By Michael Stearns, MD, CPC, CRC, CFPC

[Editor’s Note: This article was updated on May 7, 2020.]

Telehealth has enjoyed a gradual but steady rise in adoption over the past decade. More doctors and patient have come to accept—and even prefer—virtual care as an alternative to some in-office visits. The technology has grown more advanced and secure. Telehealth has also notched inconsistent but promising wins on the reimbursement front.

COVID-19 has made telehealth an indispensable service for an overwhelmed U.S. healthcare system. While some health systems enjoyed robust telehealth programs long before the emergence of the novel coronavirus, many hospitals will be jumping into the deep end of the telehealth pool in the middle of the most significant public health crisis in modern history.

Fortunately, private and public stakeholders have worked to streamline the transition to virtual care encounters. Commercial payers and Medicaid organizations have moved quickly to authorize additional services and normalize payments. Additionally, the Centers for Medicare and Medicaid Services (CMS) has temporarily waived several telehealth requirements for the duration of the crisis1, 22—more on this below.

The hope is that improved reimbursement models and a liberalized regulatory framework will help hospitals smooth the transition from in-person office visits with sustainable virtual encounters.

Telehealth Regulations—What’s Allowed and What’s Not

The U.S. Health Resources Services Administration (HRSA) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.”2

CMS updated the list of codes3 eligible for telehealth services on April 30, 2020.  The process through which codes are approved for telehealth services has also been expedited22 and additional codes will likely be added.  The April 30, 2020 version of the code list identified 238 telehealth eligible services for Medicare beneficiaries. This includes approximately 135 additional services that have become became temporarily eligible for telehealth in response to the pandemic. These requirements are retroactive to March 1, 2020. (Note that a few of the codes in this table have Medicare payment limitations).

A provision in the federal Coronavirus Preparedness and Response Supplemental Appropriations Act allows CMS to temporarily waive certain Medicare telehealth requirements during the current public health crisis4. Impactful changes include:

  • Qualified healthcare professionals may now provide telehealth services to Medicare beneficiaries regardless of the patient’s physical location, including their homes. Previously, patients had to live in rural areas or near a designated clinic or hospital to receive telehealth services
  • Medicare has waived penalties for HIPAA violations against clinicians that “act in good faith” to provide care though telehealth communication tools that may not be fully HIPAA compliant,5 such as Apple FaceTime, Skype, Google Hangouts, Facebook Messenger, and WhatsApp
  • Practices that do not have a HIPAA Business Associate Agreement in place with the app developer organization, which under normal circumstances would be required, will not be penalized
  • Medicare practitioners are allowed to provide telehealth services to patients that reside in other states (if also permitted by state requirements)
  • The U.S. Department of Health and Human Services (HHS) allows providers to reduce or waive cost-sharing for telehealth visits paid for by federal healthcare programs6,7
  • CMS will not conduct audits to determine if Medicare patients that receive a telehealth encounter had a previously established relationship with the provider
  • The Drug Enforcement Agency will no longer require that patients submit to in-person physical exams prior to being prescribed controlled substances. Instead providers can use a real-time, two-way, audio-visual communications device prior to prescribing controlled substances8
  • Telehealth professional claims submitted to Medicare for services provide on or after March 1, and for the duration of the public health emergency can be equal to what would have been claimed had the service been provided in-person11
  • Many behavioral health and education services may now be furnished via telehealth using audio-only technology. On April 30, 2020 CMS added a column that identified 89 HCPCS codes as audio-only services in the CMS telehealth code list file3
  • Allowing providers to have flexibility to reduce or waive cost-sharing for telehealth visits paid for by federal government healthcare programs. On March 17, 2020, OIG issued “OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak.”6 The OIG later clarified7 that it “intends for the Policy Statement to apply to a broad category of non-face-to-face services furnished through various modalities, including telehealth visits, virtual check-in services, e-visits, monthly remote care management, and monthly remote patient monitoring”

All clinicians that are eligible to bill for Medicare services may now provide telehealth services22. Clinicians that were previously not allowed to provide telehealth services, including physical therapists, occupational therapists, speech language pathologists and others may now provide these services. Despite the waivers, providers must abide by local regulations and licensure requirements, which can vary significantly from state to state.9 Organization also will need to maintain compliance with anti-trust and anti-kickback regulations and laws.10

Telehealth services authorized by Medicare are listed below. They are loosely organized into groups based on type of service or patient location.  Abbreviated terms are used to describe codes and groups of similar codes.

(Consult the American Medical Association’s CPT® codebook12 and HCPCS code book for full descriptions of these services.)

Evaluation and Management Services

Codes impacted by the waivers include:

  • Office Visits: 99201-99215
  • Nursing facility care, initial: 99304-9306
  • Nursing facility care, subsequent: 99307-99310
  • Nursing facility discharge day management: 99315-99316
  • Domiciliary/rest home new patient: 99324-99328
  • Domiciliary/rest home established patient: 99334-99337
  • Home visits: 99341-99350
  • Prolonged Services, Office: 99354-99355
  • Smoking Behavior Change: 99406-99407
  • Care planning for patients with cognitive impairment: 99483
  • Transitional care management: 99495-99496
  • Advanced Care Planning: 99497-99498
  • Prolonged preventive services, outpatient: G0513-G0514
  • Annual Wellness Visit (includes personalized prevention plan): G0438-G0439
  • Annual depression screening: G0444
  • High intensity behavioral counseling to prevent sexually transmitted diseases: G0445
  • Annual, face-to-face intensive behavioral therapy for cardiovascular disease: G0446
  • Behavioral counselling for obesity: G0447

CMS has also accelerated the changes to the documentation requirements for outpatient E/M services  99201-99215 that were finalized for 2021. The level of service for these codes when provided via telehealth is determine by either time or the complexity of medical decision making.  This is retroactive to March 1, 2020.

Under the temporary waivers, history and physical documentation requirements have been removed for telehealth visits. CMS elected to retain the same requirements for complexity of MDM determination that have been in effect since 1995. However, a revised method of determining the complexity of MDM is still slated for 2021.

Time refers to the total time providing care to a patient during a calendar day, including, but not limited to synchronous audio and video “face-to-face” time during the telehealth encounter.  Using time to determine the level of service no longer requires that over 50 percent of the time spent with the patient must be for counseling and coordination of care.  On April 30, 2020 CMS updated guidance22 on how time should be used when determining the level of service. CMS stated “…the typical times for purposes of level selection for office/outpatient E/M are the time listed in the CPT code descriptor.”22 Typical times are reflected in Table 1.

Table 1: Physician Time for the Office/Outpatient E/M Services Code Set
CPT Code Typical Total Time Spent Providing Care During a Calendar Day
NEW PATIENT TELEHEALTH ENCOUNTER
99201 10 minutes
99202 20 minutes
99203 30 minutes
99204 45 minutes
99205 60 minutes
ESTABLISHED PATIENT TELEHEALTH ENCOUNTERS
99212 10 minutes
99213 15 minutes
99214 25 minutes
99215 40 minutes

Telephone E/M visit codes 99441-99443 for established patients were recently approved for temporary use1 by Medicare for the public health emergency. CMS significantly increased payment for these codes in the April 30, 2020 IFR22 – making payment equivalent to office E/M services 99212-99214.

The time requirements for telephone E/M service codes are listed in Table 2.  Telephone service codes may be reported when a physician or other qualified health care professional provides E/M services to an established patient, parent, or guardian via an audio-only device. The service cannot be related to an E/M service provided within the previous seven days or lead to an E/M service or procedure within the next 24 hours or “soonest available appointment.”12

Table 2: Requirements for Telephone E/M Service Codes 99441-994432
Code Required Amount of Medical Discussion Time Equivalent Office CPT Code (By Payment)
99441 5-10 minutes 99212
99442 11-20 minutes 99213
99443 21 or more minutes 99214

Telephone E/M services 98966-98968 are provided by clinicians that are not eligible to bill for E/M services.  Reimbursement for these codes was not changed in the April 30, 2020 IFR.

Inpatient, Observation and Emergency Department Services

Medicare will reimburse for telehealth services provided to patients in the inpatient, ICU, and Emergency Department (ED) settings. Several services in these areas have been added in response to COVID-19, including:

  • Observation care discharge: 99217
  • Initial observation care: 99218-99220
  • Initial hospital care: 99221-99223
  • Subsequent observation care: 99224-99226
  • Subsequent hospital care: 99231-99233
  • Observation/inpatient hospital care including same day admission/discharge: 99234-99236
  • Hospital discharge day management: 99238-99239
  • Emergency department visit: 99281-99285
  • Critical care services: 99291-99292
  • Prolonged services, inpatient: 99356-99357
  • Inpatient neonatal critical care: 99468-99469
  • Inpatient pediatric critical care: 99471-99472
  • Initial day neonatal care, hospital: 99477
  • Subsequent intensive care, low birth weight neonates: 99478-99480
  • Follow-up inpatient telehealth consultation: G0406-G0408
  • Telehealth consultation, emergency department or initial inpatient: G0425-G0427
  • Critical care telehealth consultation: G0508-G0509
  • Inpatient telehealth pharmacologic management: G0459

Mental and Behavioral Health Telehealth Services

Mental health is particularly well-suited to telehealth encounters. Telehealth visits for behavioral and mental health encounters are generally perceived as equivalent to face-to-face visits in the areas of the quality of the assessment and management. The following services are eligible for Medicare reimbursement.

  • Psychotherapy – complex interactive: 90785
  • Psychiatric diagnostic evaluation: 90791
  • Psychiatric diagnostic evaluation with medical services: 90792
  • Psychotherapy patient and family: 90832-90834, 90836-90838
  • Psychotherapy crisis: 90839-90840
  • Psychoanalysis: 90845
  • Family psychotherapy without patient: 90846
  • Family psychotherapy with patient: 90847
  • Group psychotherapy: 90853
  • Psychophysiological therapy: 90875
  • Neurobehavioral assessment: 96116, 96121
  • Brief emotional/behavioral assessment: 96127
  • Psychological/neuropsychological test administration/scoring by physician/QHP: 96136-96137
  • Psychological/neuropsychological test administration/scoring by technician: 96138- 96139
  • Health behavior assessment/reassessment: 96156
  • Health behavior intervention, individual, first 30 minutes: 96158
  • Health behavior intervention, group: 96164-96165
  • Health behavior intervention, family: 96167-96168
  • Health behavior intervention individual: 96158-96159
  • Health behavior intervention family without patient: 96170-96171
  • Behavior identification assessment by QHP: 97151
  • Behavior identification supporting assessment by technician: 97152
  • Adaptive behavior treatment by technician: 97153
  • Group adaptive behavior treatment, administered by technician: 97154
  • Adaptive behavior treatment by qualified health professional: 97155
  • Family adaptive behavior treatment guidance by qualified health professional: 97156
  • Multiple-family group adaptive behavior treatment guidance, by QHP: 97157
  • Group adaptive behavior treatment with protocol modification by QHP: 97158
  • Group psychotherapy partial hospitalization: G0410
  • Adaptive behavioral therapy: 0373T

As with other codes, the documentation requirements are the same for telehealth visits as they are for face-to-face encounters, including the documentation of time where applicable.

Substance Use/Abuse Counseling Services

These services are commonly provided by primary care providers, mental health professionals, and other clinicians. For codes G2086-G2088, the “office-based” component in the description may be replaced by “virtual-based” when provided via a telehealth encounter.

  • Smoking and tobacco use cessation counseling visit: 99406-99407 (Note, the Medicare telehealth services files also lists HCPCS codes G0436 and G0437 for these services, but these codes were deleted in 2016)
  • Alcohol/substance abuse structured assessment and intervention: G0396-G0397
  • Annual alcohol misuse screening: G0442
  • Brief face-to-face behavioral counseling for alcohol misuse: G0443
  • Office-based treatment for opioid use disorder: G2086-G2088

End-Stage Renal Disease and Related Services (ESRD)

ESRD services and codes that may be provided through telehealth during the health care emergency. Medicare released a fact sheet specific to ESRD services.14

  • ESRD services: 90951-90955, 90957-90962
  • ESRD home patient services: 90963-90970
  • Face-to-face educational services related to the care of chronic kidney disease: G0420-G0421

The following codes are temporary additions to those approved for telehealth under Medicare:

  • ESRD Services – 1 visit per month, age <2 years: 90953
  • ESRD Services – 1 visit per month, ages 12-19 years: 90959
  • ESRD Services – 1 visit per month, age ≥ 20 years: 90962

Nutritional and Diabetic Care Services

The services are eligible for telehealth encounters under Medicare. No new codes have been made available in this category for telehealth under the public health emergency.

  • Medical nutrition therapy assessment and intervention: 97802-97803
  • Medical nutrition therapy; group: 97804
  • Diabetes outpatient self-management training services, individual, per 30 minutes: G0108
  • Diabetes/outpatient self-management training services – group session: G0109
  • Medical nutrition therapy; reassessment and subsequent interventions: G0270

Speech Language Pathology, Physical and Occupational Therapy Telehealth Services

Physical and occupation therapy may now be provided to patients covered by Medicare Part B (and potentially commercial insurance carriers).  CMS stated in its March 30 waiver guidance4 that these services can be paid for as Medicare telehealth services. However, therapy professionals should review state and federal requirement before providing these services. A number of services have been approved for telehealth during the public health emergency.

  • Treatment of speech, language, voice, communication, and/or auditory processing disorder: 92507
  • Speech/hearing therapy: 92508
  • Speed therapy reevaluation: S9152
  • Evaluation of speech fluency and production: 92521-92522
  • Evaluation of speech production and comprehension: 99523
  • Behavioral and qualitative analysis of voice and resonance: 92524
  • Therapeutic exercises: 97110
  • Neuromuscular re-education: 97112
  • Gait training therapy: 97116
  • Physical therapy evaluation: 97161-97163
  • Physical therapy reevaluation: 97164
  • Occupational therapy evaluation: 97165-97167
  • Occupational therapy reevaluation: 97168
  • Self-care/home management training: 97535
  • Physical Performance Test or Measurement: 97750
  • Assistive technology assessment: 97755
  • Orthotic Management and Training, Initial Orthotic(s) Encounter: 97760
  • Prosthetic Management & Training, Initial Prosthetic(s) Encounter: 97761

Miscellaneous Telehealth Eligible Services

  • Radiation therapy management: 77427*
  • Eye examination codes: 92002, 92004, 92012, 92014
  • Cochlear implant services: 92601-92604
  • Ventilator management codes: 94002-94005
  • Evaluate patient use of inhaler: 94664
  • Developmental screening/scoring: 96110, 96112-96113
  • Patient and Caregiver Health Risk Assessment: 96160-96161
  • Group therapeutic procedures: 97150
  • Therapeutic activities: 97530
  • Wheelchair management training: 97542
  • Counseling visit to discuss need for lung cancer screening using Low Dose CT scan (LDCT): G0296
  • Comprehensive assessment of and care planning for patients requiring chronic care management services: G0506
  • Acute nursing facility care: G9685

E-Visits

E-visit codes 99421-99423 may be submitted when an established patient initiates a service inquiry and a physician or other qualified health care provider spends five or more minutes of cumulative time in a seven-day period providing remote evaluation and management services.12

Clinicians that do not have evaluation and management services in their scope of practice can bill for these services through HCPCS codes G2061-G2063.4 The communication must occur via a HIPAA-compliant secure platform such as a patient portal, e-mail, or other digital applications. The initiating communication from the patient must occur via a HIPAA-compliant secure platform such as a patient portals, e-mail, or other digital applications. It cannot be through a phone call.

The patient must verbally consent to receive these services. Medicare coinsurance and deductibles apply to these services4.  However, the HHS OIG has stated it will exercise enforcement discretion for e-visit copayments during the public health emergency.7

These codes became eligible for reimbursement on January 1. The patient can receive this service from any geographic location and a claim submitted, unless the patient receives an E/M service within seven days or the patient-initiated inquiry stems from an E/M service provided in the past seven days and is for the same problem. Additional details are provided below:

  • Online digital evaluation and management services provided by a physician or qualified health care professional, cumulative time during up to 7 days
    • Duration 5-10 minutes: 99421 (Non-facility reimbursement: $15.84)
    • Duration 11-20 minutes: 99422 (Non-facility reimbursement: $31.62)
    • Duration 21 or more minutes: 99423 (Non-facility reimbursement: $51.12)
  • Online digital assessment services provided by a nonphysician health care professional (i.e., practitioners who cannot bill Medicare for evaluation and management services)
    • Duration five to 10 minutes: G2061 (Non-facility reimbursement: $12.53)
    • Duration 11 to 20 minutes: G2062 (Non-facility reimbursement: $22.10)
    • Duration 21 or more minutes: G2063 (Non-facility reimbursement: $34)

Clinicians should document the amount of time spent during each patient interaction and the topics discussed.4 Clinicians may use the time spent reviewing the initial inquiry, records review, ordering tests, writing prescriptions, developing a management plan and in follow-up communication with the patient through online portal communications, telephone calls, e-mail, or other forms of communication. The encounter must be permanently documented. Clinical staff time is not included in the reported service time.

If the patient receives an E/M service within seven days of the initiation of the online service the visit service should be billed (and not the e-visit), but the time or complexity of medication decision making spent providing the e-visit service may be incorporated into the E/M visit when determining the level of service.

Virtual Check-In Services

There are two codes in this category—G2010 and G2012—and both compensate providers for brief virtual interactions with patients as described below. They may be billed for established patients only and the service need to be provided by a physician of other qualified health care professional.

There services cannot be billed if they originated from a related E/M service within the past seven days and must not lead to an E/M service or procedure within 24 hours or the “soonest available appointment.”

This service should also be initiated by the patient. As per Medicare,4 standard coinsurance and deductibles are “generally applicable,” although the HHS OIG may exercise discretion when copayments are waived or reduced for this service.7

Summary and Conclusions

Telehealth and other remote services have been heavily adopted during the COVID-19 pandemic. This is in part due to waivers instituted by CMS and other payers to reduce barriers to their use, as detailed in this article. Telehealth requirements continue to evolve, however, and readers are encouraged to periodically check CMS and commercial payer resources for new information.

CMS stated that these changes are temporary and limited to the duration of the public health emergency. Whether this trend will persist after the pandemic is uncertain, but a large percentage of the healthcare workforce, payers and many patients will have gained first-hand experience with telehealth.

Notes

  1. Centers for Medicare and Medicaid Services (CMS). ‘Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, Interim Final Rule.” Federal Register, April 6, 2020. (CMS-1744-IFC), 85 CFR 19268-19269. https://www.federalregister.gov/documents/2020/04/06/2020-06990/medicare-and-medicaid-programs-policy-and-regulatory-revisions-in-response-to-the-covid-19-public.
  2. US Department of Health and Human Services (HHS), Health Resources and Services Administration. Telehealth Programs. https://www.hrsa.gov/rural-health/telehealth.
  3. List of Telehealth Services. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
  4. “Medicare Telemedicine Health Care Provider Fact Sheet.” March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
  5. “Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.” March 24, 2020. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.
  6. Office of the Inspector General (OIG). “OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak.” March 17, 2020. https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf.
  7. OIG. “FAQs—OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak.” March 24, 2020. https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/telehealth-waiver-faq-2020.pdf.
  8. United States Department of Justice Diversion Control Division. “COVID-19 Information Page.“ https://www.deadiversion.usdoj.gov/coronavirus.html.
  9. COVID-19: Telehealth Billing Correction, Nursing Home Recommendations, Billing for Multi-Function Ventilators, New ICD-10-CM Diagnosis Code, April 3, 2020. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-03-mlnc-se.
  10. Ibid
  11. American Health Information Management Association. Telemedicine Toolkit. http://bok.ahima.org/PdfView?oid=302358.
  12. American Medical Association. Current Procedural Terminology (CPT) 2020. Chicago, IL: AMA 2020.
  13. End Stage Renal Disease (ESRD) Facilities: CMS Flexibilities to Fight COVID-19. March 28, 2020. https://www.cms.gov/files/document/covid-19-esrd-facilities.pdf.
  14. “Medicare Telemedicine Health Care Provider Fact Sheet.” March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
  15. American Medical Association. Current Procedural Terminology (CPT) 2020. Chicago, IL: AMA 2020.
  16. “Medicare Telemedicine Health Care Provider Fact Sheet.” March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
  17. Ibid
  18. OIG. “FAQs—OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak.” March 24, 2020. https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/telehealth-waiver-faq-2020.pdf.
  19. “Medicare Telemedicine Health Care Provider Fact Sheet.” March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
  20. Ibid
  21. OIG. “FAQs—OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak.” March 24, 2020. https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/telehealth-waiver-faq-2020.pdf.
  22. Centers for Medicare and Medicaid Services (CMS). ‘Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program.” April 30, 2020 Interim Final Rule. Available at: https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf

 

Michael Stearns (michael@apollohit.com) is the founder and CEO of Apollo HIT, LLC.