When the COVID-19 pandemic struck, a lot of people in a lot of states were ordered to "shelter in place" which meant that meant no going anywhere non-essential, including physician visits.  In Illinois, if a person was considering going to the Emergency Department of a hospital at the beginning of the pandemic, they had to call first for permission or be brought in by ambulance.  Elective surgeries were cancelled across the country as hospitals and clinics were closed. These factors lead to the emergence of telemedicine visits as the main way to receive treatment, which seemed like a win-win, except for payor restrictions on payment.

Prior to the pandemic, requirements for payment for telehealth visits depended on the payor.  Many commercial insurances paid for telehealth visits when the patient was at home, but not Medicare.  In order to be paid for telehealth visits by Medicare prior to the Public Health Emergency (PHE), specific criteria had to be met:

If the above criteria were met, then Medicare would pay the service at full fee schedule value.

A public health emergency was declared by the Secretary of Health and Human Services (HHS) on January 31, 2020.  The World Health Organization (WHO) declared COVID-19 as a pandemic on March 11, 2020.   On March 13, 2020 President Trump declared COVID-19 a national emergency, referring to sections 201 and 301 if the National Emergencies Act and section 1135 of the Social Security Act.

On October 2, 2020, the Secretary of Health and Human Services (HHS), Alex Azar II, renewed the public health emergency status of the United States.  This means that Medicare and anyone other payor that has proclaimed to continue paying for telehealth until the pandemic is over, will continue to pay for telehealth services through the rest of the year.

The 1135 Waiver allows Medicare to pay for telehealth services in a much more expanded way.  The patient may receive telehealth in their home and does not have to be in a rural HPSA or non-MSA county.  

The request to add to the list of telehealth services may be done at any time, but ones received on or before December 31 of the calendar year will be considered for the following year.  According to the CMS website, the requests are separated into two categories:

Under the 1135 Waiver, CMS was able to add services to the covered telehealth services list.  CMS put out an interim final rule (Medicare and Medicaid Programs. Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency) stating that these services would be covered for the duration of the COVID-19 pandemic.

The Secretary of the Department of Health and Human Services relied on other new legislation, namely the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act, and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) to enable HHS to waive or modify Medicare telehealth payment requirements during the declared COVID-19 PHE.  Physicians and other providers had to change the way they were delivering health care to patients because of the need to social distance from COVID-19 to avoid exposure.  They needed to be paid for the services they provided.  The legislation passed allowed them to be able to accommodate the changes so physicians and other providers could still get paid.  

One big thing is that it allowed CMS to remove the place of service restriction on delivery of telehealth services so a patient could receive telehealth from home and have the services covered.  It also allowed CMS the ability to:

The interim services will be allowable until the end of the PHE.  Then, instead of just deleting them from the list, Medicare will allow the services to be considered for permanent addition to the Medicare approved telehealth list.  In the proposed fee schedule, CMS laid out how it plans on using this new category.

For fiscal year 2021, CMS wants to add a new category due to COVID-19; Category 3 codes.  These codes will be added to the list of covered telehealth services on a temporary basis during a declared public health emergency.  The codes will be covered until the end of the year in which the public health emergency expires.  So, if the public health emergency is cancelled on January 3, 2021, the Category 3 codes will be covered until December 31, 2021.  This will give practices time to transition back to more face-to-face visits with patients.  But there is also another benefit to this new category addition.

Before they expire, they will be considered for movement to Category 1 or 2 codes.  For Category 3 codes to be changed to permanent status, CMS will require the submission of the following:

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In the proposed final rule, CMS stated that the codes chosen for Category 3 status were the ones that CMS stated had the "potential likelihood of clinical benefit when furnished as telehealth services, and as such, the potential likelihood to meet the Category 1 or Category 2 criteria for permanent addition to the Medicare telehealth services list with the development of additional evidence."

So, they are kind of like Category III CPT codes.  They are added into the CPT book and assessed to see if they need to be changed to Category I, "regular" CPT codes.  These "T Codes" have a time limit, and if they are not found to be a necessary addition to the permanent list of CPT codes, they are "sunsetted" and deleted from the CPT book.  Similarly, Category 3 telehealth services are approved on a temporary basis and must be proven to provide the benefits of the other services approved on the Medicare telehealth list to be changed to Category 1 or Category 2 codes.  If not found to meet the criteria, they are moved off of the covered services list and no longer payable when performed via telehealth.  

In the proposed Final Rule, CMS proposed to change 13 codes to Category 3 codes that are currently being paid because of the public health emergency and delete 74 codes from the list. The only codes that will be added as Category 3 codes and continue to be paid when performed via telehealth for FY2021 are:

All other current codes that are being covered due to the pandemic will no longer be paid as telehealth services.  CMS closed the comment period for this proposal October 5, 2020.

As of the writing of this article, CMS has not released the Final Rule, so it is unclear if the 13 codes described above are still on the covered list, or if others were added to it.  Practices need to make sure that this Category is reviewed, and any changes made to billing practices.  If not, a practice may continue to offer services via telehealth for Medicare patients that no longer get paid, which could cause a huge problem with the AR.  

Betty brings over thirty years of healthcare experience. She has worked for practices both large and small with the same intensity and attention. She has spent years on the "front lines" for practices handling medical billing, coding, claims, and denials.  She has also managed practices and directed healthcare system departments. Her areas of expertise include Evaluation and Management, Primary Care, Dermatology, Plastic Surgery, Cardiology, Cardiothoracic Surgery, General Surgery, GI, E/M and procedural auditing, and ICD-10-CM.

 

As a speaker and trainer, Betty brings a welcoming mannerism that her attendees relate to and enjoy. She brings humor and real life experience to her educational sessions that allow her to ensure that everyone understands the training and has a good time. Betty has educated medical coders, managers, health plans, administrators, physicians and non-physician practitioners all across the country. She has co-written manuals on ICD-10-CM, ICD-10-PCS, and CPT specialty areas.  She most recently authored a chapter for the soon to be released book, Telemedicine in Orthopedics and Sports Medicine: Development and Implementation in Practice.

 

Betty is a Certified Coding Specialist-Physician based (CCS-P) and a Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association (AHIMA). Through AAPC she holds certifications as a Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA), Certified Professional Coder for Dermatology (CPCD), Certified Professional Biller (CPB), and a Certified Professional Coder Instructor (CPC-I).  Betty is also a member of Sigma Beta Delta-an International Honor Society for Business, Management, and Administration.

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