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On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a second Interim Final Rule—COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers—in response to the coronavirus pandemic. This Rule adds to and changes many of the recent telehealth coverage expansions with waivers of the provisions previously outlined by CMS in the wake of the declared Public Health Emergency (PHE). In light of this, several of the answers below have been updated to reflect the second Interim Final Rule. A summary of the telehealth provisions in the second rule is available here.
With the dawn of the COVID-19 pandemic, telehealth has become an essential method of delivering care to many patients. For patients with compromised immune systems who are more vulnerable to the virus, being able to access care remotely can be a lifesaving option.
ACCC recently hosted a webcast in which Teri Bedard, BA, RT(R)(T), CPC—the Director of Client Services at Revenue Cycle Coding Strategies LLC—discussed the rapid changes in the coverage of and billing for telehealth services stemming from the COVID-19 public health emergency. Since this national emergency declaration, the Centers for Medicare & Medicaid Services (CMS) has issued a series of waivers and flexibilities relaxing restrictions regarding telehealth, including an Interim Final Rule, which was released March 30.
During the webinar, Bedard updated participants about the details of the new Interim Rule coverage adopted by CMS. Below, she answers questions submitted by webinar participants regarding the coverage of telehealth and telephone visits and the coding for those services. The archived webinar featuring Bedard further addresses the implications of the temporary CMS telehealth coverage decisions in response to the pandemic.
Coverage of Telehealth Services
Q. Is there a checklist or "to do" list for a practice (freestanding) to establish telehealth visits?
A. 1) Establish how you will be doing your A/V visits and purchase Zoom, Skype, Go to Meeting, etc., licenses as necessary to conduct the length of the meetings you desire. 2) Determine which patients need telehealth vs. in-person visits. 3) Ensure the patient has the capability to conduct an A/V visit and downloads the necessary app. 4) Send an invitation to the patient for a visit. 5) Ensure your billing system can add the address of physician's home if they are conducting telehealth visits from there. 6) Document the visit in the patient’s medical record.
Q. Can a facility charge for a telehealth visit?
A. There is no facility charge for the expanded telehealth services under the public health emergency. The expansion of services only applies to services billed by the physician. April 30 UPDATE: If the patient is at the hospital, and the physician is at their home quarantined during a telehealth visit, the hospital cannot bill the telehealth originator code Q3014 for the technical resources provided to the patient.
Q. Can providers bill for telephone or telehealth visits outside of the medical office? Can they bill for telehealth visits from their home?
A. A physician can be at home while providing telehealth visits. When billing for the service, indicate the place of service as where the visit would have occurred if in person. List the address of the physician for the telehealth visit on the CMS1500 claim.
Codes on the list of approved telehealth services allow for various settings, but there must be both audio and video in real time between the physician and patient. If there are no video capabilities, the visit is not a telehealth visit and would most likely be a telephone visit if only audio is used.
Q. What are the requirements for a patient consenting to a telehealth visit?
A. For code G2012, you must document that the patient has consented to be billed for the visit. For telephone calls that require initiation by the patient, CMS explains that talking to patients about their options for visits (other than in-person visits) and their consent or agreement to a telephone visit will suffice for initiation. You must document this part of the conversation as well. For telehealth visits, document where a patient is located, where the physician is located, and the need for the visit by telehealth.
Q. How would you prove that video/audio telehealth services occurred between a provider and a patient for billing?
A. The documentation in the medical record needs to support where the patient was located, where the physician was located, a statement of how the visit was conducted (what A/V system was used), and what took place during the encounter as well as the time. CMS has expanded these services in the good faith that providers will not abuse that expansion. You may also need to review any medical record retention or destruction of anything that may be recorded (review of state laws may also be necessary) or documented with the patient.
Q. Would recording the call be good practice for proof of a telehealth visit?
A. There are state laws regarding recording phone calls. The use and documentation of phone calls have not changed; they have been used in the past and have been available prior to the public health emergency. Documentation is key to supporting the call, what was discussed, and the time and initiation. The expansion of services by CMS and other payers rests on the assumption the services are provided in good faith and not inappropriately.
Q. If the physician consults with a patient via telehealth, and then determines that the patient needs to be seen in the office, can we bill the initial visit using a telehealth code, and then charge a follow-up visit when the patient comes in and is physically examined?
A. As with any scenario, if a patient is seen by the physician and another E/M is necessary, there must be medical necessity and some change in the patient from the initial visit to the next one to support the visit. If the initial visit is conducted by phone, e-visit or portal, that initial visit is not billable when a subsequent visit is conducted and billed.
Q. What is the best way to capture a physical exam?
A. If the visit is by telehealth with real-time A/V, the history and exam are not the components of the visit that determine the level of the visit. The telehealth visit is based on MDM, or time only, and the documentation must support it. If the visit is in-person, then the '95 or '97 guidelines in full must be performed and documented to support the visit.
Q. Under the Interim Rule, can physician-administered cancer drugs (incident to) be administered in a patient’s home and billed as if administered in the physician’s office?
A. The expansion of telehealth services and change in supervision for office settings does not extend to drug administration codes. Those are still performed in-person under the supervision guidelines and any necessary paperwork. If a physician defines a patient as homebound due to their diagnosis, and they are receiving chemo and cannot be out in public, they would need to document this. The patient could now be eligible for treatment and services under home health guidelines.
Q. Can you explain what a portal entry is? Is it only electronic, or does it also include telephone/email/text messages?
A. Your entity, hospital, or health system should have a patient portal already established for use by patients. This is not the same as using standard email or phone calls and text messages.
Q. Regarding e-visits, does all correspondence need to be done via an online patient portal or just initiated that way, and follow-up can be done via secured email?
A. E-visits are provided through the portal and the documentation retained to support what took place.
Coding for Telehealth Services
Q. Does CMS have a specific fee schedule for the new telehealth services? If so, where can we find it?
A. The approved telehealth services during the public health emergency are paid per your current MPFS (fee schedule), just as the in-person codes are paid. This is why you list the POS where the telehealth visit would have taken place if done in person. The telephone codes 99441-99443 have been assigned work RVUs. April 30 UPDATE: The updated RVUs can be downloaded from the CMS website.
Q. If a physician is providing telehealth from home instead of the hospital-based clinic, does their home address need to be listed on the claim or is that for POS of 11 only?
A. If physicians are performing approved telehealth services from their home, the E/M visits etc. on the list are billed on the claim, regardless of POS, with the home address of the physician listed under the TIN's legal entity name above.
Q. Can you differentiate between GT and 95 modifiers? When they should be used?
A. GT modifiers are used for traditional telehealth services in the CAH II method billing. Modifier 95 is the one CMS is directing those using the expanded telehealth guidelines to use. Modifier 95 should be used to report that the service was provided by real-time A/V communication between the patient and physician.
Q. Is obtaining a verbal consent for a telemedicine visit acceptable?
A. Some codes like G2012 require consent to bill for the visit. Other codes such as phone ones require the patient to initiate the visit. Document this by stating that discussion with the patient for an alternate type of visit took place.
Q. We have dual billing at our hospital. I do the facility/technical billing. Our RNs have always seen the consultations and follow up, and we bill the 99 codes with a 25 modifier added. MDs bill their professional services. Can we continue to bill for the facility? What codes would we use for telehealth and telephone calls?
A. In a hospital outpatient setting, there has been the opportunity to bill for a facility or clinic visit. This is typically the work of the nurse and is independent of the physician, and it is provided in alignment with your clinic visit policy. The CMS code is G0463. You should have levels to the policy and crosswalk CMS ones to G0463 regardless of level. For commercial payers that accept billing for the clinic visit, you can report the 992xx code if they do not accept G0463. There is no technical component to the physician E/M; this now includes the expanded telehealth services. If a clinic visit is supported, it is independent of the physician's work in seeing the patient for the E/M.
Coding for Telephone Visits
Q. Is there any support for billing telephone-only visits for those without technology access?
A. CMS has set RVUs for telephone calls: 99441-99443. These were previously not covered by Medicare. During the public health emergency, they are being covered. April 30 UPDATE: CMS updated the RVUs to increase in alignment with mid-level established outpatient E/M services. An update of the RVUs was released by CMS on 4/30/20 and can be downloaded from the CMS website.
Q. Can a phone visit be with a caregiver who is not a parent or guardian?
A. The definitions of the codes indicate patient, parent, or guardian. CMS has not expanded this definition, and you will have to determine internally from a legal standpoint what can be supported and defended.
Q. When would you use G2012 for a phone call vs. 99442?
A. When a payer only accepts G2012 and not 99442. Initially, CMS did not cover codes 99441-99443, so code G2012 was the only one available.
Q. Commercial payers have not honored payment for "telephone conferences" in the past. How can we ensure that we will be paid now by them?
A. You will need to review plans or payer information about expansion of services in response to COVID-19, as they are establishing guidelines. Some indicate they will follow the patient's plan to determine if they are covered.
Q. For a 40-minute physician telephone visit (audio only) for a Medicare patient, is the only option to bill 99443?
A. Correct. The codes define the time, and a 40-minute phone call corresponds to code 99443.
Q. Do the full '95 or '97 guidelines need to be met for regular office visits?
A. If the outpatient visit is done in person, then you must meet the full '95 or '97 guidelines for documentation and billing purposes.
Q. Can you bill the telephone codes on a new patient?
A. For the duration of the public health emergency, CMS is relaxing the definitions of the codes that allow for services only to established patients and expanding them to include new patients. CMS will not conduct reviews to determine if a service was furnished to established patients.
Clarification, 5/20/20: Code Q3014 v. Code G0463
Code Q3014 was updated for the public health emergency (PHE) to be billed by a facility where the patient is at the facility and the physician is at their home when a telehealth visit was done. Because the patient is using the resources and staff time of the audio-video telecommunication technology, the facility can bill the standard originator code for this resource. The physician would be considered at a distant site, their home, and bill their respective telehealth audio-video code.
Code G0463 is the clinic visit code, billable only in the hospital setting for outpatients and only billed by the hospital. The facility needs to have a clinic visit policy in place already and would bill this code for the work detailed as necessary by the ancillary staff, typically a nurse. This is independent of any work provided by the physician as part of their E/M visit. Only if the clinic visit policy outlines that services can be provided by real time audio-video capabilities would there be any charge for this work by the facility. Most clinic policies include in-person work by the nurse with the patient, but a review of a facility’s clinic visit policy would be needed. This is not billed simply because the physician provided an E/M, in-person or telehealth. There are work and resources provided to the patient separate from the physician work.