Telehealth expansion during the COVID-19 outbreak. What you need to know.


In response to COVID-19, healthcare payers have established less stringent Telehealth requirements for the duration of the COVID-19 Public Health Emergency

Besides telehealth, many payers have started covering telephonic services. Providers must understand the difference between telehealth and other services such as virtual check-in, e-visit, online digital E&M services as those have different requirements that will affect documenting and billing.

Specific CPT and HCPCS codes are assigned to Virtual check-in, E-visit, and online digital E&M services. More details are described below.

Other services, such as face-to-face encounters that are being performed through an interactive audio and video telecommunication system, must be billed with regular CPT/HCPCs codes adding a specific modifier and/or place of service. Providers are required to deliver the same level of service that they would in person, and document such services the same way providers normally would in the patient record for face-to-face encounters. The documentation should also include a statement that the services were provided through telehealth (and the system used). Both the location of the patient and the provider must be included, as well as the names and roles of any other individual participating in the telehealth. The same fees will be applied regardless of whether the services were performed face-to-face or via telehealth.

We described below the recent updates that have been made by the major payers.



  • Define payers and follow their policies and requirements
  • Define communication technologies to use
  • Check eligibility prior to the services
  • Maintain accurate documentation
  • Communicate with your biller to make sure you are compliant


President Trump signed into law the Families First Coronavirus Response Act, effective March 18. This law requires group health plans, health insurances offering group, and individual health insurance coverage, regardless of grandfathered status, to WAIVE cost-sharing (including deductibles, copayments, and coinsurance) and prior authorization, including other medical management requirements for COVID-19 diagnostic testing and in-person and telehealth services related to COVID-19 diagnostic testing. https://www.congress.gov/bill/116th-congress/house-bill/6201/text

Some healthcare payers also waived cost-sharing for routine care and mental health telemedicine visits. 


Make sure you use appropriate ICD-10 CM codes as it may affect cost-sharing.


As for New York State, The Department of Financial Services (DFS) announced a new emergency regulation under New York Insurance Law requiring New York State insurance companies to waive cost-sharing, including deductibles, copayments (copays), or coinsurance for in-network telehealth visits whether or not those are related to coronavirus (COVID-19). 

https://www.dfs.ny.gov/reports_and_publications/press_releases/pr20203171


Medicare

Telehealth

Under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth.

Medicare will now make payments for Medicare telehealth services IN ALL AREAS of the country and in any facility, including the PATIENT'S HOME.  The changes were applied with the effective date of March 6, 2020, for the duration of the COVID-19 Public Health Emergency. 


Providers who can furnish and get payment for covered Medicare Telehealth services (subject to State law):

·         Physicians

·         Nurse practitioners (NPs)

·         Physician assistants (PAs)

·         Nurse-midwives

·         Clinical nurse specialists (CNSs)

·         Certified registered nurse anesthetists

·         Clinical psychologists (CPs) and

·         clinical social workers (CSWs)

·         Registered dietitians or nutrition professional

PT/OT/SLP provider types were not added to the list of approved distant site providers.


Prior to this waiver, Medicare was covering the telehealth on a limited basis: for patients in a clinic, hospital, or certain other types of medical facilities in a designated rural area.


There are also changes in the list of services payable under the Medicare

Covered Medicare telehealth services include Psychotherapy, E&M services, TCM, AWV, PT/OT/Speech Therapy services, and others. The entire list is available here.


General documentation and coding requirements will apply with some waivers.

According to the CMS-1744 IFC, the office/outpatient E/M level selection for the services, when furnished via telehealth, can be based on MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter; policy specifies to remove any requirements regarding documentation of history and/or physical exam in the medical record. This policy is similar to the policy that will apply to all office/outpatient E/Ms beginning in 2021 under policies finalized in the CY 2020 PFS final rule. Practitioners still will need to document E/M visits as necessary to ensure quality and continuity of care. This policy only applies to office/outpatient visits furnished via Medicare telehealth, and only during the PHE for the COVID-19 pandemic. 


How to determine what E&M code must be billed when performed via telehealth?

The CPT codes describing E/M services reflect an assumption that the nature of the work involved in evaluation and management visits varies, in part, based on the setting of care and the patient’s status. Consequently, there are separate sets of E/M codes for different settings of care, such as office/outpatient codes, nursing facility codes, home visits, or emergency department codes. Since all of the above E&M types are now in the list of covered Telehealth services, how to determine what E/M code must be used when services were delivered via telehealth at the time the patient was located in his/her home? 

As according to the CMS-1744 IFC, CMS  expects physicians and other practitioners to use the E/M code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient.


Medicare Physician Supervision requirements: For services requiring direct supervision by the physician or other practitioner, physician supervision can now be provided virtually using real-time audio/video technology.


Additionally, 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.


Communications technologies.

Also, during the COVID-19 Public Health Emergency, the 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

Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. 

More information can be found here. FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency are also available here.

If providers only use the telephone instead of an interactive audio/video telecommunication system, consider the below E-Visits, Virtual Check-In, Telephone E&M services. 


E-VISITS Patient-initiated online evaluation and management conducted via a patient portal


For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period.

In all types of locations, including the patient’s home (in all types of areas, including rural), Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. 

While some of the code descriptors refer to “established patient,” during the PHE, CMS is exercising enforcement discretion on an interim basis to relax enforcement of this aspect of the code descriptors.  Specifically, they will not conduct a review to consider whether those services were furnished to established patients.

The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive the services. Document this consent in the patient’s record. The Medicare coinsurance and deductible would apply to these services.

·         99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes

(Fee is based on the locality $16.00-$18.00, coinsurance and deductible would apply)

·         99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes

(Fee is based on the locality $32.00-$36.00, coinsurance and deductible would apply)

·         99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

(Fee is based on the locality $53.00-$59.00, coinsurance and deductible would apply)


E-VISITS by physical therapists, occupational therapists, speech-language pathologists, clinical psychologists.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech-language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

·      G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes (Fee is based on the locality $12.00-$13.00, coinsurance and deductible would apply)

·      G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes (Fee is based on the locality $22.00-$24.00, coinsurance and deductible would apply)

·       G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes. (Fee is based on the locality $35.00-$38.00, coinsurance and deductible would apply)


The online digital evaluation and management service includes time spent on the following:

• Review of an initial patient’s inquiry (start of the 7-day period)

• Review of patient record for assessment of the patient’s problem

• Interaction with other healthcare professionals focused on the patient’s problem

• Development of management plans (prescriptions, test orders, etc.)

• Communication with the patient (online, email, etc.)

Document the time spent accurately!


KEY TAKEAWAYS:

  • This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
  • For new and established Medicare patients
  • Patients can communicate with their doctors without going to the doctor’s office by using online patient portals.
  • 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 services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable.
  • The Medicare coinsurance and a deductible would generally apply to these services.

VIRTUAL CHECK-INS

In all areas (not just rural), new and established Medicare patients in their home might have a brief communication service with practitioners via several communication technology modalities, including synchronous discussion over a telephone or exchange of information through video or image. Medicare expects that the patients will initiate these virtual services; however, practitioners may need to educate beneficiaries on the availability of the service before patient initiation. 

Medicare pays for these “virtual check-ins” (or brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. Document this consent in the patient’s record.  The Medicare coinsurance and deductible would generally apply to these services.

Doctors and certain practitioners (licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists) may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  In addition, separate from these virtual check-in services, captured videos or images can be sent to a physician (HCPCS code G2010).

Fees are based on the locality G2012 - $ 15.00-$17.00, G2010 - $13.00-$14.00. Standard Part B cost-sharing applies to both.

KEY TAKEAWAYS:

  • This is not limited to only rural settings or certain locations.
  • For new and established Medicare patients
  • Individual services need to be agreed to by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient agreement. 
  • HCPCS code G2012: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can 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 an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
  • HCPCS code G2010: Remote evaluation 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 e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
  • 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.


Telephone E&M

A broad range of clinicians, including physicians, can now provide certain services by telephone to their patients (CPT codes 98966 -98968; 99441-99443).

For physicians and practitioners who can furnish evaluation and management (E/M) services the below CPT codes can be used.

99441 - Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

99442 – …..; 11-20 minutes of medical discussion

99443 – …..; 21-30 minutes of medical discussion


LCSWs, clinical psychologists, and physical therapists, occupational therapists, and speech-language pathologists when visit pertains to a service that falls within the benefit category of those practitioners can bill using the below CPT codes.

98966 - Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian

not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967 - …..; 11-20 minutes of medical discussion

98968 - …..; 21-30 minutes of medical discussion


According to the CMS-1744-IFC, while some of the code descriptors refer to “established patient,” during the PHE, CMS is exercising enforcement discretion on an interim basis to relax enforcement of this aspect of the code descriptors.   Specifically, they will not conduct a review to consider whether those services were furnished to established patients.


*The above information contains updates issued under CMS -1744-IFC

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

https://www.cms.gov/files/document/covid-final-ifc.pdf


Medicaid of NY

Telehealth including Telephonic Services During the COVID-19 State of Emergency

Medicaid issued guidance intended to provide broad expansion for the ability of all Medicaid providers in all situations to use a wide variety of communication methods to deliver services remotely during the COVID-19 State of Emergency, to the extent, it is appropriate for the Care of the member.

Telehealth services will be reimbursed at parity with existing off-site visit payments (clinics) or face-to-face visits (i.e., 100% of Medicaid payment rates). The guidance relaxes rules on the types of clinicians, facilities, and services eligible for billing under telehealth rules. The guidance additionally addresses some technological barriers to telehealth by allowing clinicians and health care organizations to bill for telephonic services if they cannot provide the audiovisual technology traditionally referred to as “telemedicine.”

Effective for dates of service on or after March 1, 2020, for the duration of the State Disaster Emergency declared under Executive Order 202, herein referred to as the “State of Emergency,” New York State Medicaid will reimburse telephonic assessment, monitoring, and evaluation and management services provided to members in cases where face-to-face visits may not be recommended and it is appropriate for the member to be evaluated and managed by telephone. The guidance is to support the policy that members should be treated through telehealth provided by all Medicaid qualified practitioners and service providers, including telephonically, wherever possible, to avoid member congregation with potentially sick patients. Telephonic communication will be covered when provided by any qualified practitioner or service provider. All telephonic encounters documented as appropriate by the provider would be considered medically necessary for payment purposes in Medicaid FFS or Medicaid Managed Care. All other requirements in the delivery of these services otherwise apply.

 

Office of Mental Health (OMH), the Office for People with Developmental Disabilities (OPWDD), and the Office of Addiction Services and Supports (OASAS) have issued separate guidance on telehealth and regulations that will align with state law and Medicaid payment policy for Medicaid members being served under their authority.

 

Telephonic Reimbursement Overview

See the table below for the billing pathways available for telephonic encounters during the COVID-19 State of Emergency by both FFS and Managed Care:


Managed care plans may have separate detailed billing guidance but will cover all services appropriate to deliver through telehealth/telephonic means to properly care for the member during the State of Emergency.


Telehealth

The originating site is where the member is located at the time health care services are delivered to him/her through telehealth. Originating sites during the State of Emergency can be anywhere the member is located. There are no limits on originating sites during the State of Emergency.


Options to Support Members with Limited or Lack of Access to Devices and Services can be viewed here


The distant site is any location, including the provider’s home that is within the fifty United States or United States' territories. It’s where the provider is located while delivering health care services by means of telehealth. During the State of Emergency, all sites are eligible to be distant sites for delivery and payment purposes, including Federally Qualified Health Centers for all patients, including patients dually eligible for Medicaid and Medicare. It includes clinic providers working from their homes or any other location during the State of Emergency.

Telehealth Providers

During the State of Emergency, all Medicaid provider types are eligible to provide telehealth. Meanwhile, services should be appropriate for telehealth and should be within the provider’s scope of practice.


Medicaid of NY also covers Store-and-Forward Technology and Remote Patient Monitoring (RPM). For more information access the full guidance


Patient Rights and Consents

The practitioner shall confirm the member’s identity and provide the member with basic information about the services that he/she will be receiving via telehealth/telephone. Written consent by the member is not required. Telehealth/telephonic sessions/services shall not be recorded without the member's consent.

Confidentiality

Services provided using telehealth must be compliant with the Health Insurance Portability and Accountability Act (HIPAA) and all other relevant laws and regulations governing confidentiality, privacy, and consent (including, but not limited to 45 CFR Parts 160 and 164 [HIPAA Security Rules]; 42 CFR, Part 2; PHL Article 27-F; and MHL Section 33.13).

However, during the COVID-19 nationwide public health emergency, the Department of Health and Human Services Office for Civil Rights (OCR) has issued a Notification of Enforcement Discretion for telehealth remote communications. OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html 

All providers must take steps to reasonably ensure privacy during all patient-practitioner interactions.

Medicaid Managed Care Considerations

Medicaid Managed Care (MMC) plans are required to cover, at a minimum, services that are covered by Medicaid fee-for-service and also included in the MMC benefit package, when determined medically necessary. Managed care plans should follow the FFS telehealth billing policy included in this guidance.


https://www.health.ny.gov/health_care/medicaid/program/update/2020/docs/mu_no05_2020-03-21_covid-19_telehealth.pdf


NY State OASAS Telepractice Guidance

OASAS Expedited Approval Process

OASAS Certified Treatment Program Providers must:

• Review the Telepractice Guidance and Supplemental Guidance 

• Complete a Telepractice Self Attestation Form, and

• Return it to Certification@oasas.ny.gov

This approval is time-limited and effective only during the disaster emergency.

Programs/agencies already designated to offer telehealth, do not need to seek additional approval.

OASAS Telehealth Service

Telehealth for Medicaid-reimbursable services is temporarily expanded and includes:

• Two-way audio/video communication;

• Video, including technology commonly available on smartphones and other devices; and/or

• Telephonic communication (NEW).

Services to be delivered are those allowable under current program regulations or state-issued guidance as clinically appropriate. They include assessment, individual, group, medication management and collateral services.

Peer Services delivered by CRPAs are allowable services. They may be delivered by providers who have submitted a telepractice attestation or are otherwise approved to deliver telepractice services. https://oasas.ny.gov/system/files/documents/2020/03/telepractice-update-ii_0.pdf

Review Telepractice FAQs for more information.

 

OMH 

Guidance on COVID-19 can be found here.


Fidelis Care 

Fidelis care updates can be found here.


Healthfirst 

All cost shares for telehealth visits have been temporarily waived for all lines of business. Healthfirst is temporarily waiving the telehealth privileging process and allowing providers to render and bill for medically needed telehealth services through September 7, 2020 or later, if the state emergency persists past this date. Originating site restrictions have been lifted as well for all lines of business. Details can be found here.  


Metroplus 

MetroPlus members will have zero cost-sharing for telehealth/telephone appointments with their existing/current in-network doctors. Details can be located here.


Empire BlueCross BlueShield of NY 

Telehealth (Telephonic/FaceTime care) coverage updates can be found here:

https://providernews.empireblue.com/article/information-from-empire-for-care-providers-about-covid-19

https://mediproviders.empireblue.com/ProviderUpdates/NYNY_CAID_PU_TalkingPointsCOVID19.pdf

 

United Healthcare 

UnitedHealthcare is temporarily waiving the CMS and state-based originating site restrictions and audio-video requirement, where applicable, for Medicare Advantage, Medicaid and commercial members. Care providers will be able to bill for telehealth services performed using audio-video or audio only communication while a patient is at home.

 UnitedHealthcare added Virtual check-in and E-VISITS into a coverage.

 UnitedHealthcare will also reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology

Starting March 31, 2020, until June 18, 2020, UnitedHealthcare will now also waive cost-sharing for in-network, non-COVID-19 telehealth visits for its Medicare Advantage, Medicaid, Individual and Group Market fully insured health plans.


For details go to:

https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19/covid19-telehealth-services/covid19-telehealth-services-telehealth.html

https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19/covid19-telehealth-services/covid19-telehealth-pt-ot-st.html

https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19.html

https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19/covid19-telehealth-services.html


United Behavioral Health 

Starting March 31, 2020 until June 18, 2020, United Behavioral Health (dba Optum Behavioral Health) will waive cost-sharing for in-network, outpatient, behavioral health telehealth visits for members of  Medicare Advantage, Medicaid and fullyinsured Individual and Group market UnitedHealthcare (UHC) health plans.

Optum Behavioral Health WAIVED the ORIGINATING SITE RESTRICTION so that care providers can bill for telehealth services performed while a patient is at home. This change in policy is effective until April 30, 2020, but may extend if necessary. Optum Behavioral Health will also reimburse providers for telephonic care and Virtual visits.

For details go to:

https://www.providerexpress.com/content/ope-provexpr/us/en/COVID-19_Provider_Updates/covid19-OP_Policies.html

https://www.providerexpress.com/content/dam/ope-provexpr/us/pdfs/home/covid-19/ubhCoPayWaiver.pdf


Cigna 

Cigna Telehealth expansion can be found here.


Cigna Behavioral Health 

Changes in coverage of behavioral telehealth sessions effective from March 17, 2020 through May 31, 2020 can be found here.


Aetna 

Aetna Commercial patients pay $0 for covered telemedicine visits until June 4, 2020.

Until further notice, Aetna is also expanding coverage of telemedicine visits to its Aetna Medicare members, so they can receive the care they need from you without leaving their homes. Aetna Medicare members can now see their providers virtually via telephone or video. 

Aetna is offering its Medicare Advantage brief virtual check-in and remote evaluation benefits to all Aetna Commercial members and waiving the co-pay.


For detailed information, go to:

https://www.aetna.com/health-care-professionals/provider-education-manuals/covid19-letter.html

https://www.aetna.com/health-care-professionals/provider-education-manuals/covid-faq.html#acc_link_content_section_responsivegrid_copy__responsivegrid_accordion_10

 

Horizon BCBSNJ 

Horizon BCBSNJ is relaxing telemedicine rules to allow telephone visits with providers. Horizon BCBSNJ is waiving member cost-sharing for covered telemedicine visits, which now include common video platforms like Facetime and Skype as well as telephone-only, with in-network health professionals.

 

For details visit:

https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/providing-telephonic-care-no-costs-to-members

https://www.horizonhealthnews.com/horizon-eliminates-cost-sharing-for-qualified-in-network-telemedicine-services/

https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/covid-19-response-eliminating-cost-sharing-for

For more information, view Telemedicine and Telehealth Services Reimbursement Policy.

 

AmeriHealth 

AmeriHealth is expanding telemedicine service availability to Specialists and the following ancillary services effective March 6 – June 4, 2020:

    • PT/OT/ST (video only)
    • urgent Care (audio and video)
    • nutrition (audio and video)

Telephone communication is also available in certain circumstances for more information visit:

https://provcomm.amerihealth.com//ah/Pages/Home.aspx

https://provcomm.amerihealth.com/ah/news/Pages/20-2351-Telemed-AHNJ.aspx 

 

WCH Team monitors updates on a daily basis. We are here to Help! Contact us for more information!