More Telehealth Flexibility for Billing Medicare

UPDATED MAY 14, 2020: On Thursday, April 30, the Centers for Medicare and Medicaid Services (CMS) issued a second round of sweeping changes to support the U.S. healthcare system during the COVID-19 pandemic. This article has been updated to reflect those changes.

UPDATED APRIL 1, 2020: On Monday, March 30, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule which includes several telehealth changes in response to the ongoing COVID-19 public health emergency (PHE). This article has been updated to reflect those changes.

The Centers for Medicare and Medicaid Services (CMS) has further expanded coverage for telehealth services during the COVID-19 pandemic, building off of the changes Congress implemented in their first COVID-19 relief package earlier in March.

Relaxed Guidelines

Beginning retroactively with March 6, 2020, dates of service through the end of the declared national emergency, Medicare will cover telehealth services under several relaxed guidelines, including the following:

Telehealth services can include normal office and outpatient visits, ER and inpatient visits, speech, occupational, and physical therapy services, psychiatric services, and other designated telehealth options.
Telehealth services can be offered to new and established patients.
Telehealth services can be offered by a range of providers, including doctors, nurse practitioners, clinical psychologists, licensed clinical social workers, physical therapists, occupational therapists, and speech language pathologists.
Telehealth services will be covered in all locations across the country, including patients’ homes.
Telehealth services taking the place of normal office and outpatient visits will be paid at the same rate as in-person services.

Under normal circumstances, Medicare’s telehealth coverage is limited …

To certain services,
By certain eligible providers,
In originating sites in either a county outside a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) in a rural census tract (except in cases of acute stroke, treatment of a substance use disorder or a co-occurring mental health disorder, and certain renal dialysis facilities.)

CMS made these changes to telehealth coverage using an 1135 waiver based on the President’s declaration of a national emergency and the HHS Secretary’s declaration of a public health emergency, along with the Coronavirus Preparedness and Response Supplemental Appropriations Act passed by Congress and signed by the President earlier in March. As well, two other federal agencies have announced their own easing of enforcement efforts to allow providers even more flexibility with telehealth.

Updated Code Set

The expanded services being offered via telehealth during the COVID-19 public health emergency are divided into two categories. Category 1 includes services similar to professional consultations, office visits, and office psychiatry services that are currently on the list of telehealth services. Category 2 includes services not similar to those on the current list but when furnished via telehealth would offer clinical benefit to the patient during this time and would improves the diagnosis or treatment of an illness or injury or improves the functioning of a malformed body part.

Some of the services included under Category 2 include emergency department evaluation and management, critical care services, speech, occupational, and physical therapy, and home visits, among others. These services will be covered as telehealth services beginning March 1, 2020, through the end of the COVID-19 public health emergency.

Place of Service

Another change implemented through the interim rule is place of service (POS). Typically, a provider offering telehealth services indicates the POS as 02 for telehealth and is paid the facility rate of the professional services. The facility hosting the patient for the telehealth service bills HCPCS code Q3014 and is paid the telehealth originating site facility fee.

Given the extraordinary circumstances of the COVID-19 public health emergency and the need to keep patients safe from unnecessary trips to medical facilities, many patients will be receiving telehealth services in their home and providers will be offering services from their offices. In this case, no originating site facility fee will be paid, and according to CMS, “the relative resource costs of furnishing these services via telehealth may not
significantly differ from the resource costs involved when these services are furnished in person.”

However, hospitals may bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home.

As a result, CMS has temporarily changed the billing guidelines for POS for telehealth services through the end of the COVID-19 public health emergency. For POS, providers should report the POS code that would have
been reported had the service been furnished in person. Additionally, the CPT telehealth modifier, -95, should be applied to claim lines that describe services furnished via telehealth.

HIPAA Considerations

The Office of Civil Rights (OCR) at the Department of Health and Human Services will temporarily suspend HIPAA enforcement to allow telehealth services to be conducted on any device that has audio and video capabilities and any non-public-facing app, such as Apple’s FaceTime or Google’s Hangouts. Normally, telehealth providers are required to use a HIPAA-compliant interactive audio and video telecommunications system that permits real-time communication between the provider at the distant site, and the beneficiary at the originating site.

The OCR does recommend that providers notify patients of the potential privacy risks of these devices and third-party applications and that providers enable all available encryption and privacy modes when using such applications.

Cost Sharing Waivers and Reductions

Additionally, the HHS Office of Inspector General (OIG) will allow providers to waive or reduce cost-sharing requirements for telehealth visits paid by federal healthcare programs. Normally, providers who offer reductions or waivers of costs owed by federal health care program beneficiaries, such as coinsurance and deductibles, are in violation of federal anti-kickback statutes, the civil monetary penalty and exclusion laws related to kickbacks, and the civil monetary penalty law prohibition on inducements to beneficiaries.

According to the OIG, during the COVID-19 outbreak, however, OIG will not subject physicians and other practitioners to OIG administrative sanctions if they reduce or waive cost-sharing obligations for telehealth services during the time period of the COVID-19 Emergency Declaration. The OIG did clarify that this policy does not require providers to offer a reduction or waiver of cost-sharing obligations to patients.

Other Telehealth Services

In their announcement about the broadened access to telehealth services, CMS also highlighted two other types of telehealth services that Medicare providers may want to utilize with their established patients: virtual check-ins and eVisits. Virtual check-ins are patient-initiated telephone calls or other “synchronous discussions” that allow established patients to “avoid unnecessary trips to the doctor’s office.” Similarly, eVisits are patient-initiated communications with an established provider using a patient portal over a series of days. Guidelines for these services also have been relaxed during the COVID-19 national emergency.

The chart below, provided by CMS, offers a brief overview of all the telehealth services available for Medicare patients:

CMS also has temporarily approved payment for non-face-to-face telephone service CPT codes 99441-99443, available for use by physicians with either “established” or “new” patients, and CPT codes 98966-98968, available for use by nonphysician practitioners with either “established” or “new” patients.

“In the context of the goal of reducing exposure risks associated with the PHE for the COVID-19 pandemic, especially in the case that two-way, audio and video technology required to furnish a Medicare telehealth service might not be available, we believe there are many circumstances where prolonged, audio-only communication between the practitioner and the patient could be clinically appropriate yet not fully replace a face-to-face visit,” CMS explained in the interim final rule.

In the April 30 update, CMS increased the payments for these telephone visits from a range of about $14-$41 to about $46-$110. The new payment rates now match payments for similar office and outpatient visits. The payments are retroactive to March 1, 2020.

Learn More

For more information about the latest telehealth flexibilities for billing Medicare, check out the following resources:

Telehealth Cheat Sheet

Having trouble keeping track of all the details of telehealth?

Download our Telehealth Cheat Sheet to help you understand important dates, temporary code changes, and how to bill Medicare and other payers for telehealth in your practice.

Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.