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To help patients receive medical care without having to travel to a healthcare facility, Medicare (CMS) and many commercial payers announced in March 2020 that they will lift geographical restrictions and will pay for telehealth services in all areas of the country and in all settings, for the duration of the COVID-19 Public Health Emergency (PHE). CMS Telehealth visits are paid at the same rate as regular, in-person visits. See the complete list of all Medicare telehealth services here

Prior to this temporary telehealth expansion, CMS made several changes to improve access to virtual care. In 2019 and 2020, Medicare started making payment for many other telemedicine services (see blog post "What is new in 2019 for Telehealth and Telemedicine?")

Since CMS flexibilities to fight COVID-19 were put in place, the use of telehealth has skyrocketed. Based on these results, in August 2020, an executive order was published with the goal of permanently expanding telehealth access in rural communities beyond the PHE. Consistent with that directive, CMS proposed some changes to expand telehealth permanently. See blog post "A peek into 2021 - CMS proposals and implications for wound care programs".

On December 1., CMS released the 2021 physician fee schedule with expanded telehealth services. This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE. These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home. However, according to CMS, this is an important step, and as a result, Medicare beneficiaries in rural areas will have more convenient access to health care.

This blog post summarizes CMS coding, coverage and reimbursement information on some of the telemedicine services that are relevant to the wound care healthcare professional. Roughly, these telemedicine services can be classified as intended for communication between provider and patient and between providers about a patient. For details on restrictions and requirements per CMS and AMA, see 'Sample TeleVisit Workflows' in topic "Telemedicine/ Televisit Implementation Playbook - Part 2". For descriptions of CPT codes commonly used in wound care telemedicine, see topic "Telemedicine Coding for Wound Care".

Telemedicine services for communication between provider and patient

Communication Technology-Based Services (CTBS) include the modalities below: 

Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)

  • Practitioners are separately paid for the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. This increases efficiency for practitioners and provides convenience for beneficiaries.
  • (CY) 2021 PFS final rule update (12/1/20)G2251 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion), billed by licensed clinical social workers, clinical psychologists, physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs)

Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

  • Service of remote evaluation of recorded video and/or images submitted by an established patient will allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed. 
  • (CY) 2021 PFS final rule update (12/1/20): HCPCS G2250 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.), billed by licensed clinical social workers, clinical psychologists, physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs)

Online digital evaluation and management services or e-Visits for an established patient (CPT 99421-99423 and G2061-G2063 or CPT 98970-98972 for some commercial payers)

  • These services are "patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office." Under the original code description, an online patient portal is required.
    • CPT codes 99421-23: time-based codes billed by physicians and qualified healthcare professionals for "Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days". Reimbursed in increments of 5-10 minutes (99421), 11-20 minutes (99422), and 21 or more minutes (99423)
    • HCPCS/CPT 98970-98972 (previously G2061-63): similar to the CPT codes above, but can be billed by practitioners who cannot independently bill E/M services, for "Qualified non-physician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days". Reimbursed in increments of 5-10 minutes (G2061), 11-20 minutes (G2062), and 21 or more minutes (G2063)
      • Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits
CMS FLEXIBILITIES TO FIGHT COVID-19 - Communication Technology-Based Services (CTBS)

Established and new patients: 

  • Clinicians can provide Communication Technology-Based Services (CTBS, HCPCS codes G2010, G2012 and 99421-23 or G2061-63) to both new and established patients. Those services were previously limited to established patients.  

Sources: 

CMS CY2021 PROPOSED RULES - COMMUNICATION TECHNOLOGY-BASED SERVICES (CTBS)

Telehealth services

  • Commonly used CPT codes include 99201-99215 "Office or other outpatient visits" and others; see other CPT codes here 
  • These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. Prior to COVID-19 flexibilities, telehealth services were subject to geographical and care setting restrictions. See HRSA’s Medicare Telehealth Payment Eligibility Analyzer
  • An interactive audio and video telecommunications system that permits real-time communication between the distant site where the provider is and the patient is needed for providers to bill most telealth CPT codes.
  • On 4/29/20 CMS allowed 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. Note that this exception applies to regular Medicare only. Individual payment requirements should be verified with other insurers and plans.
  • On 12/1/20, CMS clarified that telehealth rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assists in furnishing a service.
CMS flexibilities to fight COVID-19 - Telehealth services and (CY) 2021 PFS final rule update

Medicare 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.

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 now 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 now 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)
    • Payment for Audio-Only Telephone Evaluation and Management Services (5/8/20): 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.
      • 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.

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);
    • A subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days (CPT codes 99307-99310)
    • 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

Hospital-based outpatient department

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) are now allowed to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. 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"
  • 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.

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.

Sources: 

Telemedicine services for communication between providers about a patient

Interprofessional internet consultation (CPT codes 99446, 99447, 99448, 99449, 99451, 99452)

The CPT codes below can only be billed by those practitioners that can independently bill Medicare for E/M services. Patient consent needs to be documented and will be responsible for the corresponding co-payment.

  • CPT 99446: Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
  • CPT 99447: Same as 99446, but 11-20 minutes of medical consultative discussion and review
  • CPT 99448: Same as 99446, but 21-30 minutes of medical consultative discussion and review
  • CPT 99449: Same as 99446, but 31 minutes or more of medical consultative discussion and review
  • CPT 99451: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time
  • CPT 99452: Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes

Modifiers

Modifiers are used to indicate what type of technology was utilized for the telemedicine encounter. Many payers will reject a claim if a modifier is not appended. 

Modifier Descriptions

  • GQ: Via Asynchronous Telecommunications systems
  • GT: Via Interactive Audio and Video Telecommunications systems
  • 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system (usually reported only with codes from CPT book Appendix P)
  • G0: Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke

For televisits between provider and patients:

  • For e-Visits (CPT 99421-99423 and G2061-G2063): if furnished by a therapist, use GO, GP or GN for Medicare (see box below). Check with your payer (e.g. UnitedHealth does not require a modifier)
  • For virtual check-ins (G2012): if furnished by a therapist, use GO, GP or GN for Medicare (see box below). Check with your payer (e.g. UnitedHealth does not require a modifier)
  • For store-and-forward (G2010): if furnished by a therapist, use GO, GP or GN for Medicare (see box below). Check with your payer (e.g. UnitedHealth does not require a modifier)
  • For telehealth as defined by Medicare: modifier 95 (as defined by CPT book Appendix P: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system ) 
CMS FLEXIBILITIES TO FIGHT COVID-19 
  • Place of Service (POS): CMS is instructing physicians and practitioners who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person (as opposed to POS 2 for telehealth).This will allow CMS systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. 
  • Modifier: To facilitate billing of the Communication Technology-Based Services (CTBS) services by therapists for the reasons described above, CMS is designating HCPCS codes G2010, G2012, G2061, G2062, or G2063 as CTBS “sometimes therapy” services  that would require the private practice occupational therapist, physical therapist, and speech-language pathologist to include the corresponding GO, GP, or GN therapy modifier on claims for these services. CTBS therapy services include those furnished to a new or established patients that the occupational therapist, physical therapist, and speech-language pathologist practitioner is currently treating under a plan of care.

Sources

Medicare Coverage and Payment of Virtual Services (5/8/20)




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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
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