CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

Medicare changes telehealth rules, again

Medicare changes telehealth rules, again: April 30, 2020 interim final rule with comment period (IFC)

https://www.cms.gov/files/document/covid-final-ifc.pdf

CMS released a second IFC with policy changes during the public health emergency. First, although it is titled “with comment period,” CMS is making these changes effective immediately, not after a 60-day comment period) and some changes are retroactive to March.  The rule is attached at the bottom of this article, and page numbers correspond to the rule.

Advance practice providers can order, furnish diagnostic tests (page 19)

CMS is adding flexibility about the types of providers (NPs, clinical nurse specialties, PAs, certified nurse midwives) can furnish services directly and incident to their own services, within their state scope of practice. Under current law, only physicians may supervise certain diagnostic tests. CMS is finalizing that during the public health emergency (PHE) advance practice providers may order, furnish and supervise diagnostic tests.

“The interim changes will ensure that these practitioners may order, furnish directly, and supervise the performance of diagnostic tests, subject to applicable state law, during the PHE.”

Hospital outpatient departments new rules (page 53)

If a patient is registered as an outpatient, certain services may be performed via telehealth. Physician supervision must be met, but CMS points out that the vast majority of these services have general physician supervision. When these services are being provided by the hospital, the patient’s home cannot be considered “home” for home health agency purposes.

Hospital based clinics can bill an originating fee (page 55)

Provider based departments (PBD) of a hospital use place of service 19 or 22, outpatient department, on or off campus. When submitting a bill, the charge is split between the professional fee and a facility fee. Up until now, the hospital could not bill a facility fee for telehealth services. There is a statute in the law that prohibited CMS from paying a facility fee to an originating site (home, in this case). But, CMS is considering “home” to be part of the outpatient department of the hospital, while allowing telemedicine during the PHE. The rule says

“…when telehealth services are furnished by a physician or practitioner who ordinarily practices in the hospital outpatient department (HOPD) to a patient who is located at home or other applicable temporary expansion location that has been made provider based to the hospital, we believe it would appropriate to permit the hospital to bill and be paid the originating site facility fee amount for those telehealth services, just as they would have ordinarily done outside of the COVID-19 PHE.”

Use G0463 as the code for the facility fee, when the patient is at home.

Telephone calls, audio only, 99441—99443 will be paid at rates for 99212—99214 (page 137)

These are now considered telehealth services. Continue to use these codes for audio only visits, but the reimbursement will be higher. CMS is not recognizing 98966—98968, which is what they said in their 2020 Final Rule.  Continue to use the telephone codes 99441—99443 for E/M services provided through audio only.  CMS has increased the reimbursement for those codes. As I read it, this section of the rule refers back to the March 30, 2020 rule and takes the effective date of March 1, 2020. I’ll check with other sources, including MGMA about the effective dates.

CMS has cross-walked the value for 99441—99443 to the values for 99212—99214. CMS has previously said that these phone call codes could be used for new or established patient visits, during the PHE, but there is no crosswalk to new patients.

2020 wRVU National non-facility payment National facility payment
99211 0.18 $23.43 $9.37
99212 0.48 $46.13 $26.31
99213 0.97 $76.04 $52.26
99214 1.50 $110.28 $80.37
99215 2.11 $148.12 $113.53

 

This change is not that a practice can bill 99201–99215 for phone only services. The change is that the reimbursement for phone only services 99441–99443 will crosswalk to rates 99212–99214.

Times for E/M services codes 99201—99215 (page 182)

In the March rule, CMS published different typical times for E/M services done via telehealth based on time. CMS now says that stakeholders told them that was too confusing. (Really?) Use CPT times.

And some quick items:

  • CMS is paying for serology testing for COVID-19
  • PT and OT can provide services via telemedicine. This was announced in their 4/29/2020 “COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.”
  • NPs and PAs may now certify and recertify HHA services. (page 76) The CARES Act required CMS to allow NPs and PAs to perform services related to ordering HHA services previously restricted to physicians. The CARES Act gave CMS 6 months from enactment of the law to enact these changes. These are enacted in this rule. NPs, clinical nurse specialists, and PAs may certify eligibility for home health services and review and recertify the plan of care. Their state must allow this within their scope of practice.

I’ll keep reading, and adding details over the weekend and changing the articles I already wrote, as needed.

 

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Comments

  6. Good afternoon
    since CMS is now showing the phone consult codes 99441-99443 on their list of approved Telehealth Codes, do you suggest to bill these with modifier 95 going forward to obtain the new higher rate?
    Thank you!

  7. Can you please tell me where it states to use POS 2 for the telephone codes, 99441-99443? I have not been able to locate this information.

  8. Does the general rule that 99441-99443 codes cannot be used for services which originated 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 hrs., etc. continue to apply or is it waived as part of the flexibility CMS is giving to physicians to “visit” with Medicare patients who need medical attention but have audio-only capability. If such a Medicare patient is in genuine need of medical evaluation for ongoing serious conditions twice in one week what is the Doctor’s option for providing and billing for his services without the risk of Covid exposure to the physician or patient?

    • I looked back through both rules, the end of March and the end of April rules, and CMS does not address this. They say the codes, 99441–99443 can be for both new and established patients, but they don’t don’t change the definition of the codes. But, the CPT definition says you can’t use these codes if they result from an E/M service in the past 7 days, or if they result in an E/M service in the next 24 hours, or next available appointment. It doesn’t specifically limit the number of times you can bill the codes in a time period. I don’t know about MAC edits, but I would report them as often as provided.

  9. Hello
    are you aware of any changes in regards to incident to rules, in other words, does the supervising physician still have to be in the suite or did these rules perhaps change, possibly to general supervision instead in order for the extender to bill under the physicians NPI?
    Thank you!

    • Hello, the 3/30/2020 rule said that supervision could be provided using real time audio visual communication, in relation to supervising auxiliary personnel collecting specimens. It did not specifically mention NPs and PAs and incident to rules. Here is what they said about auxiliary personnel:
      We note that a physician or practitioner cannot bill for services provided by auxiliary clinical staff unless those staff meet all the requirements to furnish services “incident to” services, as described in 42 CFR 410.26 and further described in section 60 of Chapter 15 Covered Medical and other Health Services in the Medicare Benefit Policy Manual 100-02. We further note that we adopted an interim final policy to permit the direct supervision requirement to be met through virtual presence of the supervising physician or practitioner using interactive audio and video technology for the duration of the PHE (85 FR 19245).
      In another section, they discuss diagnostic testing, but they don’t address your question directly.

  11. Betsy,

    I am confused on the facility billing code for the hospital do we use the Q3014? Do we need to add the PO modifier?

    Thank you for your help
    Melody

    • CMS has not been very clear about this, whether to use Q3014 or G0436. A smart colleague of mine agrees with Q3014, if you’ve designated the patient’s home as an outpatient department, which has me at a loss.

      I don’t know if you need to use modifier PO, indicating it was an off-campus provider based clinic.

      I wish had a citation from CMS. I’ll keep looking, Melody, and if I find something I will let you know and add it to an article.

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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