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UPDATE: COVID-19 Telehealth, Telemedicine and Physician Supervision Rules

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In response to the comments received from the CMS-1744-IFC issued March 26, 2020, there are several updates related to Telehealth and/or Telemedicine and the Physician Supervision Rules.

Telemedicine refers to a group of services that may be provided to a patient without any physical patient contact. Services may be provided via a telephone (audio) connection, or via some type of online communication such as a patient/provider portal or via email interactions between the patient and practitioner. This typically includes telephone calls (99441-99443), E-visits (G0425-G0427), and Brief Check-ins (G2012).

Proper modifier and POS for Telemedicine:

  • Modifier CR (do not use modifier 95 for telemedicine)
  • POS – 11

Telemedicine Update: In the CMS 5531-IFC released April 30th, Medicare is now temporarily classifying telephone calls as telehealth as well as increasing reimbursement for telephone codes 99441-99442 to the equivalent reimbursement of 99212-99213.  CMS understands these audio-only services may be used as a substitute for a face-to-face office/outpatient E/M service. These reimbursement amounts will be retroactive back to March 1, 2020.  Beneficiaries are still liable for cost-sharing for these services in instances where the practitioner does not waive cost-sharing. Of note, CMS states these services are only billable by a physician or qualified healthcare professional (QHP) and should not be used for administrative or other non-medical discussions with the patient.  Documentation should indicate an audio-only visit occurred, support an E/M visit, and the total time spent with the patient should be documented.

  • 99441 = 99212 Reimbursement (work RVU 0.48)
  • 99442 = 99213 Reimbursement (work RVU 0.97)
  • 99443 = 99214 Reimbursement (work RVU 1.50)
  • POS for Telephone calls during PHE – Use the appropriate POS where the visit would have occurred if the visit were face-to-face (these may be used for most any healthcare setting during the PHE)
  • Modifier 95

Telehealth refers to a distinct level of established services that have traditionally been performed via a face-to-face interaction between the patient and practitioner. These services have been grouped together in a distinct policy that allows this limited amount of traditional face-to-face services to be performed via an audio and video connection as a replacement to the in person, face-to-face interaction. Telehealth allows the interaction to still occur face-to-face; however, it is achieved via the audio and video connection. This includes E/M visits and other services. Telehealth services are traditionally billed with POS 02; however, during the PHE, CMS is allowing providers to use the POS in which the visit would have occurred if the visit had been provided face-to-face.

  • POS During PHE – Use the appropriate POS where the visit would have occurred if the visit were face-to-face
  • POS 02 – for traditional Telehealth
  • Modifier 95

Telehealth Update:  CMS has announced they will no longer be limiting telehealth services to physicians and other qualified healthcare professionals (QHP). Temporarily during the PHE, physical therapists, occupational therapists, and speech-language pathologists can use telehealth communication to provide many Medicare services. The therapists eligible for telehealth billing are those individuals who are in independent practice and currently use a 1500 claim form for reimbursement of services. For hospital-employed therapist providing outpatient therapy services, see Panacea Insights article “Modifications to Hospital Outpatient Services During COVID PHE”. CMS has chosen specific therapy services that can be readily conducted via two-way audio and visual communication. Outpatient therapy services may not be conducted and billed as audio-only services. Therapists will document as required for the therapy provided and also document the service was conducted as an audio-visual communication visit. Therapists will want to ensure only those services listed are reported under this temporary telehealth benefit.

Telehealth flexibility is being extended to outpatient provider-based and outpatient behavioral health (counseling) services. Practitioners who normally bill under 1500 may report many of the distant site outpatient E/M visits and behavioral health services as telehealth.

When it is not possible for some practitioners to conduct a distant site telehealth visit with the patient, physical therapists, occupational therapists, and speech-language pathologists can provide e-visits. E-visits are non-face-to-face communications with the practitioner by using online patient portals (HCPCS codes G2061-G2063).

  • POS During PHE – Use the appropriate POS where the visit would have occurred if the visit were face-to-face (we remind providers to ensure the applicable POS is reported when the telehealth service is provided to a registered outpatient of the hospital when the visit is associated with an outpatient provider-based department)
  • Modifier 95 appended first and modifier CR appended in the second position

Remote Patient Monitoring (RPM)

CMS’s combination of permanent and interim policies for the duration of the COVID-19 PHE will allow RPM services to be furnished to new patients in addition to established patients; with beneficiary consent to be obtained at the time services are furnished and by auxiliary personnel for physiologic monitoring of patients with acute and/or chronic conditions, and under general supervision.

This update means clinicians can provide remote patient monitoring services to both new and established patients. These services can be provided for both acute and chronic conditions and can now be provided for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry (CPT codes 99091, 99457-99458, 99473-99474, 99493-99494).

Current CPT coding guidance states that the remote physiologic monitoring service described by CPT code 99454 (device(s) supply with daily recordings or program med alerts transmission each 30 day(s)), cannot be reported for monitoring of less than 16 days. For purposes of treating suspected COVID-19 infections, Medicare will allow the service to be reported for shorter periods of time than 16 days as long as the other code requirements are met.

Payment for CPT codes 99454, 99453, 99091, 99457, and 99458 when monitoring lasts for fewer than 16 days of 30 days, but no less than 2 days, is limited to patients who have a suspected or confirmed diagnosis of COVID-19.

Because these codes are approved under the COVID-19 pandemic list of telehealth services, providers will need to ensure the POS and applicable 95 and CR modifiers are included on the 1500 claim form.

Supervision Requirements

As indicated previously, Medicare physician supervision requirements for services requiring direct supervision by the physician or other practitioner, that physician supervision can be provided virtually using real-time audio/video technology.

In the CMS-5531-IFC, Medicare is adding flexibility for NP, CNS, PA, and CNM services will be paid under Medicare Part B as a professional service when furnished directly and “incident-to” their own professional services to the extent under their State scope of practice. This interim change will ensure these practitioners may order, furnish directly, and supervise the performance of diagnostic tests during the PHE. The regulation at CFR 410.32(b)(3) will be amended to reflect the appropriate level of supervision required for diagnostic tests ordered and performed.

Supervision requirements for non-surgical extended duration therapeutic services (NSEDTS) as direct supervision is not required at the initiation of NSEDTS provided in hospital outpatient departments and critical access hospitals. Instead, a general level of supervision can be provided for the entire duration of these services, so the supervising physician or practitioner is not required to be immediately available.

With this latest modification, outpatient hospital services may be provided “in-person” by clinical staff of the hospital in the patient’s home or other temporary location during the PHE. Only general supervision will be required to be met for the services provided by these clinicians based on the physician’s plan of care or orders. If there is a scenario where a clinician contacts the treating or supervising physician during the “in-person” visit and a change to the patient treatment plan occurs, the physician verbally approving the change in treatment will need to authenticate the verbal order in accordance with the verbal order requirements extended under the PHE flexibilities.

We are urging all applicable practitioners to review the summary above against the CMS published documents to ensure a good understanding of coding and billing services.

 

CMS-5531-IFC dated April 30, 2020, https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf

Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19 as of 4/30/20 https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

Covered Telehealth Services for PHE for the COVID-19 pandemic updated 4/30/20 https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes