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.
Payor Restrictions on Telehealth
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:
- The originating site (patient location) had to be in a rural Health Professional Shortage Area (HPSA) or outside a Metropolitan Statistical Area (MSA)
- The visit had to be synchronous (live) not asynchronous (store and forward) unless the provider of service was in a pilot program in Alaska or Hawaii
- An approved type of provider had to deliver the service
- The physician or other approved provider had to deliver the service in an approved distant site
- The services provided had to be on the covered list of Medicare approved telehealth services
- The service had to be provided through an approved telecommunications system
- The documentation had to support the services reported
If the above criteria were met, then Medicare would pay the service at full fee schedule value.
Stages of COVID-19 in the United States
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.
Requests for Addition of Codes to the List of Medicare Telehealth Services
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:
- Category 1: This is assigned to services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the list of approved telehealth services. CMS considers codes for Category 1 if they are similar, but different, from existing covered telehealth services in respect to the roles of, and interactions between, the beneficiary, and the physician/other provider performing the service.
- Category 2: This is assigned to services that are not similar to any service on the current list of telehealth covered services. CMS considers codes for Category 2 if assessment indicates that the service matches the CPT code when it is delivered through telehealth and that there is a demonstrated clinical benefit to the patient.
Emergency Response
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:
- Remove the restrictions on the types of practitioners that can furnish telehealth services
- Allow for some telehealth services to be furnished by audio-only method
- Add or remove services to the Medicare covered telehealth list when required
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.
New Permanent Category 3 - Sort of
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:
- A description of relevant clinical studies that demonstrate the services, when furnished via telehealth, improves the diagnosis or treatment of an illness or injury, or improves the functioning of a malformed body part (including dates and findings of the studies); and
- A list and copies of published peer reviewed articles relevant to the services when furnished via telehealth
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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.
So, What is Changing?
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:
- Domiciliary, Rest Home, or Custodial Care Services, Established patients; codes 99336 and 99337
- Home Visits, Established Patient; codes 99349 and 99350
- Emergency Department Visits; codes 99281-99283
- Nursing Facilities Discharge Day Management; codes 99315 and 99316
- Psychological and Neuropsychological Testing; codes 96130-96133
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.
Call to Action
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 Hovey, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is a nationally recognized healthcare consultant and speaker. She is an expert auditor and loves to help practices stay compliant and profitable. Betty states, "Physicians work hard for their practices and they should be paid properly for what they do."
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.
References
The Centers for Medicare and Medicaid Services. (August 17, 2020). Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug under a Prescription Drug Plan or an MA-PD plan; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; and Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy. https://www.federalregister.gov/documents/2020/08/17/2020-17127/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part
The Centers for Medicare and Medicaid Services. CMS Criteria for Submitted Requests. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Criteria
Goodman, R., Lacktman, N. (August 12, 2020). COVID-19: Here’s What CMS Will Do With the Temporary Telehealth Codes When the PHE Ends. https://www.foley.com/en/insights/publications/2020/08/covid-19-cms-temporary-telehealth-codes-phe-ends
Trump, President D. (March 13, 2020). Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak. https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/
Wicklund, E. (August 14, 2020). CMS May Eliminate Most Emergency Codes for COVID-19 Telehealth Services. https://mhealthintelligence.com/news/cms-may-eliminate-most-emergency-codes-for-covid-19-telehealth-services