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As the landscape around us is rapidly changing due to the Novel Coronavirus (COVID-19) Pandemic, we have had a slew of calls regarding Telehealth.

Last Updated May 11,2020 Please note that this information was current at time of publication, however rules around Telehealth during the COVID-19 Public Health Emergency are changing daily; we will continue to update this post as information changes but we encourage you to check sources cited frequently for updates. This is not a substitute for legal advice; check with your attorney and other billing advisors. Most of the information reflects the federal government's stance; you are directed to your private payers and Medicaid plans for their policies about coding and reimbursement, which may vary from the federal government's.

AZCOMP is prepared to assist you with actual implementation of Telehealth services, however, many of the questions go beyond getting a solution in place. Therefore, we thought it would be beneficial to provide a timeline of what has transpired during the COVID-19 public health emergency as well as a summary of key points to understand regarding different types of telemedicine services, COVID-19 testing, and billing guidelines.

Current Events:

March 5, 2020 – America's Health Insurance Plans issues a statement regarding action they are taking to address prevention, testing, and treatment of the corona Virus.

March 6, 2020 – Congress passed theCoronavirus Preparedness and Response Supplemental AppropriationsAct (www.congress.gov). This new legislation will allow physicians and other health care professionals to bill Medicare fee-for-service for patient care delivered by telehealth during the current coronavirus public health emergency.

March 17, 2020 – The Trump Administration announced further expansion of Telehealth coverage for Medicare beneficiaries during the COVID-19 outbreak.

March 17, 2020 – After meeting with the Trump Administration many insurance issuers announced that they are also expanding efforts by waiving copays, waiving prior authorizations, covering the cost of the COVID-19 test, and allowing reimbursement for telehealth. (For details see Health Insurance Providers Respond to COVID-19)

March 18, 2020 – CDC Announces new ICD-10-CM code for COVID-19 will be effective April 1, 2020

March 18, 2020 The Families First Coronavirus Response Act becomes law, which among other things includes health provisions that require private health insurance to cover testing for COVID-19 without cost-sharing (deductibles, co-payments or co-insurance), and requires Medicare to cover, without cost-sharing, visits to health care providers that relate to COVID-19 testing during the public emergency.

March 30, 2020 CMS Announces Additional Waivers and New Rules to Address COVID-19 Patient Surge

March 31, 2020 CMS released an interim final rule, "Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency." This rule further expands telehealth including additional covered services and new/modified billing instructions during the COVID-19 pandemic.

April 30, 2020 Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic

To get more details on the most recent announcements we encourage you to review the following:

Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19 (published 4/29/2020)

CMS Dear Clinician Letter (published April 6, 2020)

Medicare Telemedicine Provider Fact Sheet (published March 17, 2020)

Medicare Telehealth Frequently Asked Questions (published March 17, 2020)

The following instructional video was published by CMS on May 8, 2020 and replaces the previous video:

Types of Telemedicine Visits

It is important to understand the types of telemedicine services as each type of visit will have varying requirements regarding how the service is initiated, administered and billed. All of the services listed below can now be performed for new or established patients during the public health emergency.

Telehealth Visits: The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.
- Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.
- Limitations have been removed during the emergency allowing telehealth services to be provided in all settings including a patient's home.
- Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. *New: The list of covered telehealth services was expanded to include over 80 additional services on March 30, 2020 under the interim rule- for a full list click here .
- Telehealth services are NOT limited to services related to COVID-19. In order to support social distancing strategies and reduce the risk of COVID-19 transmission the statutory provision broadens telehealth flexibility without regard to the diagnosis of the patient as long as the service billed is reasonable and necessary.
- Telehealth visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
- The HHS secretary has been given the authority to waive the originating site requirement (www.cchpca.org) for telehealth services provided by a qualified provider to Medicare beneficiaries (www.cms.gov) in any identified emergency area during emergency periods.
- Telehealth services may be provided to Medicare beneficiaries by phone, but only if the phone allows for audio-video interaction between the qualified provider and the beneficiary.
- HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html
- The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
Virtual Check-ins: Brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.
- The patient must verbally consent to receive virtual check-in services.
- Practitioners may educate beneficiaries on the availability of the service prior to patient agreement.
- Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication.
- Medicare coinsurance and deductible would generally apply to these services.
E-Visits: Patient initiated communication through an online patient portal.
- Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation.
- The patient must consent to receive virtual check-in services.
- The Medicare coinsurance and deductible would generally apply to these services.
Telephone Visits: Audio only visits. *NEW as of March 30, 2020 per the Interim Rule and further expanded on April 30, 2020 under the Second Round of Changes
- When real-time audio visual equipment is not available to conduct an E/M visit remotely, practitioners may now conduct a visit over the phone for both new and established patients. These services were previously non-covered.
- Medicare payment for telephone E&M visits is equivalent to the Medicare payment for office/outpatient visits with established patients effective March 1, 2020. (*New as of April 30, 2020 under the Second Round of Changes)
- CMS is also allowing many behavioral health and education services to be furnished via telehealth using audio-only communications. The full list of telehealth services notes which services are eligible to be furnished via audio-only technology, including the telephone evaluation and management visits can be found here. (*New as of April 30, 2020 under the Second Round of Changes)

Remote Patient Monitoring: Allows patients to use mobile medical devices and technology to gather patient-generated health data and send it to healthcare professionals.
- These services can be provided for both acute and chronic conditions and can now be provided for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient's oxygen saturation levels using pulse oximetry.
- For purposes of treating suspected COVID-19 infections, Medicare will allow the service to be reported for shorter periods of time than 16 days (the normal requirement) as long as the other code requirements are met.

Eligible Providers

CMS is allowing all providers that are eligible to bill Medicare for their professional services to bill for Medicare telehealth services, including physical therapists, occupational therapists, speech language pathologists, and others who were previously ineligible, to receive payment for Medicare telehealth services. (*New as of April 30, 2020 under the Second Round of Changes and retroactive to March 1, 2020)

Telehealth BILLING GUIDELINES DURING COVID-19

In this section we will provide information for Medicare Billing guidelines during the Public Health Emergency. Many of the private payers are following suit, but you will need to verify rules with individual payers as they may vary. One of the best guides we have seen for Medicare billing is Special Coding Advice presented by the American Medical Association. (Updated May 4, 2020) We highly recommend reviewing their guide as it includes a variety of scenarios that cover COVID-19 Telehealth billing, COVID-19 Laboratory Billing, Non-COVID-19 Telehealth Billing, and more. A great resource for checking billing guidelines for private payers can be found by clicking here.

CPT Codes

The CPT Code will depend on the type of Telemedicine Service performed. Here is a summary from CMS of the CPT codes that pertain to the type of service:

Payment for Phone Calls (NEW as of March 30, 2020 see the Interim Rule)*

CMS will now pay for phone calls using codes 99441-99443, and 98966-98968. These are time-based codes.

Physicians, nurse practitioners, and physician assistants should use codes 99441—99443
Other qualified health care professionals who may bill Medicare for their services, such as registered dieticians, social workers, speech language pathologists and physical and occupational therapists should use codes 98966—98968 with applicable GN, CO, or GP modifiers.

CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is broadening that list to include many behavioral health and patient education services. CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020. ( *New as of April 30, 2020 see Second Round of Changes)

Remote Patient Monitoring

Use CPT Codes 99091, 99457-99458, 99473-99474, 99493-99494

Place of Service (POS) Codes and Modifiers

The following information was updated April 6, 2020 after a correction was released by CMS on April 3, 2020

When billing professional claims to Medicare for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with:

Place of Service (POS) equal to what it would have been had the service been furnished in-person
95 Modifier, indicating that the service rendered was actually performed via telehealth

As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

GQ Modifier– Service was furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology.
GT Modifier– Service was furnished for diagnosis and treatment of an acute stroke.

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.

(The following information was added on April 9, 2020 to include information provided by CMS in a Special Edition Newsletter from the Medicare Learning Network dated April 7, 2020)

Providers are to apply Modifier CS on applicable claim lines to identify COVID-19 testing-related services that are not subject to cost sharing under the Families First Coronavirus Response Act. Covered services include medical visits that that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test. The effective date for modifier CS is for services performed between March 18, 2020 through the end of the Public Health Emergency.

For professional claims, physicians and practitioners who did not initially submit claims with the CS modifier must notify their Medicare Administrative Contractor (MAC) and request to resubmit applicable claims with dates of service on or after 3/18/2020 with the CS modifier to get 100% payment.

For institutional claims, providers, including hospitals, CAHs, RHCs, and FQHCs, who did not initially submit claims with the CS modifier must resubmit applicable claims submitted on or after 3/18/2020, with the CS modifier to visit lines to get 100% payment.

Revenue Codes *for institutional claims only

Revenue code 780 is used as the revenue code for telemedicine institutional claims (See Revenue Codes)

Diagnosis Codes (see CDC Official ICD-10 COVID-19 Coding Guidance)

Diagnosis of COVID-19: Effective April 1, 2020, for confirmed diagnosis of COVID-19 only, use U07.1 (For visits prior to April 1, 2020, report the code for the patient condition that is related to the COVID-19 (e.g., J12.89, "Other viral pneumonia") and B97.29, "Other coronavirus as the cause of diseases classified elsewhere." see New CDC Coronavirus Code Announcement for details)
Known Exposure to COVID-19 Without Confirmed Diagnosis of COVID-19: For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, report Z20.828, "Contact with and (suspected) exposure to other viral communicable diseases."
Possible Exposure to COVID-19 Without Confirmed Diagnosis of COVID-19: For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, assign code Z03.818, "Encounter for observation for suspected exposure to other biological agents ruled out."
Screening for COVID-19: For asymptomatic individuals who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign code Z11.59, Encounter for screening for other viral diseases.
Suspected COVID-19: For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.) but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as: R05 Cough, R06.02 Shortness of breath, R50.9 Fever, unspecified
If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, as an additional code. This is an exception to guideline I.C.21.c.1, Contact/Exposure.

We recommend checking with the CDC for ongoing announcements regarding ICD-10 Coding at: https://www.cdc.gov/nchs/icd/icd10cm.htm

Testing ( COVID-19 FAQ Sheet )

Medicare Part B will cover a test to determine if beneficiaries have coronavirus for dates of service on or after Feb. 4, 2020. However, providers of the test will have to wait until after April 1, 2020, to submit a claim to Medicare for the test.

Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and will be waiving any cost-sharing that would otherwise apply to the test.

CMS will pay hospitals and practitioners to assess beneficiaries and collect laboratory samples for COVID-19 testing, and make separate payment when that is the only service the patient receives. (*New as of April 30, 2020 see Second Round of Changes)

Medicare and Medicaid are covering certain serology (antibody) tests, which may aid in determining whether a person may have developed an immune response and may not be at immediate risk for COVID-19 reinfection. Medicare and Medicaid will cover laboratory processing of certain FDA-authorized tests that beneficiaries self-collect at home. (*New as of April 30, 2020 see Second Round of Changes)

Laboratory Billing

*New: The following information was added after the April 30, 2020 Second Round of Changes

During the COVID-19 Public Health Emergency, CMS is relaxing billing requirements for laboratory tests (PDF) required for a COVID-19 diagnosis. Any health care professional authorized under state law may order tests. Medicare will pay for tests without a written order from the treating physician or other practitioner:

If an order is not written, an ordering or referring National Provider Identifier (NPI) is not required on the claim
If an order is written, include the NPI of the ordering or referring professional, consistent with current billing guidelines

For a full list of Laboratory Tests that do not require a practitioner order during the Public Health Emergency visit https://www.cms.gov/files/document/covid-ifc-2-flu-rsv-codes.pdf

Additional/Cited Resources:

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth during the pandemic: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
CMS Telehealth: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index
Telehealth billing: https://med.noridianmedicare.com/web/jea/topics/telehealth;jsessionid=A37A1B317BF9846AC3B079E8E54EC8FF
Novitas telehealth billing: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00027460
Physicians Guide to COVID-19 by the AMA: https://www.ama-assn.org/delivering-care/public-health/physicians-guide-covid-19

Although AZCOMP Technologies makes every effort to ensure that information regarding billing guidelines are checked and accurate in both our documentation and training, it should be understood that our expertise is in the software itself and not in billing practices. Therefore, it is the sole responsibility of the user to study, interpret and remain abreast of billing requirements and deadlines, contacting authoritative sources directly as needed. Any claims documentation and training provided by AZCOMP Technologies is based on our interpretation of the rules published by nucc.org and cms.gov and are subject to change. Information and training provided is "as is" and without any express or implied warranties. AZCOMP Technologies assumes no responsibility for any inaccuracies, errors, or omissions, expressly disclaiming liability for damages of any kind arising out of the use of, reference to or reliance on any content provided.

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