May 1, 2020
Community Health Center Telehealth Services covered by Medicare during the COVID-19 Public Health Emergency Highlights from the latest Medicare Learning Network
On April 17th, CMS released the much anticipated Medicare Learning Network Matter article (SE20016) as guidance for health centers regarding telehealth reimbursement during the COVID-19 and 1135 Waiver Public Health Emergency (hereafter “COVID PHE”). Health centers had been waiting for this directive since March 17th when expanded language around Medicare billing was provided to nearly all providers, except health centers. On April 30th, the MLN SE20016 was updated to clarify areas of confusion and to add Telephone Evaluation and Management (E&M) visits as part of the list of covered telehealth services.
Guidance on telehealth has been changing rapidly as the response to caring for and treating patients with the illness and for patients with other care needs unrelated to the infection has evolved. This document is therefore a living document and will be updated as changes are made to the laws and regulations guiding treatment, billing, and payment for telehealth services.
Medicare telehealth services generally require real-time, interactive audio and visual communication between the patient and the provider. In earlier documents, we referred to these visits as Telemedicine E&M services, but the update on April 30, 2020 expanded the services to include a broader range of visit types. Medicare is using the term “telehealth” to broadly define audio and/or visual and/or electronic interactions in this way. During the COVID PHE telehealth may be used for providing E&M services to new or existing patients. In the MLN, Medicare provides a break-down of the services that may be provided under the telehealth definition.
Telehealth Covered Service Codes
CMS has provided a link to a zip file containing two Excel files that list the covered codes. The codes apply to services traditionally covered as part of telehealth, as well as the services added during the COVID PHE. The link to the resource is here. It is important to spend time with this document to understand which services are codes that fall under a Medicare PPS Qualifying Visit definition, which do not, and which ones are permitted to be audio without the video. CMS makes the distinction between services that are a health center qualifying visit and those that are not as a way to stage the needed changes to the claims processing systems. For some services, that staging translates to delayed payment. Be sure to check back to their site frequently as updates may be added.
What are the telehealth services covered by Medicare as listed in the MLN?
- Telehealth Services (that are also PPS Qualifying Visits)
- Telehealth Services (that are Not PPS Qualifying Visits)
- Virtual Communication Services
- Telephone E&M Services
Distant Site Designation
Even before the COVID PHE, an important consideration for billing for telehealth services was the location of the patient and the provider. The Originating Site was/is the location of the patient which before the COVID PHE had to be a medical practice or facility. The location of the rendering provider was/is the Distant Site. Health centers have always been a Medicare-approved Originating Site but not historically permitted to be a Distant Site. The state of the current situation is obviously requiring people to stay home and many providers to work from home. As such, CMS is now allowing health centers to be Distant Sites and for health center providers working from home to bill under the health center as a Distant site. Patient homes are also now permitted to be an Originating site. Any health care providers working for a health center – and within the scope of their practice – may provide any approved Distant Site telehealth services. Health centers need to bill under their facility NPI as a Distant Site.
It is important to note that the changes in the eligible Originating Site locations – including the patient’s home – are effective beginning March 6, 2020, and until the end of the COVID PHE. During this COVID PHE, more than one medically necessary telehealth visit may be paid on a single date of service (DOS) without meeting any other special requirement.
Evaluation and Management Documentation Requirements
CMS guidance CMS-1744-IFC speaks, on page 136, of the E&M documentations requirements with regards to telehealth services. It is similar to what will be required in the January 2021 changes to E&M documentation guidelines that will replace the 1995 and 1997 E&M Documentation Guidelines. The E&M level selection may be based on time or MDM, with time defined as “all of the time associated with the E/M on the day of the encounter.” PMG’s interpretation of this guidance would include the consideration of time spent documenting the telehealth visit. There is no change to the definition of MDM (i.e., use the three existing tables in the 1995 and 1997 E&M Guidelines). Further, documentation of history and/or physical exam in the medical record are no longer required but are expected by CMS (and other payers) for the purpose of quality and continuity of care.
Telehealth services meeting Medicare’s PPS G code Qualifying Visits rendered for DOS January 27, 2020, through June 30, 2020, health centers must submit the following three (3) HCPCS (e.g., CPT) codes for Distant Site telehealth services:
- Prospective Payment System (PPS) Code (i.e., G0466, G0467, G0468, G0469, G0470)
- A code from Telehealth Visit List that qualifies for a Medicare PPS G code with a modifier 95.
- The new G2025 code with modifier 95.
For Telehealth services provided with a DOS of July 1, 2020 through the end of the COVID PHE, health centers must submit just the new G2025 code and the 95 Modifier is optional. PMG also recommends including the HCPCS code that afforded use of G2025 BUT only after a health center’s revenue cycle management (i.e., RCM/billing) team confirms such with local/regional MAC(s).
Please note that CMS has allowed some PPS Qualifying Visit services in this section to be audio-only as listed on the Telehealth Visit List. Those services that cannot be audio-only require both audio and visual components as part of the visit.
There are a number of CMS-approved telehealth services that do not correspond to specific health center PPS codes. They include services such as TCM, psychotherapy, tobacco-use counseling, to name a few. These codes are provided as part of the CMS Telehealth Services Code list, and some of the services may be offered without video as indicated on the list.
As of this writing, CPT code 99211 also falls under this category of temporary reimbursable telehealth services that can be rendered by health centers. It is defined as a low-level E&M visit for an established patient that may not require the presence of a physician or other qualified health care professional. Typically, 5 minutes are spent performing or supervising the services and the presenting problems are minimal. These services are provided “incident to” the billing provider and are typically rendered by RNs, LPNs, and sometimes licensed/certified MAs; however, a 99211 may be rendered by any person deemed qualified by the overseeing provider and approved by health center policy. Remember to verify any care/service limitations in your respective state(s). Documentation in the patient record by the overseeing provider should indicate what services are to be fulfilled. Documentation must include the name and credentials of the staff performing the service as well as the identity and credentials of the supervising physician. Notes should indicate the degree of the physician’s involvement and document the link between the services of the provider and ancillary staff. The use of 99211 still requires audio and visual technology. Because of its higher reimbursement, it may be a better service alternative to a Virtual Communication Service or E-Visit.
For Telehealth services with DOS January 27, 2020 until the end of the COVID 19 PHE, that are not also PPS G Code Qualifying Visits, health centers must hold the claims until July 1, 2020. Claims can then be submitted with the new G2025 code and the 95 Modifier is optional. PMG also recommends including the HCPCS code that afforded use of G2025 BUT only after a health center’s revenue cycle management (i.e., RCM/ billing) team confirms such with the MAC(s).
Virtual Communication Services (HCPCS G2012 and G2010) are brief (5-10 minute) check-in services with a provider using a telephone or other telecommunication device to decide whether an office visit is needed. VCS may also be a remote evaluation of recorded video or images submitted by a patient. VCS is an option for new and established patients during the COVID PHE. VCS are initiated by the patient most typically via phone call or through a patient portal. Patient consent is required, but during the COVID PHE may be obtained during the time of service. This consent may be obtained by auxiliary staff under the general supervision of the billing provider. Auxiliary staff may be an employee, independent contractor, or leased employee.
For March 1, 2020, through to the end of the COVID PHE health centers offering VCS will need to submit:
- G0071 code
- G2010 or G2012; See coding definitions for specifics.
On-line digital E&M services, also known as E-Visits (99421-99423 or G2061-G2063) are used for established patients during the COVID PHE. They are patient-initiated most typically through the patient portal affording 24/7/365 access. Patient consent is required and, so far as we can currently find, still requires it to be obtained in advance of the time of service. Consent may be obtained by auxiliary staff under the general supervision of the billing provider. Auxiliary staff may be an employee, independent contractor, or leased employee.
Billing for E-Visits with DOS March 1, 2020, through to the end of the COVID PHE require:
- G0071 code
- 99421-99423 or G2061-G2063; See the coding definitions for specifics.
Prior to the April 30th MLN update, Telephonic E&M visits (99441-99443) were not approved as part of the CMS COVID PHE Telehealth Services list nor were they reimbursable to health centers under Medicare PPS G codes. The codes in this range are, by definition, telephonic services requiring at least 5 minutes of E&M service time by a physician or other qualified health professional. Telephone E&M services may be offered to an established patient and/or a patient’s parent or guardian. They cannot be billed if they are rendered as follow up to an E&M visit provided during a preceding 7-day visit. It also may not be billed if the service leads to a procedure or E&M visit within 24 hours or next available appointment.
For Telephone E&M services provided with a DOS March 1, 2020, and until the end of the COVID PHE, health centers must submit just the new G2025 code. The 95 Modifier is optional. DO NOT BEGIN SUBMITTING claims until July 1, 2020. PMG also recommends including the HCPCS code that afforded use of G2025 BUT only after a health center’s revenue cycle management (i.e., RCM/billing) team confirms such with local/regional MAC(s).
PMG and NACHC are seeking clarification on whether CMS will change its guidance and allow submissions of claims prior to July 1, 2020.
For services provided on March 18, 2020, through to the end of the COVID PHE CMS will pay the reasonable costs for the specified E&M services that result in the “order for or administration of a COVID-19 test that relates to the furnishing or administration of such test or the evaluation of an individual for purposes of determining the need for such test.” Telehealth services are included in this definition. In order to qualify, health centers must waive the collection of the co-insurance from the patient. The use of the “CS” modifier is required when health centers waive the co-insurance for COVID-19 testing-related services. Claims will be automatically reprocessed on July 1, 2020. These claims will be paid with the coinsurance applied.
Telehealth Technology and HIPAA guidance can be found through the Office for Civil Rights FAQs. While there is flexibility during the COVID PHE exception, HIPAA-secure technology is strongly recommended. Latitude exists for providers using non-HIPAA-secure technology (e.g., FaceTime or Zoom). When used in good faith the OCR will “exercise enforcement discretion and waive penalties for HIPAA violations” around non-HIPAA compliant technology. In short, use HIPAA secure systems as able. When unable, document notification of patients of such and exercise caution around securing PHI.
Lastly, if you hear something new or unusual, or just want to affirm something you believe to be true, please be in touch with the PMG team. Even if you are not a current client PMG is here to support the health center community in any way we can.
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