Regulatory Agencies Help Expand COVID-19 Telehealth Services
On Tuesday, March 17, 2020, CMS issued guidance as part of the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074). This guidance loosens restrictions and expands the use of technology to help broaden access to healthcare in response to the novel coronavirus disease 2019 (COVID-19) public health emergency.
In prior CMS guidance, telehealth services were limited to patients located in eligible rural, nonurban originating sites meeting either metropolitan statistical area or health professional shortage area criteria and services rendered face-to-face by a qualified distant site provider. There was an exception for a patient in their own home, but only for home dialysis end-stage renal disease-related medical evaluations. A distant site provider was identified as a physician or nonphysician practitioner. According to the Medicare Benefit Policy Manual, rural health clinics (RHC) and FQHCs are excluded from eligibility as distant site providers for primary Medicare beneficiaries. RHCs and FQHCs are excluded from billing for distant site professional services or including the visit cost on the annual cost report.
See what’s changed—and what’s remained the same—under the 1135 waiver:
- Telehealth audiovisual visits will be covered without site or geographic restrictions, including to a patient’s home, effective Friday, March 6, 2020.
- Telehealth audiovisual visits will be covered for new or established patients. Although the waiver requires a patient to have a prior established relationship with their healthcare provider, Section 1135(b)(8) of the Social Security Act states the U.S. Department of Health & Human Services “will not actively pursue audit activities to assess whether a prior relationship exists” for claims submitted during the current public health emergency.
- Revisions were not made to the criteria for distant site providers. Consequently, RHCs and FQHCs may serve as originating sites (where the patient is located) but are still excluded from serving as distant site providers. The National Association of Rural Health Clinics (NARHC) and National Rural Health Association (NRHA) are actively challenging CMS on this restriction. State Medicaid, commercial and/or Managed Care Organization (MCO) plans generally cover both in RHC or FQHC settings, although we recommend verifying payor billing and reimbursement guidelines before filing claims.
As of Thursday, March 19, 2020, there has been movement on the legislative side after the NARHC and NRHA sent letters to Congress that encouraged it to pass revisions to the current COVID-19 bills to remove restrictions on RHCs and FQHCs and allow these entities to serve as distant site providers. The third version of COVID-19 legislation, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), has been introduced and is pending a final vote to pass. This act contains language in §4405 addressing various needs of the RHC and FQHC community to include expanding telehealth distant site services during this emergency period, if not permanently. Be on the lookout for further communication on this topic.
- No revisions were made to the criteria for virtual check-ins or e-visits.
- Telehealth visits require interactive audio and video telecommunications that allow for real-time communication between the patient in any originating site, including their home, and the distant site provider. A list of eligible telehealth professional services can be found here. Telehealth visits essentially take the place of in-person visits that would have occurred if the patient was able to come into the clinic to see the physician or nonphysician practitioner. Per Healthcare Common Procedure Coding System (HCPCS) Code Q3014, no originating site fee is submitted if the patient is located in the home.
- Virtual check-ins are brief (5 to 10 minute) technology-based communications initiated by a patient who is established with the healthcare provider. The intent of the communication is not to discuss established problems or management of a chronic condition; instead, the patient is querying the provider to determine if additional care is needed for new signs or symptoms. The virtual communication is not billable if the intent is to discuss established problems addressed at a visit within the previous seven days, or it results in a medical appointment in the next 24 hours. The patient must give consent for the use of virtual communication, and the provider must document the consent in the medical record and provide a description of the communication itself. The patient may initiate communication by telephone or other electronic means or submit a video or image for the provider’s evaluation.
- E-visits or e-consultations must be initiated by the patient through the use of an electronic portal. This method of virtual communication is not eligible for billing in the RHC or FQHC setting for primary Medicare. This method is eligible for patients who are established with their healthcare provider. Verbal consent must be obtained and documented in the medical record prior to initiation. These communications may occur over a seven-day period.
- Place of service code 02 is reported on a CMS-1500 claim form for both the originating site code (Q3014) and the distant site professional service code(s).
- In the RHC or FQHC setting, revenue code 780 is reported on a UB-04 claim form to primary Medicare (or State Medicaid if required) for the originating site (Q3014).
- For a virtual check-in, RHCs and FQHCs will report HCPCS code G0071. For additional information, please refer to this CMS FAQ.
- The GT Modifier is not appended to either the originating site code (Q3014) or the distant site professional service code(s) for primary Medicare, but may be required by State Medicaid, commercial or MCO plan. The GQ Modifier is still needed for the use of an asynchronous telecommunications system.
Refer to the CMS Fact Sheet coding tool (see the summary at the bottom of the page) for a list of telehealth or virtual communication services, pertinent CPT® or HCPCS codes and a brief outline of the guidance.
As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication.
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