Update: Medicare telehealth payment policies

• The public health emergency federal designation expired March 11, 2023
• However, the end of the PHE did not signal the end of all Medicare coverage telehealth services
• Congress provided an extension of some of the telehealth flexibilities through the end of December 2024
• This update is posted in July, 2023

Prior to the PHE, telehealth could only be provided in certain geographic areas and the patient could not be in their home for telehealth services. This changed with two CMS rules in March and April of 2020. Some flexibilities have expired but this article will describe which flexibilities are still in place under Medicare Part B payment policies through the end of 2024. These are described in the 2024 Proposed Rule and made possible by the provisions of the Consolidated Appropriations Act 2023. That is, Medicare is implementing through rulemaking the changes mandated by Congress. (The CAA of 2022 allowed continued flexibilities for 151 days after the PHE ended, but the 2023 Act replaces that with the end of 2024.)

Here are the temporary provisions extended until the end of December, 2024.

• Expansion which allows telehealth services be provided in any site in the United States where the beneficiary is located, including the patient’s home
• Audio only services may continue to be performed during this period
• Qualified occupational therapist, qualified physical therapists, qualified speech language pathologist, and qualified audiologists may continue to be telehealth providers
• The CAA also mandated coverage for marriage and family therapists (MFTs) and mental Health counselors (MHCs) effective January 1, 2024. These conditions will be able to perform their services via telehealth. (There is an article on CodingIntel that describes this.)
• Payment for telehealth services furnished by FQHCs and RHCs continues
• The CAA 2023 delays the implementation of the requirement for an in person visit with a physician or practitioner within six months prior to initiating mental Telehealth services. This delay applies to FQHCs and RHC, as well. Effectively, this means that until the end of 2024 all behavioral health services can be performed for Medicare patients via telehealth.
• Continued coverage and payment of services included on the Medicare telehealth services list as of March 15, 2020 until December 31, 2024

Frequency limitations

During the PHE, frequency limits on telehealth subsequent hospital visits (once every 3 days), nursing facility visits (once every 14 days) and critical care consultations (once per day) were lifted. This flexibility will continue until Dec. 31, 2024. This wasn’t in the CAA, but CMS is using its discretion and is not re-implementing frequency limits for the remainder of 2023 and 2024.

Direct supervision via two-way A/V equipment

Direct supervision is required for certain diagnostic tests and to bill incident to services. CMS defines direct supervision as the physician or NPP being in the suite of offices when the service is performed, immediately available to provide assistance. The supervision practitioner does not need to be in the same room during the service.

During the PHE, this supervision was allowed via the use of two-way audio/visual equipment. This will continue to be allowed through December 31, 2024. CMS is seeking comments for future rulemaking about what if any services could have permanent supervision flexibility when performed by auxiliary personnel.

Telephone E/M services

CMS will continue to recognize and pay for telephone codes 99441—99443 through December, 2024. In a sentence that is difficult to decipher, they say they will continue to pay for 98966—98968, assessment and management codes by qualified non-physician healthcare professionals, “however they are not telehealth services.”

Resources to download regarding telehealth

• CMS Interim Rule – March 30, 2020
• CMS Interim Rule – April 30, 2020
• List of covered CMS telehealth services
• Behavioral health and telemedicine
• Read the article about modifier CS and cost sharing here

Medicare telehealth policies during the public health emergency

• Telephone codes were added to the list of services that can be billed via telehealth, and the rates for codes 99441–99443 were increased, to match the rates for 99212–99214
• Office visit codes must still use two-way audio and visual, real time interactive technologies, but the payment rates for audio only codes (99441–99443) were increased
• CMS added to the list of services that can be provided via telehealth to include additional hospital services, home visits, and domiciliary services, inpatient neonatal and pediatric critical care and intensive care codes may be performed via telehealth
• Additional services that are temporary additions to the services that may be performed via telehealth include care planning for patients with cognitive impairment, psychological and neuropsychological testing, physical therapy and occupational therapy and occupational therapy. The blanket waivers were updated at the end of April and physical therapists, occupational therapists and speech-language pathologists are now on the list of clinicians who can bill telehealth
• Subsequent inpatient telehealth may be performed daily, without the prior limit of once every three days
• See the full list here.
• The  list of telehealth services include some that may be reported using audio equipment only
• In order to bill office visits or any of the services that are not indicated as video only, on the list above, you must have interactive, real-time audio visual with the patient.

Telehealth across state lines

In many states, a physician may not treat a patient who is in another state. Check with your board of medical practice or professional society. Or, look here for licensure requirements for telehealth during the pandemic, go here: FSMB (Federation of State Medical Boards): https://www.fsmb.org/

Search by typing in telehealth, it takes you to here:  https://www.fsmb.org/search-results/?q=telehealth

Click on: States waiving licensure requirements in Response to COVID-19

This document has been updated monthly during the state of emergency. The “notes section” of each state will either summarize the rule for treating out of state patients via telehealth or will provide a link to the policy.

Here is the direct link to the July 2022 publication from their website: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf

Selecting a level of service

Use MDM or time to select a level of service for two-way, audio/visual communication.

Not defined as telehealth

On-line digital E/M (99421–99423 and 98970–98972), virtual check in (G2010, G2012) and remote monitoring are not considered telehealth services. Do not use POS 02 or modifier 95 with these.

For Medicare, telephone codes (99441–99443) are now defined as telehealth services, because they are on the CMS telehealth list.

On-site visits via video or through a window–report as telehealth?

CMS’s FAQ from 4/9/20 said that if the physician/NPP and the patient are located in the same facility, but not in the same room, and are communicating via telecommunication, these do not need to be reported as telehealth. Use the codes that describe the in person communication. (COVID-19 Interim Final Rule FAQs)

Supervision

CMS said in their 3/30/20 rule that direct supervision could be provided via audio/visual, real time communication.

RHCs and FQHCs

The CARES Act opened up payment for E/M services in these locations. Use code G2025.

RHCs and FQHCs may bill G0071, payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an RHC or FQHC practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or image by an RHC or FQHC practitioner, occurring in lieu of an office visit; (RHC or FQHC only). The updated rate is $24.76.

CMS finally released instructions about FQHC and RHC billing.   There is a link to the MedLearn matters document at the article.

https://codingintel.com/telemedicine-in-rhcs-and-fqhcs/

Payment for phone calls

• CMS will pay for phone calls using codes 99441—99443, and 98966—98968
• CMS stated in their 3/30/2020 rule that these codes may be used for new and established patient visits during the public health emergency
• Physicians, nurse practitioners, and physician assistants should use codes 99441—99443
• Other qualified health care professionals who may bill Medicare for their services, such as registered dieticians, social workers, speech language pathologists and physical and occupational therapists should use codes 98966—98968

Real-time audio visual equipment is not required for G2012, G2010 or 99421—99423 because those are not considered telehealth services. The requirements for those are described in the article on telehealth, and in separate entries on CodingIntel.com. Links are listed later in this article.

Per the CPT definition, phone call codes 99441—99443 and 98966—98968 are services initiated by the patient (CMS did not discuss if this requirement was waived or not). They may not be provided if they are in follow-up for a visit within the past 7 days, or if they result in a visit in the next 24 hours, or next available appointment.   While 99441–99443 were added to the telehealth list and the rates increased, the same is not true for 98966–98968.

Physicians, nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants use these codes:

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

99442              11-20 minutes of medical discussion

99443              21-30 minutes of medical discussion

Registered dieticians, social workers, speech language pathologists and physical and occupational therapists use these codes

98966  Telephone evaluation and management service by a qualified nonphysician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967              11-20 minutes of medical discussion

98968              21-30 minutes of medical discussion

Resources

• Coding Guidance from the AMA
• CMS enrollment COVID-19 PEHotline
• Aledade guide to getting started with telehealth

Virtual check-ins (some payers use these, not office visits)

CMS is still paying for their HCPCS codes G2012 and G2010. You know what I think about these codes. Too little money for the effort to do and document. But, these don’t require real time audio/video, the way office visits do.  CMS stated in their 3/30/2020 rule that G2012 may be billed for both new and established patients during the public health emergency period.

Read more about Virtual Communication Codes.

On-line digital E/M (some payers paying these, not office visits)

CMS began paying for these in 2020. These aren’t office visits via audio/video, but are more complex and convoluted to do and document. But, they were mentioned in CMS’s rules, and so I’m including them.

Read more about On-line digital E/M services

Interprofessional consults (may be useful in the hospital setting)

These are not officially part of telehealth, but some groups are using them now in the hospital, so that fewer physicians see each patient in the hospital. They allow a consultant to do a time-based chart review and provide a verbal and written report back to the requesting clinician without seeing the patient.

Read more about Interprofessional Internet Consultations

Telehealth place of service and modifier for Commercial Payers

The place of service for telemedicine is 02.

CPT ^® added modifier 95 to the CPT book in 2017. Medicare now requires it for telehealth, and many commercial payers do, as well. Experienced coders, billers, and administrators know that it is too much to hope that all of the payers will want claims to be submitted in the same way.

Modifier -95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.

The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Modifier 95 may only be appended to the services listed in Appendix P in the CPT book or on the list of CMS telehealth services, referenced at the start of this article. Appendix P is the list of CPT codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.