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How COVID-19 is Altering Telehealth


The rules for telehealth offerings and reimbursement under Medicare are quickly changing during the current public health crisis. Providers should review the following guidelines to ensure compliance and to provide optimal services to their patients.

Setting up and promoting telehealth
Encouraging Medicare patients to participate in telehealth is essential for public safety during the current COVID-19 pandemic. Many of these patients fall under the parameters for people at extra risk for the virus, due to age and/or pre-existing conditions, so protecting them through social distancing is important. Healthcare providers can promote their telemedicine capabilities on their practice’s website, social media pages and in emails to patients. In the office, post signs to educate patients. Before in-person visits, staff could call patients to tell them about the availability of a tele-health alternative and messages can also be placed within automated scheduling reminders.

If telehealth is new for a practice, providers should consult with their EHR vendor to see if it offers a telemedicine platform. Educating themselves and their staff on how systems function is crucial. Can they use the existing scheduling software to also book virtual visits? Is there a template within the EHR for such visits?

Obtaining patient consent for telemedicine is important. Under the relaxed provisions an annual single beneficiary consent is enough. CMS also said consent may be obtained by auxiliary staff under general supervision, as well as by the billing provider. If the practice prefers to have the patient sign a written consent form the document should provide assurances standard doctor-patient confidentiality will be followed; affirmation of patient’s right to withdraw consent to telemedicine without jeopardizing future care or treatment; affirmation that patient had the opportunity to ask questions about telemedicine and the provider answered such questions; and affirmation that the patient understands there may be financial responsibility on their part for the visit, i.e. copay.

Reimbursement under Medicare
During the period of the declared Public Health Emergency (PHE), Congress and state legislatures have enacted several laws that enhance the authority to offer telehealth services. Normally, Medicare would only pay for telehealth on limited basis. Patients receiving the service had to live in a designated rural area and leave their home to go to a clinic, hospital, or certain other type of medical facilities for the service.

As of March 21, 2020, 15 states have specifically authorized out-of-state providers to provide telehealth services without needing a state-specific license. That number is subject to change. Providers should contact their malpractice carrier to determine if they will be covered for services offered to a patient who is not located in the state where they are licensed and practice.

Under the new statutes, during the PHE, Medicare patients can receive telehealth services at their home, regardless of their geographic location. Patients no longer need to reside in designated rural areas or go to a medical facility to access services in order for healthcare providers to bill Medicare.

CMS Interim Final Rule Released March 30, 2020
The CMS Interim Final Rule released on March 30, 2020 made sweeping changes to telehealth billing. Prior to the CMS Interim Final Rule, when billing Medicare for telehealth services, practices were instructed to use Place of Service (02). Now in order to be paid for an office visit done via telehealth, at the same rate as your office setting, practices should use the Place of Service (POS) that would have been used if the patient had been seen face-to-face (POS 11) and attach Modifier 95. If practices bill POS 02, the lower facility rates will be paid. All changes are retroactive back to March 1, 2020.

The required documentation for telehealth also was addressed. In a section titled, “W Level Selection for Office/Outpatient E/M Visits when Furnished Via Medicare Telehealth” CMS outlined the upcoming changes in 2021 for codes 99202–99215. These changes allow a provider to select a level of service based on total time for the day or medical decision making (MDM). The time spent includes non-face-to-face time spent by the provider and does not need to be dominated by counseling.

During the public health emergency CMS is allowing providers to apply these rules to office/outpatient visits performed via telehealth. CMS removed requirements for history and/or physical exam. Providers can use medical decision making (MDM) or time to select the code level. Time is defined as “all of the time associated with the EM on the day of the encounter.”  CMS is using the existing time guidelines and are keeping the current definitions of MDM, not the revised set that will be implemented in 2021.

“Given the potential importance of using telehealth services as means of minimizing exposure risks for patients, practitioners, and the community at large, we believe this interim change will help medical practices deliver patient appropriate care and eliminate potential financial deterrents to the clinically appropriate use of telehealth,” says Cindy Dunn, RN, FACMPE, Director, Client Services for IntrinsiQ Specialty Solutions.

Eligible telehealth providers can reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs, under new flexibility offered by the Office of the Inspector General. Also, during the Public Health Emergency, the department of Health and Human Services will not check Medicare telehealth claims to make sure there was a prior relationship between provider and patient.

New provisions allow physicians, physician assistants and advanced nurse practitioners to offer new and existing patients online electronic medicine services, or e-visits through secure platforms. Patients must provide their consent each year. The Medicare reimbursement rate for such offerings varies based on the length of the consultation. Providers bill for these EM services under CPT codes 99421-99423 and HCPCS codes G2061-G206. When the qualified healthcare professional performs the first review of a patient’s question, it starts a 7-day clock. A service can only be reported to Medicare once during that time period. If a practice doesn’t have a patient online portal as part of their services, they cannot bill for such offerings.

Alternate means of access
Face-to-face consultations, even via video chat are the preferred method for communication between providers and patients. Yet, what if bandwidth is limited or patients don’t have access to the necessary technologies?

CMS, in the interim final rule, also decided to reimburse practices for telephone calls with patients (CPT 99441-99443 and 98966-98968). Providers can bill telephone services for new and established patients. Code descriptors require there to be an established patient relationship, but CMS stated they will exercise their enforcement discretion on an interim basis and not conduct reviews to consider whether these services were furnished to established patients. This provision applies for the duration of the PHE. This ruling will help patients without smartphones or internet access care while remaining socially distant during the pandemic.

Also, during the declared PHE, the Office for Civil Rights will allow health care providers to serve patients via one-on-one communication technologies like FaceTime, Skype, Facebook Messenger video chat, Google hangout videos, Updox, or Zoom for Healthcare. Those apps can be used on smartphones, tablets or laptops, and more critically, patients can use some of them with data from their carrier, no internet connection needed. Patients must be made aware such platforms could pose a privacy risk. Providers and patients should take care not to communicate via public services, like Facebook Live, Twitch or TikTok. Healthcare providers won’t accrue the typical HIPAA penalties for using these platforms during the crisis.

Providers should check with their attorney and/or malpractice insurance carrier to confirm any questions around offering and billing telehealth services to Medicare patients during the Public Health Emergency.

To learn more about Medicare telemedicine during the Public Health Emergency, read this Interim Rule.