Telehealth and telemedicine can be confusing to navigate, especially during the COVID-19 pandemic. We have gathered our top questions to get you the exact information you need to bill and code telehealth correctly.
The originating site is where a patient is located when they receive telehealth services . These normally include a clinical settings, such as physician offices and hospitals. Additionally, the originating site normally must be in a county located outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract to be eligible for telehealth services.
For the duration of the public health emergency, CMS is waiving the geographic and originating site restrictions. Patients may receive telehealth services in any setting, including their homes.
The HHS Office for Civil Rights will waive penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care providers serving patients in good faith via non-public-facing everyday communication technologies, such as FaceTime or Skype, during the COVID-19 public health emergency.
Medicare is waiving and will cover cost-sharing for COVID-19 diagnostic tests and visits related to COVID-19 testing. Physicians may voluntarily waive cost-sharing for non-COVID-19-related telehealth and virtual/digital services. However, Medicare will not pay any cost-sharing waived at a physician’s discretion.
In addition to waiving cost-sharing for COVID-19 testing and related visits, many payers are waiving cost-sharing for non-COVID-19-related visits. Policies vary by payer. Review the Private Payer FAQ or contact your provider relations representative for additional information.
Note: Self-funded plans may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state level and may differ from national policies.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Families First Coronavirus Response Act require Medicare and group health plans to cover diagnostic testing related to COVID-19 at no cost to patients. As defined by the laws, COVID-related services include:
CMS will temporarily cover telephone E/M services (CPT 99441-99443). CMS recently announced an increase in the values of telephone E/M codes. On an interim basis, the relative value units and payment amounts will align as follows: 99441 will align with 99212, 99442 will align with 99213, and 99443 will align with 99214.
The telephone E/M codes have also been added to the list of telehealth services. A select group of services, including telephone E/M services, can be provided using an audio-only connection. However, the audio-video requirement remains in place for most services, such as office visit E/M services. An updated list of telehealth services that shows which services may be provided using audio-only can be found here.
Private payers also cover telephone E/M services. Their policies on audio-only office visit E/M services vary. More information can be found in the Private Payer FAQ or by contacting your provider-relations representatives to verify policies.
Physicians should bill the visit that most appropriately describes the service. If the visit is conducted primarily via audio, it would be appropriate to use the applicable telephone E/M code (CPT codes 99441-99443).
No. If a telephone visit lasts more than 30 minutes, physicians should bill the CPT code 99443.
Yes — if they are coded correctly. Visits must be coded according to each payer’s guidance. Visits that are not coded correctly may be denied or paid at a lower rate. CMS recently announced it will pay telephone E/M services (CPT codes 99441-99443) at parity with office-visit E/M codes. Payment will range from $46 to $110. Please see the Private Payer FAQ and Coding Scenarios for additional information. CMS has indicated it will instruct Medicare Administrative Contractors to reprocess previously submitted claims. Contact your MAC for additional information.
To ensure proper payment, the AAFP recommends that practices update their billing system's allowable amounts to reflect the updated payment rates. Claims submitted with the previous, lower amounts may not be paid the full amount.
In most cases, yes. Medicare is waiving patient cost-sharing for services related to COVID-19 testing. Medicare will pay 100% of the allowable. Physicians should use the CS modifier on the claim lines for services related to COVID-19 testing. Physicians may waive cost-sharing for non-COVID-related services and telephone E/M services (CPT codes 99441-99443). However, Medicare will not pay any cost-sharing voluntarily waived by the physician at his or her discretion.
Most private payers have indicated they will pay the full allowed or contracted amount for covered telehealth services, which includes any member cost-sharing. Their billing/coding requirements related to this vary. Review the Private Payer FAQ or contact your provider relations representative for additional information.
Note: The HHS Office of Inspector General has said it’s permissible for physicians to routinely waive Medicare cost-sharing for telehealth services during the public health emergency, even if they are not COVID-19-related. In that case, it’s the physician’s choice, and if he or she waives the cost-sharing, that would represent lost revenue, since Medicare will pay only its portion.
Medicare’s cost-sharing waivers are in effect until the end of the PHE. The PHE was originally set to expire July 24, 2020, but HHS recently extended it until October 23, 2020.
Expiration dates for private payers vary. The AAFP is advocating for the extension of current flexibilities and waivers until at least the end of the year.
Neither CMS nor the private payers have indicated whether they intend to continue their updated telehealth policies after the COVID-19 pandemic has subsided.
Verify that the claim was coded according to the payer’s requirements. Common causes of reduced payment or missing cost-sharing waivers include incorrect place of service and missing modifiers. Additionally, self-funded plans may opt out of a payer’s national policy. If the claim appears to be coded correctly, contact your provider-relations representative.
Note: Resolving claim-level issues often requires the physician’s NPI and information from the claim. The quickest way to resolve a claim-level issue is through your provider-relations representative. The AAFP monitors policy trends and is in regular contact with national payers.
The Medicare AWV codes (HCPCS codes G0438 and G0439) are on the list of approved Medicare telemedicine services. CMS states that self-reported vitals may be used when a beneficiary is at home and has access to the types of equipment they would need to self-report vitals. The visit must also meet all other requirements.
The Welcome to Medicare visit (code G0402, “Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment”) is not on the list of approved Medicare telemedicine services.
Commercial and private payers may have different policies. Please check with your provider relations representatives for additional guidance.
Yes. CCM is already considered a non-face-to-face service. Patient consent is required. Verbal consent is sufficient and must be documented in the patient medical record. Patients that have not been seen in the office in the past 12 months must have an initiating visit, such as an office visit.
TCM is on Medicare’s list of covered telehealth services. Per Current Procedural Terminology (CPT), TCM codes 99495 and 99496 include one face-to-face (but not necessarily in-person) visit that is not separately reportable. CMS has not specifically addressed this question but is otherwise covering such visits as stand-alone services.
To date, CMS is not considering a phone (audio-only) visit equivalent to a telehealth visit involving audio and visual technology. Given that CPT describes the visit included in TCM as “face-to-face,” we do not advise conducting that visit as a telephone (audio-only) visit.
Telephone E/M (CPT codes 99441-99443) and e-visits (CPT codes 99421-99423) should not be billed during the same month as CCM or during the same service period as TCM.
No. Per CPT, total time for purposes of reporting the level of service for an office/outpatient visit code includes the face-to-face and non-face-to-face time spent by the physician and/or other qualified health care professional and does not include time normally performed by clinical staff.
CMS has temporarily amended the teaching physician regulations to allow supervision by interactive telecommunications technology (i.e., real-time audio and video) to satisfy the requirement for the presence of a teaching physician for the key portion of the service. CMS will also allow teaching physicians to review the services provided with the resident during, or immediately after the visit, through interactive telecommunications technology. All other policies continue to apply.
CMS will also temporarily allow all levels of office visit E/M services (CPT codes 99201-99205 and 99211-99215) furnished in a primary care center to be provided under direct supervision of the teaching physician by interactive telecommunications technology.
For the duration of the PHE, CMS will allow the following services under the primary care exception:
No. In its recent Interim Final Rule, CMS stated it believes virtual check-ins (HCPCS codes G2012 and G2010) are reportable only by physicians and practitioners (e.g., nurse practitioner or physician assistant), who can provide evaluation and management services as the service describes a check-in “directly with the billing [physician or] practitioner to assess whether an office visit is needed.”
As such, G2012 cannot involve only clinical staff (e.g., a nurse who is not a nurse practitioner) and be reported “incident-to.” Thus, the only way to capture phone calls between nurses who are not nurse practitioners and patients for Medicare billing purposes is to count the time toward an appropriate chronic care management code or transitional care management code.
Yes. CMS has released guidance allowing FQHCs and RHCs to provide distant-site telehealth services. Telehealth services can be provided by any practitioner working for the FQHC or RHC within their scope of service, and there are no restrictions on where the service is provided, meaning physicians or practitioners may provide the service from their homes.
The payment rate for telehealth services furnished by an FQHC or RHC practitioner is $92. FQHCs and RHCs must use the -95 modifier for distant-site services provided between Jan. 27 and June 30, 2020. FQHCs will be paid their Prospective Payment System (PPS) rate, and RHCs will receive their all-inclusive rate (AIR). Claims will be automatically reprocessed in July, when the Medicare claims processing system is updated with the new rate.
For distant-site services provided between July 1, 2020, and the end of the COVID-19 public health emergency, FQHCs and RHCs should use HCPCS code G2025 to identify the services furnished via telehealth.
CMS is waiving cost-sharing for services related to COVID-19 testing; FQHCs and RHCs should append the -CS modifier to claims related to COVID-19 testing. Coinsurance should not be collected from beneficiaries when cost-sharing is waived. MACs will automatically reprocess these claims beginning on July 1.
Additional information can be found in this Getting Paid blog post.
Aetna, Anthem, Cigna, Humana, and United Healthcare (UHC) have all announced that they will waive cost-sharing for treatment related to COVID-19. Review the Private Payer FAQ or contact your provider relations representative for additional information.
Medicare has not announced any specific cost-sharing waivers for COVID-19 treatment.
Yes. The Families First Coronavirus Response Act prohibits plans from imposing prior authorization requirements on COVID-19 testing. Private payers are offering additional prior authorization flexibilities. Contact your provider-relations representatives for their policies.
Commercial payers have also started to offer financial assistance programs. On April 7, the nation’s largest private payer, UnitedHealth Group, announced that it would accelerate payments and other financial support to health care providers to address the short-term financial pressure caused by the COVID-19 emergency. Similarly, two Blue Cross Blue Shield plans have announced related policies available to physicians affected by the pandemic. Humana announced that it is expediting claims processing.
CMS has not indicated whether the extreme and uncontrollable circumstances policy will apply to the 2020 MIPS performance year.
If an accountable care organization participating in the MSSP is unable to report quality data, the ACO will receive a quality score equal to the mean quality score across all MSSP ACOs. If the ACO is able to completely and accurately report all quality data for the performance year, the ACO will receive a quality score based on the ACO’s quality performance or the mean quality score across all ACOs, whichever is higher.
CMS may make additional changes through future rulemaking. Please check with your ACO’s administration for additional information on quality reporting requirements.
The MSSP extreme and uncontrollable circumstances policy mitigates potential financial losses by reducing the amount of losses owed by multiplying the percentage of total months affected by an extreme and uncontrollable circumstance by the number of beneficiaries residing in an area affected by an extreme and uncontrollable circumstance.
Because the PHE includes the entire country, 100% of beneficiaries will be considered to reside in an area affected by an extreme and uncontrollable circumstance. If the PHE is extended through the 2020 performance year, 100% of potential losses will be mitigated. Additional adjustments, including adjusting expenditures and benchmarks, were addressed in the May 8 Interim Final Rule. CMS has also published a fact sheet on COVID-10 flexibilities for MSSP participants.