealth (95 and GT) and/or separately billable
service (25) modifiers, even on claim lines where a modifier is not required. If a certain
modifier is present on the claim line, the claim line will bypass the edits and be paid. According
to CMS, the CWF system has no edits in place to reject claims where a modifier should not be
appended or was used inappropriately for the claims in our audit.
When there are no edits, CMS in conjunction with the MACs can develop edits primarily
through the National Correct Coding Initiative (NCCI). NCCI edits prevent improper payments
by ensuring correct coding practices and identifying potentially inappropriate code
combinations or quantities. MACs are responsible for implementing these edits within their
claim processing systems. There are various types of NCCI edits such as procedure-to-
procedure edits. These edits identify combinations of codes that should not be billed together
on the same day. They help prevent double billing for services that are inherently included
within another code.
11 Sections 1862(a)(1)(A) and 1833(e) of the Social Security Act.
12 A modifier is a two-character code that can be reported with a CPT code and used to give Medicare additional
information needed to process a claim (National Correct Coding Initiative Policy Manual for Medicare Services,
chapter I, § E).
13 Medicare used modifier 95 during the public health emergency (PHE) to indicate when a service was provided
via telehealth. After the PHE, CMS reverted to the place-of-service code to indicate when a service was provided
via telehealth and no longer requires modifier 95.
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Appendix B contains the details of selected Medicare coverage and payment requirements for
communication technology-based services.
HOW WE CONDUCTED THIS AUDIT
Our audit covered Medicare payments totaling $12,479,542 for 1,341,652 virtual check-in claim
lines and $11,671,785 for 600,235 e-visit claim lines with dates of service from January 1, 2019,
through December 31, 2022 (audit period).14, 15
For virtual check-in services that were within the previous 7 days and within the next 24 hours
(or soonest appointment available) of an E/M service, we identified only claim lines for which
the diagnosis code for both the virtual check-in service and the associated enrollee’s E/M
service were the same. This enabled us to determine whether the virtual check-in service was
for the same medical condition, which would make the payment potentially unallowable.
Additionally, using the virtual check-in and E/M services data described above, we identified all
E/M claim lines that were billed with a 25, 95, or GT modifier. Modifiers are not required to be
used with communication technology-based services, and use of a modifier with corresponding
E/M services on a claim can increase the likelihood that the claim line will be improperly paid.
For e-visit services that were within 7 days of each other, we identified claim lines that were
billed with the same diagnosis codes to identify whether the e-visit service was potentially
unallowable.
For both the virtual check-in and e-visit services, we could not determine with certainty that
these claim lines were unallowable because we did not conduct a review of medical records,
and the diagnosis code was the only indicator to determine whether these services were billed
for a related medical condition that may have originated from or led to an E/M service.
However, we concluded that these claim lines may be potentially improper payments based on
an assessment of the specific data for each claim when compared to the Medicare
requirements.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Appendix A contains the details of our audit scope and methodology.
14 This was the most recent data available at the start of our audit.
15 CMS did not add e-visit CPT codes until January 2020 (CY 2020 PFS); therefore, there was no claim line data for e-
visit services in the first year of our audit period (84 Fed. Reg. 62568, 62797 (Nov. 15, 2019)).
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FINDINGS
CMS paid providers for virtual check-in and e-visit services during our audit period that may not
have complied with Medicare requirements. Specifically, CMS made 183,524 potentially
improper payments totaling $2,262,325 for virtual check-in services ($1,964,125 for 173,287
claim lines) and e-visit services ($298,200 for 10,237 claim lines).
CMS made these potentially improper payments because CMS and MACs did not have system
edits in place to identify communication technology-based services that may have been related
to the same medical conditions addressed during other services. Also, providers may not have
been aware of CMS requirements for billing these newly created services.
VIRTUAL CHECK-IN SERVICE PAYMENTS MAY NOT HAVE MET FEDERAL REQUIREMENTS
We found that CMS made potentially improper payments for virtual check-in services for which
a recent E/M service was billed using the same diagnosis code; therefore, the services appeared
to be related to the same medical condition and may have originated from or led to the E/M
service. If these virtual check-in services were for the same medical condition, providers should
not have billed these services separately. Rather, only an E/M service potentially should have
been billed.
Additionally, we noted that many of the E/M service claim lines that were associated with a
potentially improperly paid virtual check-in service were billed with a payment modifier. One
modifier frequently used (25) indicates a separately identifiable service that bypasses a system
edit and results in the provider being paid for the additional service. Other frequently used
modifiers (95 and GT) indicate that the service was provided via telehealth and may have
resulted in payments for services that should not have been made for the same medical
condition as a recent E/M service.
Medicare Requirements
Medicare pays for virtual check-in services for enrollees to communicate with providers and
avoid unnecessary trips to providers’ offices. According to the 2019 Medicare PFS, these
services are for enrollees with an established (or existing) relationship with a provider and for
which the communication is not originating from a related E/M service within the previous
7 days and does not lead to an E/M service or procedure within the next 24 hours (or soonest
appointment available).16
16 According to the HCPCS descriptions of a virtual check-in (G2010 and G2012), HCPCS code G2010 is a remote
video and/or image, including interpretation with follow-up within 24 business hours, not originating from a
related E/M service or procedure within the next 24 hours or soonest available, and HCPCS code G2012 is a brief
communication technology-based service 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;
5−10 minutes of medical discussion.
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Claims for Virtual Check-in Services With Same Diagnosis Code as a Recent
Evaluation and Management Service
We identified CMS payments totaling $1,964,125 for 173,287 claim lines for virtual check-in
services associated with 66,899 enrollees that occurred within 7 days after or within 24 hours
prior to an E/M service for the same enrollee using the same diagnosis code. If the virtual
check-in services were for the same medical condition addressed during the corresponding E/M
service, as indicated by the diagnosis code, the virtual check-in services should not have been
separately billed because they should have been covered as part of the corresponding E/M
service.
For example, a provider saw an enrollee on Thursday, November 5, 2020, and billed for an E/M
service with the diagnosis code E78.5—a billable code used to diagnose hyperlipidemia, a
condition characterized by high levels of lipids in the blood. CMS paid the provider $42.52 for
the E/M service. The provider also
billed and provided two virtual
check-in services with the same
diagnosis code (E78.5) that Friday
and Monday (November 6 and 9,
2020) for $10.43 each. If these
virtual check-in services were
related to the same medical
condition addressed on November
5, the provider should not have billed separately for the virtual check-in services (totaling
$20.86) since they were within 7 days of the E/M service. Rather, the provider should have
billed only the initial E/M service, resulting in a total payment of $42.52 rather than $63.38, a
potential overpayment of $20.86.
Inappropriate Use of Modifiers With Evaluation and Management Services
Each of the 173,287 claim lines for virtual check-in services with the same diagnosis code as a
recent E/M service had an associated E/M service claim line, of which 120,316 were billed with
a payment modifier. We noted that 30,743 claim lines for E/M services were billed with
modifier 25, which is used to bill for a significant, separately identifiable service. This modifier
bypasses automated prepayment edits in Medicare’s prepayment processing system, and use
of the modifier seems to contradict the billing requirements in the HCPCS definition for virtual
check-in services. By definition, the virtual check-in service is not supposed to originate from a
related E/M service within the previous 7 days and is not supposed to lead to an E/M service
within the next 24 hours (or soonest appointment available). CMS made potentially improper
payments totaling $337,033 for virtual check-in services because the services were identified as
separately billable when they should have been covered as part of the originating E/M service
that was provided and billed. (This figure is included in our total calculation of $1,964,125 of
potentially improper payments for virtual check-in services.) We were unable to determine
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whether the E/M service or the virtual check-in service was the appropriate service to be billed
because we did not review medical records as part of this audit.
For example, a provider billed for an E/M service provided on April 20, 2020, using diagnosis
code U07.1, an asymptomatic individual who tested positive and was considered to have the
COVID-19 infection, with modifier 25 appended and was paid $45.49 for that line item. For the
same enrollee, the provider billed a virtual check-in service with this same diagnosis code for
the same day and was paid $11.58. This service was within the 7-day window of the E/M
service and likely should have been covered as part of the associated E/M service. However, by
using modifier 25, the
provider’s claim for the E/M
service bypassed CMS system
edits. As a result, the MAC
identified both payments as
payable. For this enrollee’s
next three visits, the provider
also billed both an E/M
service and virtual check-in service using the same diagnosis code. Payments for the four E/M
services totaled $228.28 rather than $181.96, a potential overpayment of $46.32 (for the four
virtual check-in services).17
For the remaining 89,573 claim lines for the E/M services billed, the claim lines included
telehealth modifiers 95 and GT. These modifiers do not impact the associated Medicare
payment; they are used to indicate that the service was performed via interactive audio and
video communication technology. An E/M service provided via telehealth, and billed with
modifier 95 or GT, is similar to a virtual check-in service. Therefore, if both services were billed
on a claim for an enrollee, the services appear to be duplicative in nature, and only the E/M
payment or the virtual check-in service likely should have been allowed.
For example, on April 28, 2020, a provider billed for a high-level E/M service under code 99215
with a modifier 95 appended to the line item. This modifier indicates that the service was
performed via telehealth. The payment for the service is the same whether it was provided via
telehealth or in person; however, on the same date of service, the provider also billed HCPCS
code G2012 for a virtual check-in. If the E/M service was provided virtually, or in person, it is
likely that the service was for the same medical reason as the recent virtual check-in, thereby
making the payment for either the E/M service or the virtual check-in improper.
Without a review of the medical records associated with these types of claims, we were unable
to verify which payment may be improper. If an edit were put in place to identify claims where
both an E/M service and virtual check-in were billed with the same diagnosis code, these types
of payments could be denied.
17 We did not determine whether the payments for the E/M services were in compliance with Medicare
requirements because that was outside the scope of this audit.
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E-VISIT SERVICE PAYMENTS MAY NOT HAVE MET FEDERAL REQUIREMENTS
E-visit services offer quick, safe patient access to virtual health care without needing a
scheduled visit, transportation, or time off work. These services are for enrollees with an
established (or existing) relationship with a provider and should be billed on a claim using a CPT
code reflective of the cumulative communication time spent with the patient over 7 days.18
The CY 2020 PFS final rule introduced three CPT codes for e-visit services; CPT 99421 Online
digital evaluation and management services for up to 7 days, cumulative time during the 7 days
of 5−10 minutes, CPT 99422 for 11−20 minutes, and CPT 99423 for 21 or more minutes.
Using data analysis, we found that CMS made potentially improper payments for individual
e-visit services that were performed within a 7-day period of another e-visit service and that
were billed using the same diagnosis code. If these e-visit services were billed for the
treatment of the same medical condition, they should have been billed with a higher level CPT
code encompassing the cumulative interaction time within the 7 days. We found that
payments totaling $298,200 for 10,237 claim lines for e-visit services associated with 6,809
enrollees were potentially improper.19
For example, a provider billed three e-visit services for an enrollee that were performed within
7 days of each other and used diagnosis code E11.35—a billable code for Type 2 diabetes
mellitus with
proliferative diabetic
retinopathy.20
Specifically, the
provider billed for e-
visits on January 29,
2022, with CPT
99423 for more than
21 minutes; January
30, 2022, with CPT
99422 for 11−20 minutes; and again on January 31, 2022, with CPT 99421 for 5−10 minutes.
If these visits were for the same medical condition, the provider should have only billed once
for the 7-day period based on the cumulative time spent with the enrollee. In this instance,
18 CPT copyright 2019 American Medical Association. All rights reserved.
19 If there were multiple claim lines for e-visit services billed within 7 days, we considered the billing of the
additional e-visit service(s) to have been potentially improper and used the accumulated time the provider spent
treating the patient during a 7-day period to derive the potentially unallowable payment.
20 People with diabetes can have an eye disease called diabetic retinopathy. This is when high blood sugar levels
cause damage to blood vessels in the retina. Proliferative diabetic retinopathy is the more advanced stage of
diabetic eye disease. It happens when the retina starts growing new blood vessels.
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since all three visits cumulatively exceeded 21 minutes and appeared to be the same medical
condition, the provider should have only billed one time (using CPT 99423). Because it billed for
three different e-visit services, the provider was paid $71.55 instead of $36.99, a potential
overpayment of $34.56.
SYSTEM EDITS NOT DEVELOPED TO IDENTIFY POTENTIALLY IMPROPER PAYMENTS
Medicare made potentially unallowable payments to providers for virtual check-ins and e-visit
services because CMS and the MACs did not have system edits in place within the CWF to
detect certain payments at risk for noncompliance. CMS’s website provided guidance to
providers on how to bill these services, but the guidance was limited to the types of providers
that could bill for these services, communication modalities that could be used, established
patient relationships, and other similar directives. CMS’s guidance within the PFS was limited
to brief descriptions of the CPT and HCPCS codes and the time interval requirements, which
may have led to inconsistent or inaccurate billing by providers. In addition, we found that
providers often used modifiers when billing E/M services with associated virtual check-in
services. Providers used these modifiers because they were not properly educated on the use
of modifiers when billing E/M services. Although the use of these modifiers did not impact the
associated payment amount, at least one of the modifiers (modifier 25) could have allowed the
providers to bill for both virtual check-in and E/M services on a claim when they should have
only been paid for one of the services. Also, CMS did not have system edits in place to identify
multiple e-visit services within a 7-day period that were billed using the same diagnosis code.
RECOMMENDATIONS
• We recommend that CMS develop the following system edits for billing communication
technology-based services that could have saved the Medicare program up to
$2.3 million during our audit period:
o (1) edits to identify payments for further review for (a) virtual check-in services
that occur within 7 days after or 24 hours prior to an E/M service and are billed
with the same diagnosis code and (b) e-visits that occur and are billed separately
with the same diagnosis code but should be billed only once within 7 days; and
o (2) edits to identify and reject claims where virtual check-in services and E/M
services are billed on the same claim.
• We recommend that CMS strengthen the HCPCS code descriptions for virtual check-ins
in the PFS to clarify the meaning of “related or same medical condition” and “soonest
available appointment” to ensure accurate billing of virtual check-ins.
• We recommend that CMS further educate providers on the proper billing requirements
for virtual check-in and e-visit services.
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CMS COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE
In written comments on our draft report, CMS concurred with our first and third
recommendations and described corrective actions it planned to take, or has already taken, to
address the recommendations. However, CMS did not concur with our second
recommendation as written. After reviewing CMS’s comments, we maintain that our second
recommendation is valid.
CMS also provided technical comments, which we addressed as appropriate. CMS’s comments,
excluding the technical comments, are included as Appendix C.
CMS COMMENTS
CMS concurred with the first recommendation that it develop system edits for billing
communication technology-based services. CMS stated that it has implemented system edits to
reduce the risk of improper payments for these services. In addition, CMS stated that it will
determine whether additional edits or modifications are appropriate based on OIG’s findings
and recommendations.
CMS did not concur with the second recommendation that it strengthen the HCPCS code
descriptions for virtual check-in services in the PFS. CMS stated that it believes this
recommendation would be better achieved through language in subregulatory guidance rather
than modifications to the code descriptions. CMS stated that it will take OIG’s findings and this
recommendation into consideration as CMS continues to educate providers on the proper
billing requirements for virtual check-ins.
CMS concurred with the third recommendation to further educate providers on proper billing
requirements for virtual check-in and e-visit services and stated that it will continue to educate
providers.
OFFICE OF INSPECTOR GENERAL RESPONSE
We acknowledge the actions that CMS has taken and plans to take to address the first and third
recommendations. We disagree with CMS that the second recommendation can be better
achieved through subregulatory guidance because this type of guidance is not legally binding
and cannot be enforced.
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
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APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our audit covered Medicare payments totaling $12,479,542 on 1,341,652 claim lines for virtual
check-in services and $11,671,785 on 600,235 claim lines for e-visit services with dates of
service from January 1, 2019, through December 31, 2022 (audit period).
For both the virtual check-in and e-visit services, we could not determine with certainty that
these claim lines were unallowable because we did not conduct a review of medical records,
and the diagnosis code was the only indicator to determine whether these services were billed
for a related medical condition. However, we concluded that these claim lines were vulnerable
to being improperly paid.
We did not contact providers associated with the paid claim lines; nor did we have the claims
reviewed by an independent medical reviewer to determine medical necessity. Rather, we
relied on the diagnoses codes and dates of services contained in the claim data to determine
whether the associated claim lines were for the same medical condition to determine whether
the virtual check-in and e-visit services complied with Medicare regulations.
We did not assess CMS’s overall internal control structure. Rather, we limited our audit of
internal controls to those applicable to our audit objective. Specifically, we assessed CMS’s
oversight activities to identify potentially vulnerable payments made to providers for
communication technology-based services, including assessing whether there were any system
edits in place for the billing of virtual check-in and e-visit services.
We conducted our audit work from January 2023 through October 2025.
METHODOLOGY
We took the following steps to accomplish our objective:
• Reviewed Federal laws, regulations, and CMS guidance
• Met with CMS program officials to gain an understanding of how virtual check-in and e-
visit services are used and billed
• Used CMS’s Integrated Data Repository file to identify the following claim lines with
dates of service during our audit period:
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
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o Virtual check-in (HCPCS codes G2010 and G2012) services that were provided
and paid within 7 days after or 24 hours before an E/M service (CPT codes 99202
through 99215) for the same enrollee21
o E-visit (CPT codes 99421 through 99423) services that were provided and paid
more than once during a 7-day period for the same enrollee
• Identified claim lines where the diagnosis codes for both the virtual check-in service and
the E/M service were the same because they may have been for the same medical
condition and therefore potentially unallowable
• Identified all E/M claim lines that contained modifiers 25, 95, and GT in conjunction with
a virtual check-in service to determine what effect the modifier had on the payment of
the service
• Discussed the results of our audit with CMS officials
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
21 CPT copyright 2019 American Medical Association. All rights reserved.
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
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APPENDIX B: MEDICARE REQUIREMENTS FOR COVERAGE OF
COMMUNICATION TECHNOLOGY-BASED SERVICES
VIRTUAL CHECK-IN SERVICES
In the CY 2019 PFS final rule (83 FR 59452 through 60303), CMS required separate payment for
a number of services that could be furnished via telecommunications technology. Please see
the table below for the description of virtual check-in HCPCS codes.
Table 1: Virtual Check-in Service HCPCS Codes and Descriptions
HCPCS Code
Description
G2010
Remote evaluation of recorded video and/or images submitted by an
established patient, including interpretation with follow-up with the
patient within 24 business hours, 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.
G2012
Brief communication technology-based service by a provider or other
qualified health care professional who can report evaluation and
management services, 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; 5-10 minutes
of medical discussion.
E-VISIT SERVICES
On November 15, 2019, CMS issued CY 2020 PFS, final rule (84 FR 62568 through 63563),
effective on or after January 1, 2020.
The CY 2020 PFS final rule is one of several rules that reflect a broader Administration-wide
strategy to create a health care system that results in better accessibility, quality, affordability,
empowerment, and innovation.
The CY 2020 PFS final rule included new CPT codes for e-visits, which are non-face-to-face
patient-initiated digital communications. CPT codes 99421–99423 are for providers that can
independently bill E/M services.22
Please see the table on the next page for the description of e-visit CPT codes.
22 CPT copyright 2019 American Medical Association. All rights reserved.
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
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Table 2: E-Visit CPT Codes and Cumulative Communication Time Over 7 Days
CPT Code
Description
99421
Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during
the 7 days; 5–10 minutes
99422
Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during
the 7 days; 11–20 minutes
99423
Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during
the 7 days; 21 or more minutes
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
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APPENDIX C: CMS COMMENTS
DATE:
February 2, 2026
TO:
John D. Hagg
Acting Deputy Inspector General for Audit Services
Office of Inspector General
FROM:
Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
SUBJECT:
Office of Inspector General (OIG) Draft Report: CMS Could Strengthen Program
Safeguards To Prevent and Detect Potentially Improper Payments for Virtual
Check-in and E-visit Services (A-05-23-00001)
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the Office of Inspector General’s (OIG) draft report.
CMS recognizes the importance of providing Medicare beneficiaries with access to medically
necessary services, while also working to protect the Medicare Trust Funds from improper
payments. CMS uses a robust program integrity strategy to reduce and prevent Medicare
improper payments, including automated system edits within the claims processing systems, and
conducting prepayment and post-payment reviews. As part of this strategy, CMS recovers
identified overpayments in accordance with agency policies and procedures.
CMS acknowledges that the use of communication technology has broadened over time and has
enhanced the capacity for medical professionals to care for patients. Beginning January 1, 2019,
Medicare began paying separately for a discrete set of services defined by and inherently
involving the use of communication technology. OIG’s audit covered claims that included virtual
check-in and e-visit services with dates of services in 2019 through 2022 (the audit period). It is
important to note that the audit period covers the initial implementation of these services, as well
as the COVID-19 Public Health Emergency (PHE), which likely impacted how services were
provided and/or how they were billed during the audit timeframe. CMS has continued to refine
the policies and codes associated with these services since the OIG’s audit period.1
Additionally, CMS has taken action to educate health care providers on the proper billing of
Medicare services. For example, during the COVID-19 PHE, CMS published a Medicare
Telemedicine Health Care Provider Fact Sheet which includes information on virtual check-in
and e-visit services.2 Additionally, CMS maintained the COVID-19 Frequently Asked Questions
1 The Medicare Physician Fee Schedule Federal Regulation Notices are available at:
https://www.cms.gov/medicare/payment/fee-schedules/physician/federal-regulation-notices
2 Medicare Telemedicine Health Care Provider Fact Sheet. Available at: https://www.cms.gov/newsroom/fact-
sheets/medicare-telemedicine-health-care-provider-fact-sheet.
Medicare Virtual Check-in and E-Visit Services (A-05-23-00001)
18
(FAQs) on Medicare Fee-for-Service (FFS) Billing which included information on virtual check-
in and e-visit services.3
The OIG’s recommendations and CMS’ responses are below.
OIG Recommendation
The OIG recommends that the Centers for Medicare & Medicaid Services develop the following
system edits for billing communication technology-based services that could have saved the
Medicare program up to $2.3 million during our audit period:
(1) edits to identify payments for further review for (a) virtual check-in services that occur
within 7 days after or 24 hours prior to an E/M service and are billed with the same
diagnosis code and (b) e-visits that occur and are billed separately with the same
diagnosis code but should only be billed once within 7 days; and
(2) edits to identify and reject claims where virtual check-in services and E/M services are
billed on the same claim.
CMS Response
CMS concurs with this recommendation. Since the OIG’s audit period, CMS has implemented
system edits to reduce the risk of improper payments, including improper payments for
communication technology-based services such as virtual check-in services and e-visits. CMS
will determine whether additional edits or modifications are appropriate based on the OIG’s
findings and recommendation.
OIG Recommendation
The OIG recommends that the Centers for Medicare & Medicaid Services strengthen the HCPCS
code descriptions for virtual check-ins in the PFS to clarify the meaning of “related or same
medical condition” and “soonest available appointment” to ensure accurate billing of virtual
check-ins.
CMS Response
CMS does not concur with this recommendation as written. Clarifications regarding the meaning
of “related or same medical condition” and “soonest available appointment” would be best
achieved through subregulatory guidance, rather than modifications to the code descriptions.
CMS will take OIG’s findings and this recommendation into consideration as we continue to
educate providers on the proper billing requirements for virtual check-ins.
OIG Recommendation
The OIG recommends that the Centers for Medicare & Medicaid Services further educate
providers on the proper billing requirements for virtual check-in and e-visit services.
CMS Response
CMS concurs with this recommendation. CMS will continue to educate providers on Medicare
requirements.
3 COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Available at:
https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf.
1
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