Updated: March 26, 2020, 11:20 am.
- Medicare releases its rule, relaxing restrictions on telemedicine during the state of emergency
- Place of service, and CPT modifier 95
- Other national payers, and Medicaid programs–page down for links to other payers and their rules, that I have as of this date
- Guidance from the AMA
- CMS enrollment COVID-19PEHotline
- Aledade guide to getting started with telehealth
CMS releases its rule!
March 6, Congress passed a law relaxing geographic restrictions and distant site mandates on Medicare telemedicine, during a government declared state of emergency. Specifically, medical practices may provide telemedicine services to Medicare patients located anywhere, not just in underserved geographic areas. And, the patient can be in their home, not in an “originating” site. CMS also said that they are waiving HIPAA privacy rules, and allowing applications such as FaceTime and Skype to be used. (CMS uses both terms: telemedicine and telehealth).
Medicare telehealth visits are for office, hospital visits and other services allowed via Medicare’s existing policy for telehealth services. This includes the psychiatric diagnostic interview, psychotherapy, and Medicare wellness visits. There is a full list of these in the article on Medicare telehealth. Under the new regulations, to bill office visits and other approved telehealth services:
- The provider must use an interactive audio and video telecommunication system.
- HIPAA privacy rules waived: may use FaceTime, Skype, Messenger video chat, Google hang out video
- May not use applications that are front facing, such as facebook live, twitch or TikTok
- CMS instructs groups to notify the patient that third party platforms may have privacy risk
- Practitioners who may bill for telehealth include physicians, advanced practice registered nurses, physician assistants, CRNAs, clinical psychologists, clinical social workers, registered dietitians and nutrition professionals.
- Visits are paid at the same rate as in person visits.
- The provider may waive the co-pay/deductible but is not required to do so.
- Submit these claims with place of service 02.
- For Medicare, modifier 95 is not required
- RHCs and FQHCs should use modifier GT on claims.
- This relaxation of rules is in effect during the state of emergency, and isn’t a permanent change, under the law passed March 6.
- CMS is paying the service using the facility (lower) rate not the non-facility (office rate)
RHCs and FQHCs
I do not believe that RHCs and FQHCs are exempted from this, and may use telemedicine for Medicare patients. However, the CMS documents don’t mention them. Usually, if a service cannot be done by those entities (some care management services, for examples) the service must be reported with a HCPCS code instead of a CPT code, CMS mentions it.
Take a look at this article:
However, I heard from someone that the National Rural Health Association did not believe that this included RHCs. When there is a definitive answer, I’ll edit this article.
In plain english: yes, you can bill an office visit via interactive video.
Virtual check-ins (some payers are 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.
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.
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.
Telehealth place of service and modifier
The place of service for telemedicine is 02.
CPT added modifier 95 to the CPT book in 2017. Medicare does not require it, but some payers will. 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. Some payers do want modifier 95 on telehealth claims.
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. 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.
Other payers: Here is a terrific summary of telemedicine coverage policies
from the Center for Connected Health Policy
- Discusses diagnosis coding and new test codes
- Update on March 17, 2020, UHC expands policies for telehealth for Medicare Advantage, Medicaid and commercial insurance
- Waives originating site requirements for commercial insurance for services provided via a real time audio and video communication
- Use modifier 95 for services recognized in the CPT book in Appendix P
- Recognizes place of service 02, but not required
BCBS of RI
To help increase access to care during this time of heightened concern about coronavirus disease (COVID-19), BCBSRI has made temporary changes to our policies. We have taken the following steps for our members and providers:
- Reimbursing participating primary care providers who treat patients over the phone
- Reimbursing participating behavioral health providers who treat patients over the phone
- Allowing members to fill prescriptions earlier than the standard 30 days
For details and additional information, please log in to the BCBSRI provider portal to read our COVID-19 FAQs.
BCBS of Florida
Download their policy Here
Aetna and telehealth
- Waiving co-pays for diagnostic tests
- Offering $0 co-pays for telehealth services for any reason for 90 days, effective March 6.
- However, office visits are not included in the list of services
- Use place of service 02 or modifier -95
- The network of 36 independent BCBSA companies will have the same policy
- Waive prior-authorization for diagnostic test and covered services if members diagnosed with COVID-19. This may be useful for CT scans, which are being used for diagnosis.
- Will cover medically necessary diagnostic test without cost sharing that are consistent with CDC guidance. Care needed once diagnosis is established “will be covered consistent with the standard provisions of the member’s health benefit.” (That is, not waiving all cost sharing for that.)
- BCBS will “encourage the use of virtual care and will also facilitate member access and use of nurse/provider hotlines.” That doesn’t look to me like “we’ll cover telehealth.”
- From their release, “To mitigate exposure risks, customers are reminded that telehealth options are available for seeking on-demand medical attention, as appropriate. To access telehealth options, visit mycigna.com and select the “Connect Now” button on the home page to talk with a doctor or nurse any time day or night.”
- That is, telehealth with their doctor, not the patient’s doctor.
- Cigna did say they would pay for G2012 and 99241 via telehealth. See the link above.
- They have another policy (you can download) that shows an effective date of 6/15/2020.
- Testing for COVID-19 is fully covered, no out of pocket expense for the member.
- Telemedicine visits for all urgent care needs are covered. Waiving out of pocket costs, but no information for providers about how to bill. This page is intended for consumers.
State of Massachusetts issues an order requiring insurers to cover telehealth, on 3/15/2020
Governor Baker issued the order at 6:50 pm on March 15. (link at the end of the paragraph). “To protect the Public’s health and to mitigate exposure to and the spread of COVID-19, the Group Insurance Commission (“GIC”), all Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc, and Health Maintenance Organizations (Carriers) regulated by the Division of Insurance (“Division”), are herby required to allow all in-network providers to deliver clinically appropriate, medically necessary covered services to members via telehealth.”
The Massachusetts order goes on to say
- GIC and all Carriers may establish reasonable requirements for telehealth, including and with respect to documentation and record keeping but these may not be more restrictive that those established by the MassHealth Program, Bulletin 289
- The GIC and all Carriers shall ensure that rates of payment for in-network services delivered vie telehealth are not lower than in person methods
- The GIC and all Carriers shall notify providers of any instructions to facilitate billing for these services
- The GIC and all Carriers are required to cover without cost sharing treatment related to COVID-19 at in-network providers
- The GIC and all Carries shall not impose prior authorization requirements on medical necessary treatment delivered via telehealth related to COVID-19 at in network providers
My take away from this:
- Expect guidance from insurance carriers about how to bill (place of service, whether or not to use modifier 95) and if phone alone is sufficient
- In the absence of that guidance, I suggest using place of service 02 (telehealth) and modifier 95 (telehealth) but notice that BCBS of NC, which has a policy, distinguishes between phone and services with video and audio.
Check back! I’ll update as more information is provided.
Here’s the link to the state of Mass. https://www.mass.gov/doc/march-15-2020-telehealth-order/download
And, if you get guidance from your carrier or from another state, please email it to me at email@example.com and I’ll update this page.
I’ll also update this page as soon as CMS clarifies how it wants telemedicine to be billed, now that it is updating its policies. (early this week, the week of 3/16)
What about diagnosis coding?
Beginning April 1, there is a new ICD-10 code U07.1, 2019-nCoV acute respiratory disease.
I also heard on the news that insurances wouldn’t charge patients a co-pay for treating this illness. Is that true?
Not to my knowledge. There is no federal law currently that mandates coverage for treatment of COVID-19. Some states are discussing this, so you’ll need to check in your own state. The state of Massachusetts 3/15/2020 decree requires insurance companies to cover the care without cost-sharing. This is going to be on a state by state basis, and will change in the days ahead.
AHIP (America’s Health Insurance Plans) published an article about testing for COVID-19, on an insurance by insurance basis, that you can read here.
Check back for updates.