What You Need to Know About Medicare Telehealth Coverage and COVID-19

April 21, 2020 | Article

Expanded Medicare telehealth coverage recently released by the Trump administration will enable beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility. Medicare, which is administered by the Centers for Medicare & Medicaid Services (CMS), will now be temporarily paying clinicians to provide telehealth services for beneficiaries residing across the entire country.

What Is Included in the Expanded Telehealth Coverage
On March 13, 2020, President Trump announced an emergency declaration under the Stafford Act and the National Emergencies Act. Consistent with President Trump’s emergency declaration, CMS is expanding Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act. This guidance and other recent actions by CMS provide regulatory flexibility to ensure all Americans, including high-risk individuals, are aware of easy-to-use, accessible benefits while helping to contain the spread of coronavirus disease 2019 (COVID-19).

It’s hard to know everything that impacts a healthcare entity when it comes to relief provisions. We’ve broken down what will impact your healthcare organization.

A range of healthcare providers such as doctors, nurse practitioners, physician assistants, clinical psychologists, and licensed clinical social workers will be able to offer telehealth to Medicare beneficiaries. Beneficiaries will be able to receive telehealth services in any healthcare facility, including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.

Medicare beneficiaries will be able to receive various services through telehealth including:

  • Common office visits
  • Mental health counseling
  • Preventive health screenings

How the CARES Act Impacted Telehealth Services
On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) was signed into law. Section 3704 of the CARES Act authorizes RHCs and FQHCs to furnish distant site telehealth services to Medicare beneficiaries during the COVID-19 PHE. Medicare telehealth services generally require an interactive audio and video telecommunications system that permits real-time communication between the practitioner and the patient. RHCs and FQHCs with this capability can immediately provide and be paid for telehealth services to patients covered by Medicare for the duration of the COVID-19 PHE.

Distant site telehealth services can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice. Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the RHC or FQHC, and can furnish any telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS).

For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, RHCs and FQHCs must put Modifier “95” (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) on the claim. RHCs will be paid at their all-inclusive rate (AIR), and FQHCs will be paid based on the FQHC Prospective Payment System (PPS) rate. These claims will be automatically reprocessed in July when the Medicare claims processing system is updated with the new payment rate. RHCs and FQHCs do not need to resubmit these claims for the payment adjustment.

How to Start Providing Telehealth Services
Here are a few tips to help you get started:

  1. Gather a team to facilitate the expedited implementation of telemedicine services and be able to make decisions quickly to ensure launch as soon as possible.
  2. Check with your malpractice insurance carrier to ensure your policy covers providing care via telemedicine.
  3. Familiarize yourself with payment and policy guidelines specific to various telemedicine services.
  4. Review your telehealth and telemedicine capabilities.
    1. Check with your existing EHR vendor to see if there is telehealth functionality that can be turned on.
    2. Reach out to your state medical association/society for guidance on vendor evaluation, selection and contracting.
    3. There are many resources available at the American Telemedicine Association to identify possible vendors to work with. Some are actively supporting quick and effective use of telehealth services. 

What If You Need to Introduce a New Technology?
Introducing new technology into practice quickly can be challenging, but a few things to keep in mind as you navigate a speedy implementation:

  • Ensure HIPAA-compliance. Given the special circumstances of the COVID-19 pandemic, the federal government has announced that the Office for Civil Rights (OCR) will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA).
  • Make sure you understand who has access to and owns any data generated during a patient visit.
  • Get clear on the pricing structure.

Workflow & Patient Care
Determine protocols and application requirements for telehealth/telemedicine as well as care parameters. Be sure to address the following:

  • Work with your vendors and staff to create a plan for supporting patients on how to access telehealth visits based on your practice’s technology and workflow.
  • Reach out to the payor with the highest percent of your patient population to discuss telehealth coverage, even if temporarily due to current events.
  • Determine when telehealth visits will be available on the schedule. For instance, will you offer them throughout the day or set a block of time devoted solely to virtual visits?
  • Set up space in your practice to accommodate telehealth visits. This can be an exam room or other quiet office space to have clear communication with patients.
  • Ensure you are still properly documenting these visits, preferably in your existing EHR, as you normally would with an in-person visit. This will keep the patient’s medical record together, allow for consistent procedures and support billing for telehealth visits.
  • Ensure you receive advanced consent from patients for telemedicine interactions. Due to the national emergency, verbal consent is temporarily allowed for now. This must be documented in the patient’s record. Check to see if your technology vendor can support this electronically.
  • Let your patients know the practice is now offering telehealth services when they call the office. Have your office staff help support proactive patient outreach. Additionally, post announcements on your website, patient portals, and other patient communications.

Policy & Payment
The policy and payment landscape around telehealth and telemedicine remains complex; however, as the country navigates this pandemic, change is happening rapidly to expand these services. 

Ensure you are providing services in accordance with your state laws and regulations. As part of emergency declarations, many governors have relaxed state laws and regulations related to the provision of telemedicine services.

Other items to consider:

  • Licensure. If you are licensed in the state where the patient is located, there are no additional requirements. If you are not licensed in the state where the patient is located:
  • CMS has issued the following waiver for Medicare patients: Temporarily waive requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state. Medicaid waivers must be requested by the individual state that wants to use them.
  • As part of emergency declarations, many governors have relaxed licensure requirements related to physicians licensed in another state and retired or clinically inactive physicians. You must contact your state board of medicine or department of health for up-to-the-minute information.
    • CMS has expanded access to telemedicine services for all Medicare beneficiaries, not just those that have novel coronavirus, for the duration of the COVID-19 Public Health Emergency. In addition to existing coverage for originating sites including physician offices, skilled nursing facilities and hospitals, Medicare will now make payments for telehealth services furnished in any healthcare facility and in the home.

How to Code Telehealth/Telemedicine Visits
A place of service (POS) code 02 has been created for telehealth or some payors still require 11.

Synchronous audio/visual visit between a patient and clinician for evaluation and management include:

  • CPT Code 99201-99205 (POS 02 for Telehealth (Medicare), Modifier 95 (Commercial Payers)) Office or other outpatient visit for the evaluation and management of a new patient
  • CPT Code 99210-99215 (POS 02 for Telehealth (Medicare), Modifier 95 (Commercial Payers)) Office or other outpatient visit for the evaluation and management of an established patient

Online Digital Visits
Digital visits are considered those employed to evaluate whether an office visit is warranted (via patient portal, smartphone). This service must be patient initiated:

“During the COVID-19 Crisis and in an attempt to provide uninterrupted care to our patients we have opted to participate in CMS’ allowed Telehealth/Telemedicine Services. In the absence of definitive guidance, we have taken the position that if a patient contacts the office to schedule an appointment and opts for an audio-visual encounter, that constitutes patient initiation and our provider(s) may contact them at the number provided to conduct the service(s).”

AMANDA L. WAESCH, Esq.
  • CPT Code 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
  • CPT Code 99422 - 11-20 minutes
  • CPT Code 99423 - 21 or more minutes
  • CPT Code 98970* - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • CPT Code 98971* - 11-20 minutes
  • CPT Code 98972* - 21 or more minutes
  • HCPCS Code G2061 - Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • HCPCS Code G2062 - 11-20 minutes
  • HCPCS Code G2063 - 21 or more minutes
  • HCPCS Code G2012 - Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, 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
  • HCPCS Code G2010 - Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), 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

CPT codes 98970-98971 were modified in 2020 to match the CMS language captured in HCPCS code G2061-G2063.

How does COVID-19 impact medical procedure codes?

Remote Patient Monitoring
Collecting and interpreting physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or qualified health care professional.

  • CPT Code 99453 - Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. (Initial set-up and patient education of monitoring equipment)
  • CPT Code 99454 - Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. (Initial collection, transmission and report/summary services to the clinician managing the patient)
  • CPT Code 99457 - Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
  • CPT Code 99458 - Each additional 20 minutes (List separately in addition to code for primary procedure)
  • CPT Code 99091 - Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/ regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days)

Important Use Case
Leverage CPT codes 99453 (if patient education is performed) and 99457 to manage pulse oximetry data from the patient’s home to keep them out of the emergency room and the inpatient hospital, unless it becomes necessary.

Telephone Evaluation and Management Service
CPT codes to describe telephone evaluation and management services have been available since 2008. Relative values are assigned to these services. Medicare MAC’s currently list these codes to be covered and reimbursable. However, check with private payors regarding payment for these new services codes.

  • CPT Code 99441 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian 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
  • CPT Code 99442 - 11-20 minutes of medical discussion
  • CPT Code 99443 - 21-30 minutes of medical discussion

Note: CMS added Medicare coverage of and payment for telephone evaluation and management (E/M) services (CPT codes 99441-99443). Although the code descriptors only reference “established patients,” CMS will cover and pay for both new and established patients during the emergency. In fact, CMS now allows almost all telehealth, virtual check-ins, and e-visits to be provided to any patient—new or established.

New Release from CMS
Clinicians who may not independently bill for evaluation and management visits can also provide these e-visits and bill the following codes:

  • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
  • G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11–20 minutes
  • G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

How to Utilize Telehealth in the Wake of COVID-19
These services are not only limited to rural settings during the emergency declaration. Rather, there is no geographic or location restrictions for these visits. Individual services need to be initiated by the patient when it comes to telehealth services. However, practitioners may educate beneficiaries on the availability of the service.

The expanded use of telehealth and telemedicine will be critical during the coronavirus pandemic. Patients can communicate with their doctor without visiting their doctor’s office, driving down the spread of the virus.

Telemedicine and telehealth can help in times like these. But they can also be complicated.

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