CMS flexibilities to fight COVID-19 - Telehealth servicesMedicare Telehealth Eligible Providers - Licensed physical therapy services, occupational therapist services, and speech language pathology services can now be paid for as Medicare telehealth service providers (4/29/20).
- Previously only these distant site practitioners could furnish and get payment for covered telehealth services (subject to state law): physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals (3/17/20).
- Practitioner Locations: CMS temporarily waives Medicare and Medicaid’s requirements that physicians and non-physician practitioners be licensed in the state where they are providing services. State requirements will still apply. See Current State Laws & Reimbursement Policies, including medical licensure requirements.
- Provider Enrollment: CMS has established toll-free hotlines for physicians, non-physician practitioners and Part A certified providers and suppliers establishing isolation facilities to enroll and receive temporary Medicare billing privileges.
- Originating site: Effective March 6, 2020, the patient’s home can serve an originating site for the duration of the COVID-19 PHE (5/27/20)
- Distant site: There are no payment restrictions on distant site practitioners furnishing Medicare telehealth services from their home during the public health emergency. The practitioner should report the place of service (POS) code that would have been reported had the service been furnished in person (4/9/20)
- After the PHE ends: See section 'Updates' above
Beneficiary consent: - Beneficiary consent should not interfere with the provision of telehealth services. Annual consent may be obtained at the same time, and not necessarily before, the time that services are furnished.
New telehealth codes: - Clinicians can provide more services to beneficiaries via telehealth so that clinicians can take care of their patients while mitigating the risk of the spread of the virus. Under the public health emergency, all beneficiaries across the country can receive Medicare telehealth and other communications technology-based services wherever they are located. Clinicians can provide these services to new or established patients. In addition, providers can waive Medicare copayments for these telehealth services for beneficiaries in Original Medicare. To enable services to continue while lowering exposure risk, clinicians can provide the following additional services by telehealth:
- 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)
- Initial and Continuing Intensive Care Services (CPT code 99477- 994780)
- Care Planning for Patients with Cognitive Impairment (CPT code 99483)
- Psychological and Neuropsychological Testing (CPT codes 96130- 96133; CPT codes 96136- 96139)
- Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507)
- Radiation Treatment Management Services (CPT codes 77427)
- (CY) 2021 PFS final rule update (12/1/20) the following CPT codes were permanently added to the to the Medicare telehealth list on a Category 1 basis. Services added to the Medicare telehealth list on a Category 1 basis are similar to services already on the telehealth list:
- Group Psychotherapy (CPT code 90853)
- Psychological and Neuropsychological Testing (CPT code 96121)
- Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99334-99335)
- Home Visits, Established Patient (CPT codes 99347-99348)
- Cognitive Assessment and Care Planning Services (CPT code 99483)
- Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M) (HCPCS code G2211)
- Prolonged Services (HCPCS code G2212)
- After the PHE ends: These services will remain on the Medicare Telehealth Services List and will be available through the end of CY 2023, and we anticipate addressing updates to the Medicare Telehealth Services List for CY 2024 and beyond through CMS' established processes as part of the CY 2024 Physician Fee Schedule proposed and final rules.
- Payment for Audio-Only Telephone Evaluation and Management Services (5/8/20): For beneficiaries who do not have access to smart phones or other technology that supports two-way, audio and video telecommunications technology or patients that do not want to use video, the CARES Act waiver allows the use of audio-only equipment to furnish services described by the codes for audio only telephone evaluation and management services, and behavioral health counseling and educational services.
- After the PHE ends: The Consolidated Appropriations Act, 2023 extends availability of the telehealth services that can be furnished using audio-only technology through December 31, 2024
- Telephone evaluation and management services (CPT 99441 - 99443 and 98966 - 98968): While the code descriptors for these services refer to an “established patient” during the COVID-19 PHE CMS is exercising enforcement discretion on an interim basis to relax enforcement of this aspect of the code descriptors.
- (CY) 2021 PFS final rule update (12/1/20): The agency did not propose to continue those codes in the physician fee schedule after the pandemic, but did establish payment on an interim final basis for a new HCPCS G-code for 11-20 minutes of medical discussion to determine whether an in-person visit is necessary.
- After the PHE ends: The Consolidated Appropriations Act, 2023 provides for an extension for this flexibility through December 31, 2024
Update on Frequency Limitations on Medicare Telehealth: - To better serve the patient population that would otherwise not have access to clinically appropriate in-person treatment, from the beginning of the PHE until 12/31/20, the following services did not have limitations on the number of times they can be provided by Medicare telehealth:
- A subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233);
- Critical care consult codes may be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation (CPT codes G0508-G0509)
- (CY) 2021 PFS final rule update (12/1/20): CMS finalized a frequency limitation for subsequent nursing facility telehealth visits of one visit every 14 days (CPT codes 99307-99310)
- After the PHE ends: All applicable rules for furnishing these services, unless otherwise specified, will once again take effect:
- A subsequent inpatient visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233).
- A subsequent skilled nursing facility visit could be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 14 days (CPT codes 99307-99310).
- Critical care consult codes could be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation (HCPCS codes G0508-G0509).
Hospital-based outpatient department: hospital billing for remote services - Can a hospital bill the originating site facility fee when a physician/practitioner who ordinarily practices at that hospital furnishes telehealth services from his/her home to a registered outpatient of the hospital?(5/7/20): Yes, as long as the patient's home is made provider-based to the hospital (which means that all applicable conditions of participation, to the extent not waived, are met). Under the emergency waiver in effect, the patient can be located in any provider-based department, including the hospital, or the patient’s home. Note that a telehealth service would need to be furnished by a physician or other practitioner located at a distant site in order for a hospital to bill for the originating site facility fee.
- Is there a tool that can help hospitals better understand flexibilities during the COVID-19 PHE when the beneficiary’s home is serving as a provider-based department of the hospital (that is, where the hospital ensures the location meets all of the conditions of participation, to the extent not waived, and registers the beneficiary as a hospital outpatient) (8/26/20)?: Yes, see CMS decision tree for hospital telemedicine billing (See Section LL. Hospital Billing for Remote Services)
- For detailed information on when hospitals can bill the telehealth originating site facility fee “Q3014” or the clinic visit code "G0463, Hospital outpatient clinic visit”, see 'Section LL. Hospital Billing for Remote Services' in CMS' COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing
- More information on the Hospitals Without Walls initiative and on “1135 waivers” can be found here.
- After the PHE ends: Flexibilities under the 'Hospital Without Walls' initiative, such as provider-based departments that were relocated to settings outside the hospital, including patients’ homes will no longer be in effect.
Home health agencies:
- Certification of beneficiaries for eligibility (5/7/20): In addition to physicians, Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) have been allowed to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care.
- After the PHE ends: This is a permanent change that will continue after the Public Health Emergency. CMS removed the requirement that the NPs have to communicate the clinical finding of the face-to-face encounter to the ordering physician. With expanding authority to order home health services, such practitioners are now capable of independently performing the face-to-face encounter for the patient for whom they are the ordering practitioner, in accordance with state law. If state law does not allow such flexibility, the NP is required to work in collaboration with a physician.
- Revised definition of "homebound"(4/6/20): the practitioner can certify that the patient is homebound by determining that it is medically contraindicated for the beneficiary to leave the home because he or she has a confirmed or suspected diagnosis of COVID-19, or because a practitioner has determined that it is medically contraindicated for a beneficiary to leave the home because the patient has a condition that may make the patient more susceptible to contracting COVID-19 (e.g. complex wounds). Patient does not need to be "bedridden".
- Can eligible providers be paid for telehealth services furnished while patient is under a home health episode of care?(4/6/20): According to CMS: "For telehealth services that need to be personally provided by a physician, such as an E/M visit, the physician would need to personally perform the E/M visit and report that service as a Medicare telehealth service. However, we acknowledge that there may be instances where the physician may want to use auxiliary personnel to be present in the home with the patient during the telehealth service, though this is not required for telehealth services under section 1834(m) of the Act. Other services, including both face-to-face and non-face-to-face services, could be provided incident to a physicians' service by a nurse or other auxiliary personnel, as long as the billing practitioner is providing appropriate supervision through audio/video real-time communications technology (or in person), when needed. We would not expect that services furnished at a patient’s home incident to a physician service would usually occur during the same period as a home health episode of care, and we will be monitoring claims to ensure that services are not being inappropriately unbundled from payments under the home health PPS"
- After the PHE ends: The required face-to-face encounter for home health can be conducted via telehealth (i.e., 2-way audio-video telecommunications technology that allows for real-time interaction between the physician/allowed practitioner and the patient) when the patient is at home. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for the flexibility to allow the home to be an originating site through December 31, 2024.
- Can home health in-person visits be done remotely? (4/6/20): No."CMS remains statutorily-prohibited from paying for home health services furnished via a telecommunications system if such services substitute for in-person home health services ordered as part of a plan of care and for paying directly for such services under the home health benefit." Virtual visits are allowed though, as long as ordered as part of a plan of care, and do not replace in-person home health visits. For example, if the minimum number of visits required for a home health agency to receive full payment for a 30 day period of care is 4 (i.e., the low-utilization payment adjustment - LUPA - threshold is 4 visits), but the patient benefits from more frequent visits as as justified by the plan of care, visits beyond the LUPA threshold are allowed to be done virtually.
- Can home health agencies furnish services using telecommunications technology (5/1/20)? Yes. Home health agencies are able to furnish services using telecommunications technology during the PHE as long as such services do not substitute for in-person visits ordered on the plan of care. This can include telephone calls (audio only and TTY), two-way audio-video telecommunications that allow for real-time interaction between the patient and clinician (e.g., FaceTime, Skype), and remote patient monitoring. It would be up to the clinical judgment of the home health agency and patient’s physician/practitioner as to whether such technology can meet the patient’s need. The use of telecommunications technology in furnishing services under the home health benefit must be included on the plan of care and the plan of care must outline how such technology will assist in achieving the goals outlined on the plan of care.
- After the PHE ends: This provision is permanent beyond the COVID-19 PHE. Home health services furnished using telecommunication systems are required to be included on the home health claim beginning July 1, 2023.
- Can home health agencies include services furnished using telecommunications technology on the home health claim that it submits to Medicare for payment (5/1/20)? Only in-person visits are to be reported on the home health claim submitted to Medicare for payment. On an interim basis, HHAs can report the costs of telecommunications technology on the HHA cost report as allowable administrative and general (A&G) costs by identifying the costs using a subscript between line 5.01 through line 5.19.
Nursing Homes - Physician visits for nursing homes (4/29/20) CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.
- After the PHE ends: Physicians will be required to conduct any federally required in-person visits. However, there remains flexibility in some of our regulations that allows physicians to delegate visits to other practitioners, as long as they are doing so in accordance with state law
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