The latest developments about CMS Telemedicine.

Due to the current environment, practices can now utilize the patient portal to initiate a Telehealth visit. The Centers for Medicare & Medicaid Services (CMS) has made an exception to a few aspects of this:

1. They are not restricting to rural areas.

2. CMS will now pay clinicians to check in on patients instead of an office visit remotely, and we can utilize the patient portal to initiate it. It does not have to be Telehealth per se.

If you’d like an example of how to do this, reach out to your Practice Relations Manager, who will direct you to our Practice Solutions Plus team or call 631.656.7199.

TYPES OF VIRTUAL SERVICES

There are three main types of virtual services physicians, and other professionals can provide to Medicare beneficiaries summarized in this fact sheet: Medicare Telehealth visits, virtual check-ins, and e-visits. 

MEDICARE TELEHEALTH VISITS

Currently, Medicare patients may use telecommunication technology for office, hospital visits, and other services that generally occur in-person. 

  • The provider must use interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. Distant site practitioners who can furnish and get payment for covered Telehealth services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals.
  • It is imperative during this public health emergency that patients avoid travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness. Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare Telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act. To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

KEY TAKEAWAYS

  • 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.
  • These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
  • Starting March 6, 2020, and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.
  • While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, 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 beneficiaries in any healthcare facility and in their home.
  • 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.
  • To the extent, the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

VIRTUAL CHECK-INS 

In all areas (not just rural), established Medicare patients in their home may have a 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. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to 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 with an established (or existing) relationship with a physician or certain practitioners 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. The Medicare coinsurance and deductible would generally apply to these services.

Doctors and certain practitioners 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. Standard Part B cost-sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).

KEY TAKEAWAYS

  • Virtual check-in services can only be reported when the billing practice has an established relationship with the patient. 
  • This is not limited to only rural settings or certain locations.
  • 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.

E-VISITS  

In all types of locations including the patient’s home, and in all areas (not just rural), established 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. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

  • 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
  • 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
  • 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.

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
  • 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
  • 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.

KEY TAKEAWAYS

  • These services can only be reported when the billing practice has an established relationship with the patient. 
  • This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
  • Patients 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-G206, as applicable.
  • The Medicare coinsurance and deductible would generally apply to these services.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

Effective immediately, 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. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

SUMMARY OF MEDICARE TELEMEDICINE SERVICES

Beginning on March 6, 2020, Medicare—administered by the Centers for Medicare & Medicaid Services (CMS)—will temporarily pay clinicians to provide Telehealth services for beneficiaries residing across the entire country.

CMS is expanding Medicare’s Telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act. This guidance and other recent actions by CMS provide regulatory flexibility to ensure that all Americans—particularly high-risk individuals—are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the spread of coronavirus disease 2019 (COVID-19).

Prior to this announcement, Medicare was only allowed to pay clinicians for Telehealth services such as routine visits in certain circumstances. For example, the beneficiary receiving the services must live in a rural area and travel to a remote clinic or hospital will be able to receive Telehealth services in any healthcare facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.

This change broadens Telehealth flexibility without regard to the diagnosis of the beneficiary because at this critical point it is important to ensure beneficiaries are following guidance from the CDC including practicing social distancing to reduce the risk of COVID-19 transmission. This change will help prevent vulnerable beneficiaries from unnecessarily entering a healthcare facility when their needs can be met remotely. For example, a Medicare beneficiary can visit with a doctor about their diabetes management or refilling a prescription using Telehealth without having to travel to the doctor’s office.

In its Final Rule for the 2019 Medicare Physician Fee Schedule released on Friday, CMS introduced a new code, HCPCS G2012, allowing physicians and other qualified healthcare professionals (“QHCPs”) to be reimbursed for “virtual check-ins” with patients who aren’t sure whether or not their symptoms warrant an in-office visit. These virtual check-ins may be “audio-only” (e.g., a telephone call between the patient and the QHCP) or live two-way audio with video “or other kinds of data transmission.” If the check-in does not lead to an in-office visit and does not occur within seven days of a prior E/M service by the billing practitioner, it may be billed as a standalone service. HCPCS G2012 can be billed by both primary care and specialty practitioners, and the commentary to the rule suggests it could be used as part of a treatment regimen for opioid use disorders and other substance use disorders to assess whether the patient’s condition requires an office visit. The finalized code descriptor reads as follows:

 HCPCS 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.

What you need to know about HCPCS Code G2012

  1. Established Patients. The patient on the other end of the check-in must be an “established patient” of the billing physician/QHCP. The rule defines an established patient as one who has received professional services within the past three years from the physician or qualified health care professional or another physician or qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice.
  2. Billing Practitioner. The new code explicitly requires direct interaction between the patient and the billing practitioner. It is NOT billable if the evaluation is performed by clinical staff or a practitioner not qualified to furnish E/M services. (Note: in contrast, CCM codes CAN be billed for check-ins provided by nurses and other clinical staff, and can be billed concurrently with G2012 if the patient qualifies for such codes.)
  3. Copayments. As with other Medicare Part B services, the patient is responsible for a copayment for each billed service. 
  4. Consent and Documentation. Verbal consent by the patient for each virtual check-in must be documented in the medical record. There is, however, no service-specific documentation requirement. 
  5. Timing of In-person Visit. If the virtual check in (i) takes place within seven (7) days after an in-person visit, or (ii) triggers an in-person office visit within twenty-four 24 hours (or the soonest available appointment), the service is NOT billable, and its payment is considered bundled into the relevant in-office E/M code.
  6. Frequency. There is no frequency limitation on the use of the code by the same practitioner with the same patient. However, the billing practitioner should be mindful that each service must be medically reasonable and necessary to qualify for payment by Medicare.

Who can bill for remote evaluation of images?

HCPCS Code G2010 should prove especially useful in specialty practices where an evaluation of a patient’s current condition is aided by still and/or video images transmitted by the patient to his or her physician. Obvious examples include Dermatology and Ophthalmology, but use cases might also include Endocrinology, Infectious Disease, and even Primary Care practices.

The final code descriptor for HCPCS Code G2010 reads as follows: 

HCPCS 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

What you need to know about HCPCS Code G2010

  1. Established Patients. The patient whose still image(s) and/or video is being evaluated must be an “established patient” of the billing physician or QHCP. An established patient is defined as one who has received professional services from the physician or qualified health care professional (or another physician or QHCP of the exact same specialty and subspecialty who belongs to the same group practice) within the past 3 years.
  2. Billing Practitioner. The new code does not dictate what type of practitioner can bill for evaluating the image. However, HCPCS G2010 is NOT billable if the evaluation is performed by clinical staff or a practitioner not qualified to furnish E/M services.
  3. Consent and Documentation. Advance consent from the patient must be obtained verbally or electronically and must be documented in the medical record. There is no specific requirement for service-level documentation.
  4. Copayment. A practice must collect the requisite copayment from the patient for each service billed, as with all Medicare Part B services.
  5. Timing of In-person Visit. If the remote evaluation of the image (i) takes place during an in-person visit, (ii) takes place within seven (7) days after an in-person visit, or (iii) triggers an in-person visit within twenty-four (24) hours (or the soonest available appointment), the evaluation is NOT billable, and payment is considered to be bundled into the relevant in-office E/M code.
  6. Patient Follow-Up. The code requires follow-up by the practitioner with the patient based on the evaluation of the still or video image(s) in the form of a 5-10 minute discussion with the patient.

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

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