CMS has released the Interim Final Rule entitled: Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. The document contains the policies related to the changes announced throughout the last two weeks. It contained several pleasant surprises and enough changes that we are going to revisit everything that we have published regarding Telehealth. (The Interim final rule document and a list of documents including FAQs can be found on the CMS website: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers ). We will, like Medicare, refer to the crisis as a Public Health Emergency (PHE) , the time under which these rules apply.
The revisions addressed here are for the duration of the PHE and are going to:
- change the way you submit your claims,
- change the way you document and code,
- and should prompt you to resubmit your claims from the past couple of weeks.
Here are the highlights of the document:
- New (99201-99205) and Established (99212-99215) patient visit codes, as previously noted, are covered if provided with synchronous Audio and Visual communication for both new and established patients. For patients that cannot connect with Video and audio use codes 99441-99443 below. NOTE: Do not use standard E/M visits, even if you made every attempt to “connect” as previously recommended.
- Medicare has changed the way to report TeleMedicine (synchronous audio and visual encounters) visit codes. Report these services with Place of Service 11 and append modifier -95.
Medicare made this change to allow for processing of payments at the normal in-office rate they indicated would be appropriate during the PHE. This change in reporting and their system programming means that you will likely want to re-bill the services you provided remotely last week. In general, CMS has instructed physicians to report the POS, that would have been used if the visit would have occurred in a Face to Face setting. for all remote TeleMedicine services. They are relying on the physicians to select the appropriate code and place of service that is appropriate. The typical edits for place of service and code type will be applicable.
- If you have a place of service denial for a
claim or a processing error due to place of service for services paid at the
facility rate (ie. Office visits for patients in a remote facility billing as
an originating site or Inpatient phone calls such as G02425-G0247 or
G0406-G0407) try place of service 02 with and/or without modifier -95
- For those services which are provided to patients in remote sites, the remote site should be charging and will be paid for an originating site or standard facility fee. If the patient is an inpatient or outpatient when the services is provided the facility will be paid accordingly for the facility fee.
- Selection of Level of E/M service. CMS has indicated that they will allow the selection of the appropriate E/M service on a modified version of the proposed 2021 E/M changes. For component-based coding, they are going to waive requirements for History and Physical Examination. Component based billing will be based solely on the medical decision making recorded in the medical record. For Time based billing, they are waiving the requirement that 50% of the visit must be spent in counseling and/or coordination of care. The time spent has been expanded to include all time spent in providing the service throughout the date of the remote encounter (visit time plus preparation time and follow-up time in reviewing documents and data on that date) as documented.
- The list of Codes allowed to be reported when furnished with synchronous audio visual communication during the PHE has nearly doubled as 80 new codes have been added to the covered list of services. The full list of codes now covered for Telehealth can be found on the CMS website (https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes) highlights include:
- Emergency Department Visits, Levels 1-5 (CPT
codes 99281-99285)
- Initial and Subsequent Observation and Observation Discharge Day Management (CPT codes 99217- 99220; CPT codes 99224- 99226; CPT codes 99234- 99236)
- Initial hospital care and hospital discharge day management (CPT codes 99221-99223; CPT codes 99238- 99239)
- Initial nursing facility visits, All levels (Low, Moderate, and High Complexity) and nursing facility discharge day management (CPT codes 99304-99306; CPT codes 99315-99316)
- Critical Care Services (CPT codes 99291-99292)
- Domiciliary, Rest Home, or Custodial Care services, New and Established patients (CPT codes 99327- 99328; CPT codes 99334-99337)
- Home Visits, New and Established Patient, All levels (CPT codes 99341- 99345; CPT codes 99347- 99350)
- Inpatient Neonatal and Pediatric Critical Care, Initial and Subsequent (CPT codes 99468- 99473; CPT codes 99475- 99476)
- Radiation Treatment Management Services (CPT codes 77427)
- Incident to rules addressed. Medicare has expanded the definition of direct supervision to include services provided by employees or contracted auxiliary personnel under the audio and visual supervision of the physician during the PHE. If a physician is unable to come to the office, but nursing staff is available and can be supervised via Audio and Visual connection, the service can be billed as if provided by the physician who would typically be in the office during the service.
- Consent can be obtained virtually and should be documented in the patient record for at least verbal consent to treat remotely for each encounter. However, CMS has relaxed the rules for signed consent. CMS, during the PHE, has indicated that written signed consent can be obtained after services have been provided and be extended to an annual service consent for all services as a blanket consent.
Telecommunications (Telehealth)
- Telephone only visit coverage has been expanded. These changes allow for reporting of services
to new and established patients for the G2010 and G2012 as we have addressed
previously. It appears these visits were
expanded to assist with appropriate billing to patients:
- Clinicians can provide virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. Virtual check-in services were previously limited to established patients.
- CMS has reiterated that Telecommunication visits 99421-99423 will not be reviewed for the requirement of an established relationship. Therefore can be provided to new and established patients, if appropriate.
- CPT codes 98966 -98968; 99441-99443 – For those encounters for which video and audio services cannot be implemented CMS has finalized that they will pay for CPT codes 98966 -98968; 99441-99443, as appropriate, for both new and established patients. As these codes are time based, the codes can be used to more accurate provide services that can interact via phone only. Payment is not as appropriate as new patient visits but the update clarifies that standard office visits should not be reported
- Restrictions on related E/M visits either in person or remotely will remain in place for the above services as previously stated. Visits billed with these codes cannot result in “immediate” follow-up in person or remotely to complete the service required nor can these services be reported for follow-up to an in person or remote visit. The key here is to consider the related visits as bundled into the preceding or following encounter. If you are unable to resolve the patient issue in the telephone encounter and require a Telemedicine visit (video and audio) or in-person encounter to render appropriate medical care, the telephone call would be bundled into the next available visit. If the phone call is to follow up on test results that does not require further treatment, the discussion would also be considered bundled and not separately billable.
We will continue to update you as more information and interpretation becomes available.
At this time, it is not known if the private payers are going to change to meet these new reporting guidelines and recommendations.
Medicare Advantage plans must provide at equivalent coverage to traditional Medicare. This rule does not require the plans to change to meet the place of service and modifier recommendations provided by Medicare. We will all continue to monitor Medicare and the private payers and update you as we get information.
Again, we encourage you to share information with us and with others as you have it. Stay connected and monitor all sources. The process remains fluid and changes frequently as you have seen.
