Logistics of Rehabilitation Telehealth

Abstract

As a result of the COVID-19 public health emergency, the Centers for Medicare & Medicaid Services expanded its telehealth benefit on a temporary and emergency basis. Effective March 6, 2020, Medicare will pay for Medicare telehealth services at the same rate as regular, in-person visits. Medicare has prescribed specific guidance on the billing and coding of such services, having an impact on reimbursement for qualified providers. Additional guidance also exists on acceptable telehealth communication platforms and patient privacy.

Key points

• •As a result of the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services expanded its telehealth benefit on a temporary and emergency basis.
• •Effective March 6, 2020, Medicare began to pay for Medicare telehealth services at the same rate as regular, in-person visits.
• •To bill telehealth claims for services delivered during the PHE, providers should include the place of service in which the service would have been furnished if the visit was in person, and providers should add modifier 95 to denote the service took place via telehealth.
• •Non–public-facing remote communications like Apple FaceTime®, Zoom®, and Skype® can be used for the delivery of Medicare telehealth services.

Introduction

The Centers for Medicare & Medicaid Services (CMS) defines telehealth, telemedicine, and related terms as “the exchange of medical information from one site to another through electronic communication to improve a patient’s health.”¹ Additionally, the Health Resources and Services Administration of the US Department of Health and Human Services (HHS) describes telehealth as “the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and landline and wireless communications.”²

With the COVID-19 public health emergency (PHE), the CMS expanded its telehealth benefit on a temporary and emergency basis. Effective March 6, 2020, Medicare began to pay for office, hospital, and other visits furnished via telehealth. Prior to this expansion, Medicare “could only pay for telehealth on a limited basis: when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service.”¹ Furthermore, prior to the COVID-19 PHE telehealth expansion, Medicare was making payments for virtual check-ins, and Medicare Part B was paying for e-visits, which are “non-face-to-face patient-initiated communications through an online patient portal.”¹

Note that guidance from the CMS and other agencies are evolving, and the most current policies can be found on the CMS Web site. Also note that coverage for telehealth varies by payer and by state.

Medicare classifies 3 main types of virtual services that physicians and other health care professionals can provide to Medicare beneficiaries:

• 1.Medicare telehealth visits: these visits are furnished using telecommunications technology that must be real-time, 2-way interactive, and with audio and visual capabilities. Effective March 6, 2020, and for the duration of the PHE, Medicare will pay for Medicare telehealth services at the same rate as regular, in-person visits. Additional details on Medicare telehealth visits are discussed later.
• 2.Virtual check-ins: these visits are briefer than Medicare telehealth visits and do not require audio and visual capabilities for real-time communication. Examples include “synchronous discussion over a telephone or exchange of information through video or image.”¹ Virtual check-ins are done with established patients, are patient-initiated, and require verbal patient consent.
• 3.E-visits: using online patient portals, Medicare patients initiate communications with their physicians. These are established patients, and “the Medicare coinsurance and deductible would apply to these services.”¹

Medicare telehealth visits: expansions due to the COVID-19 public health emergency

On March 30, 2020, the CMS issued an Interim Final Rule with Comment Period, which, in addition to its March 17, 2020, announcement, expanded telehealth by waiving its geographic and place of service (POS) restrictions and by adding more flexibility in the use of telehealth. The key elements of this expansion are as follows:

• •The Medicare telehealth expansions are effective for March 6, 2020, through the period of the PHE.
• •The geographic and POS restrictions are waived, such that Medicare pays for Medicare telehealth visits in patient locations, such as their homes and outside of designated rural areas.
• •Medicare telehealth visits must be furnished using telecommunications technology that is real-time, 2-way interactive, and with audio and visual capabilities. An exception to this rule is that “CMS has used its waiver authority to allow, beginning on March 1, 2020, telephone evaluation and management codes and certain counseling behavior health care and educational services, to be furnished as telehealth services using audio-only communications technology (telephones or other audio-only devices).”³
• •Medicare telehealth visits can be furnished by distant site practitioners from their home during the PHE. The POS code should be reported as the place where the service would have been reported if the service had been provided in person.
• •Providers may see both new and established Medicare patients via telehealth.
• •Medicare telehealth visits must be reasonable and necessary.
• •The types of telehealth services covered by Medicare during the COVID-19 PHE can be found at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
• •
  The HHS Office of Inspector General (OIG) will not sanction health care providers for reducing or waiving cost-sharing obligations for telehealth services paid for by Medicare. More information can be found at the following:

  • ▪
    https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf
  • ▪
    https://www.oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf
  • ▪
    https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/telehealth-waiver-faq-2020.pdf
• •
  The CMS has allowed providers to deliver telehealth services across state lines. Providers are subject, however, to the requirements established by the states involved. The following resources are available:

  • ○
    Federation of State Medical Boards: this link provides a list of US states and territories that have modified their telehealth requirements in response to the COVID-19 PHE: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf.
  • ○
    Federation of State Medical Boards: this link provides a list of US states and territories that have modified licensure requirements for physicians in response to the COVID-19 PHE: https://www.fsmb.org/siteassets/advocacy/pdf/state-emergency-declarations-licensures-requirementscovid-19.pdf.
  • ○
    Federation of State Medical Boards: this link provides a list of US states and territories that have expedited licensure for inactive/retired licensees in response to the COVID-19 PHE: https://www.fsmb.org/siteassets/advocacy/pdf/states-expediting-licensure-for-inactive-retired-licensees-in-response-to-covid19.pdf.
  • ○
    The National Telehealth Policy Resource Center: this link provides information by state on changes states have made to remove policy barriers to telehealth in response to the COVID-19 PHE: https://www.cchpca.org/covid-19-related-state-actions.
  • ○
    Interstate Medical Licensure Compact (IMLC): the IMLC, created by state medical boards, executives, and administrators, significantly streamlines the licensure process for physicians wanting to practice in multiple states. The intent of the IMLC was to increase access to health care (eg, geographic access and access to specialists), and the benefits to physicians include faster licensure and fewer administrative burdens: https://www.imlcc.org/a-faster-pathway-to-physician-licensure/.
  • ○
    Medicare: this link provides information on Medicare’s recognition of IMLCs: https://www.cms.gov/files/document/SE20008.pdf.
  • ○
    IMLCs also exist for other health care providers:

    • ▪
      Emergency medical services workers: https://www.emscompact.gov/
    • ▪
      Nurses: https://www.ncsbn.org/nurse-licensure-compact.htm
    • ▪
      Physical therapists: http://ptcompact.org/
    • ▪
      Psychologists: https://psypact.org/page/PracticeUnderPSYPACT
    • ▪
      Speech language pathologists/therapists: https://aslpcompact.com/
• •
  As a result of the COVID-19 PHE, the Drug Enforcement Administration (DEA) has made the following key changes:

  • ○
    The DEA has allowed DEA-registered practitioners to prescribe schedule II–V controlled substances via telehealth. The following 3 conditions must be met:

    • ▪
      “The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice;
    • ▪
      The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and
    • ▪
      The practitioner is acting in accordance with applicable Federal and State laws.”⁴
  • ○
    The DEA, through the Controlled Substances Act, “allows practitioners to dispense narcotic drugs, including buprenorphine, to individuals with OUD [opioid use disorder] for maintenance or detoxification treatment if the practitioners separately register with DEA as an opioid treatment program.”⁵
  • ○
    The DEA has granted an exception to DEA-registered practitioners, such that DEA-registered practitioners are not required to register with the DEA in additional states where they dispense controlled substances. Further detail is available at https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-018)(DEA067)%20DEA%20state%20reciprocity%20(final)(Signed).pdf.
  • ○
    The DEA has granted an exception to requirements for paper delivery of an emergency oral prescription. Further detail is available at https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-021)(DEA073)%20Oral%20CII%20for%20regular%20CII%20scirpt%20(Final)%20+Esign%20a.pdf.

Medicaid coverage for telehealth

Because Medicaid coverage differs by state, the National Telehealth Policy Resource Center has compiled a resource on COVID-19–related state actions: https://www.cchpca.org/covid-19-related-state-actions. The link provides state-by-state information on the allowance of telehealth, changes to geographic restrictions, and coverage for telehealth services.

Uninsured patients: federal COVID-19 reimbursements

Health care providers and health centers can be reimbursed by the federal government for testing and treating uninsured individuals for COVID-19. Claims can be submitted to the Health Resources and Services Administration COVID-19 Uninsured Program Portal (https://coviduninsuredclaim.linkhealth.com/). Claims generally are paid at Medicare rates, upon availability of funding.

Medicare billing, coding, and reimbursement

The types of telehealth services covered by Medicare during the COVID-19 PHE can be found at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes. Medicare reimburses a telehealth visit at the same fee-for-service-rate as an in-person visit during the PHE. To bill telehealth claims for services delivered during the PHE, providers should include the POS in which the service would have been furnished if the visit were in person, and providers should add modifier 95 in order to denote the service took place via telehealth.

The catastrophe/disaster-related (CR) modifier is not needed when billing for telehealth services. The CMS requires modifiers, however, for Medicare telehealth professional claims for the following 2 scenarios:

• •“Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ (Via an asynchronous telecommunications system when reporting telehealth services) modifier.”⁶
• •“Furnished for diagnosis and treatment of an acute stroke, use G0 (used to identify Telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke) modifier.”⁶

For office/outpatient evaluation and management (E/M) services furnished via telehealth, level selection can be based on medical decision making or time. Medical decision making refers to the existing definition of “the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering these factors: the number of possible diagnoses and/or the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; [and] the risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.”⁷ Additional information on time can be found at https://www.aap.org/en-us/professional-resources/practice-transformation/getting-paid/Coding-at-the-AAP/Pages/Using-Time-to-Report-Outpatient-EM-Services.aspx.

Examples of Healthcare Common Procedure Coding System/Current Procedural Terminology codes: Medicare telehealth visits

Service	Healthcare Common Procedure Coding System/Current Procedural Terminology Code
New patient office/outpatient E&M services	99201 99202 99203 99204 99205
Under new or established patient office/outpatient E&M services	99221 99222 99223 99224 99225
Telehealth consultations, emergency department, or initial inpatient	G0425 G0426 G0427
Follow-up inpatient consultation, furnished via telehealth to beneficiaries in hospitals or skilled nursing facilities	G0406 G0407 G0408

Examples of Healthcare Common Procedure Coding System/Current Procedural Terminology codes: virtual check-ins

Service	Healthcare Common Procedure Coding System/Current Procedural Terminology Code
Brief virtual check-in (5-10 minutes of medical discussion) with an established patient, not resulting from a service provided within the past 7 days nor leading to a service within the next 24 hours or next available appointment	G2012
Remote evaluation with interpretation of recorded video or images submitted by an established patient, inclusive of follow-up with the patient within 24 business hours, not resulting from a service provided within the past 7 days nor leading to a service within the next 24 hours or next available appointment	G2010

Examples of Healthcare Common Procedure Coding System/Current Procedural Terminology codes: e-visits

Service	Healthcare Common Procedure Coding System/Current Procedural Terminology Code
Under non–face-to-face on-line digital E/M service	99421 99422 99423
Qualified nonphysician health care professional online assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days	G2061 G2062 G2063

• •Residents furnishing services at primary care centers may provide an expanded set of services to beneficiaries, including levels 4-5 of an office/outpatient Evaluation and Management (E/M) visit, telephone E/M, care management, and some communication technology-based services
• •This expanded set of services at CPT® codes 99204-99205, 99214-99215, 99495-99496, 99421-99423, 99452, and 99441-99443 and HCPCS codes G2010 and G2012
• •Teaching physicians may submit claims for these services furnished by residents in the absence of a teaching physician using the GE modifier.”⁶

Health information portability and accountability act

During the COVID-19 PHE, the Office for Civil Rights at HHS has issued a Notification of Enforcement Discretion and “will not impose penalties for noncompliance with the regulatory requirements under the HIPAA [Health Insurance Portability and Accountability Act of 1996] Rules against covered health care providers in connection with the good faith provision of telehealth.”⁸ Non–public-facing remote communications like Apple FaceTime®, Zoom®, and Skype® can be used. Public-facing applications like Facebook Live®, Twitch®, and TikTok® are not allowed to be used.

Clinics care points

• •The CMS defines telehealth, telemedicine, and related terms as “the exchange of medical information from one site to another through electronic communication to improve a patient’s health.”¹
• •Guidance from the CMS and other agencies is evolving, and the most current policies can be found on the CMS Web site.
• •Coverage for telehealth varies by payer and by state.
• •Providers may see both new and established Medicare patients via telehealth.
• •Medicare telehealth visits must be reasonable and necessary.
• •The CMS has allowed providers to deliver telehealth services across state lines. Providers are subject, however, to the requirements established by the states involved.
• •The DEA has allowed DEA-registered practitioners to prescribe schedule II–V controlled substances via telehealth, with specific required conditions.