UPDATED MAY 1, 2020
For years, only a handful of physicians furnished telehealth services. Now, in only a few weeks, many physician practices have transitioned to telehealth-based care delivery. This dramatic shift in response to the COVID-19 pandemic has been facilitated by the significant expansion of Medicare coverage for these services.
Historically, reimbursement for telehealth services under the Medicare Physician Fee Schedule has been extremely limited. Under Section 1834(m) of the Social Security Act, a service delivered using telehealth must meet five requirements to be covered by Medicare:
(1) The geographic requirement. The beneficiary must reside in a rural area.
(2) The location requirement. The beneficiary must be physically present at a healthcare facility when the service is provided.
(3) The service requirement. The service provided must be listed as an approved telehealth service (as defined by CPT or HCPCS code).
(4) The technology requirement. The service must be provided using a telecommunications technology with audio and video capabilities that permit real-time interactive communication.
(5) The provider requirement. The service must be provided by an eligible provider, including physicians, non-physician practitioners, clinical psychologists, clinical social workers, registered dieticians, and nutrition professionals.
As part of its initial response to the COVID-19 pandemic, Congress gave the Secretary of Health and Human Services new authority to waive the geographic and location requirements during the national public health emergency (PHE).
By exercising this authority, the Secretary expanded Medicare telehealth coverage for services furnished to a beneficiary in his or her home (or any other location) without regard to whether the beneficiary resides in a rural area. Additionally, the Centers for Medicare & Medicaid Services (CMS) has published two interim final rules (IFR I and IFR II) further eliminating barriers to telehealth adoption during the PHE.
The details regarding expanded telehealth coverage during the PHE are addressed in the following sections.
List of Approved Telehealth Services
In IFR I, CMS expanded the list of approved telehealth services from 100 to 180 for the duration of the PHE. The newly added services include the following:
|Service Category||CPT Codes|
|Emergency Department Visits||99281 – 99285|
|Initial & Subsequent Observation & Observation Discharge Day Management||99217 – 99220
99224 – 99226
99234 – 99236
|Initial Hospital Care & Hospital Discharge Day Management||99221 – 99223
99238 – 99239
|Initial Nursing Facility Visit & Nursing Facility Discharge Day Management||99304 – 99306
99315 – 99316
|Critical Care Services||99291 – 99292|
|Domiciliary, Rest Home, or Custodial Care Services||99327 – 99328
99334 – 99337
|Home Visits||99341 – 99345
|Inpatient Neonatal & Pediatric Critical Care||99468 – 99469
99471 – 99473
99475 – 99476
|Initial & Continuing Intensive Care Services||99477 – 99480|
|Care Planning for Patients with Cognitive Impairment||99483|
|Psychological & Neuropsychological Testing||96130 – 96133
96136 – 96139
|97161 – 97168
97760 – 97761
92521 – 92524
|Radiation Treatment Management Services||77427|
Subsequently, in IFR II, CMS announced it would make additional changes to the list through sub-regulatory guidance for the duration of the PHE (as opposed to publishing additional interim final rules). Using this new process, CMS identified the following additional approved telehealth services on April 30:
|Service Category||CPT Codes|
|Behavioral Health Counseling and Education Services||97150-97157|
|Eye Examinations||92002, 92004,92012, 92014|
|Use of Inhaler||94664|
|Developmental Screening/Testing||96110, 96113|
All Medicare beneficiaries are eligible to receive any listed telehealth services to the same extent they are eligible to receive the service on a face-to-face basis. In IFR I, CMS eliminated the limits on the frequency with which certain telehealth services can be provided within a specified time period. This change impacts subsequent inpatient visits, subsequent nursing facility visits, and critical care consultation services.
Regarding the selection of the appropriate E/M code for telehealth services furnished to a patient in his or her home, CMS provides the following guidance in IFR I:
The CPT codes describing E/M services reflect an assumption that the nature of the work involved in [E/M] visits varies, in part, based on the setting of care and the patient’s status. Consequently, there are separate sets of E/M codes for different settings of care…. We expect [providers] to use the E/M code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient. Under ordinary circumstances, we would expect the kind of E/M code reported to generally align with the physical location or status of the patient. In the context of the PHE, we recognize that the relationship among the setting of care, patient status, and kind of E/M code reported may depend on the needs of local communities and the capacity of local health care institutions.
In addition to expanding the list of covered services, CMS in IFR I permitted telehealth to serve as a substitute for certain required face-to-face interactions between a patient and an eligible provider. This includes: (1) clinical examination of the beneficiary’s vascular site as a component of the end-stage renal disease monthly capitated payments, (2) face-to-face visits with inpatient rehabilitation facility patients, and (3) face-to-face visits for hospice re-certification. Also, when direct supervision by a practitioner is required for a service to be billable, such supervision may be accomplished using telehealth (rather than being physically present in the same suite of offices).
Telehealth Technology Requirements
To bill for telehealth services, a practitioner must use an interactive audio and video system. On April 30, CMS announced an exception to this rule for behavioral health counseling and educational services, reimbursing these services even if performed using audio only. Otherwise, telephone-only services may be reimbursed as virtual check-ins or telephone evaluation and management services; further details follow.
On March 17, the agency responsible for HIPAA enforcement, the HHS Office for Civil Rights (OCR), issued a Notification of Enforcement Discretion relating to the emergency telehealth waiver. To prevent HIPAA from creating a barrier to telehealth usage, the OCR will not impose penalties for noncompliance with the regulatory requirements in connection with the good faith provision of telehealth. According to the OCR, a practitioner may use any non-public-facing remote communication product, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype. Not included are Facebook Live, Twitch, TikTok, and similar public-facing video communication applications.
Telehealth Eligible Providers
Under Section 1834(m)’s provider requirement, only certain types of providers have been able to bill for telehealth services under the Medicare Physician Fee Schedule. On April 30, CMS announced it would permit all types of healthcare professionals who are eligible to bill Medicare for their professional services to bill for telehealth services. This includes physical therapists, occupational therapists, and speech language pathologists.
Generally, an eligible provider must be licensed in the state in which the patient receiving telehealth services is present. CMS has waived this requirement for the duration of the PHE, so long as the eligible provider is properly licensed in his or her home state.
Regardless of any CMS waiver, however, applicable state law still may require local licensure to provide telehealth services to a person located in that state. Several states have waived these requirements for the duration of the PHE, albeit on different conditions. The Center for Connected Health Policy maintains an up-to-date resource regarding such state action.
Billing and Reimbursement for Telehealth Services
In announcing the telehealth waiver March 17, CMS stated telehealth services would be reimbursed at the lower facility rate, even for eligible providers regularly practicing in office settings (as opposed to hospital outpatient departments). CMS directed eligible providers to use POS 02 without any modifier in billing for telehealth services.
In the March 31 IFR I, however, CMS changed course, announcing that telehealth services would be reimbursed at the higher non-facility rate if furnished in a physician practice. To accomplish this, CMS directed eligible providers to discontinue use of POS 02, instead listing the location “that would have been reported had the service been furnished in person…if not for the [public health emergency] COVID-19 pandemic.” In addition, eligible providers now should include the 95 modifier on claims for telehealth services. CMS noted, however, claims would not be denied if submitted with POS 02 and no modifier, but would be paid at the lower facility rate.
Generally, providers are required to include the CR (catastrophe/disaster-related) modifier on claims for services provided under an emergency waiver. CMS, however, has directed eligible providers not to include the CR modifier on any telehealth claims.
Also in IFR I, CMS advised that for office/outpatient E/M visits furnished via telehealth, an eligible provider may select the appropriate code based on medical decision-making or time (i.e., the total time associated with the E/M on the day of the encounter). In these cases, the eligible provider does not need to document history and/or physical exam in the patient’s record. CMS notes this policy is similar to the one that will apply to all office/outpatient E/M visits beginning in 2021 under rules finalized in the 2020 Medicare Physician Fee Schedule Final Rule.
|CPT Code||Total Minutes|
An eligible provider should submit claims for telehealth services to the same Medicare Administrative Contractor (MAC) to which the eligible provider submits claims for face-to-face services, even if the telehealth patient is present in a different MAC’s jurisdiction.
In a recent FAQ, CMS advised that eligible providers who furnish telehealth services from their homes are “not required to update their Medicare enrollment with the home location. The [eligible provider] should list the home address on the claim to identify where the services were rendered. The discrepancy between the practice location in the Medicare enrollment (clinic/group practice) and the practice location identified on the claim (provider’s home location) will not be an issue for claims payment.”
CMS in IFR I clarified that if the patient is present in a healthcare facility when receiving telehealth services (e.g., a skilled nursing facility), that facility may bill Medicare an originating site fee, even if the site is not located in a rural area. This is a change in policy, as CMS has not permitted non-rural sites to bill this fee in other circumstances in which the telehealth geography and location restrictions have been waived (e.g., telestroke). Instructions for billing the originating site fee are available on MAC websites.
Deductibles and coinsurance apply to telehealth services. However, the HHS Office of Inspector General (OIG) is providing flexibility for eligible providers to reduce or waive beneficiary cost-sharing for these services during the PHE.
Telehealth Billing for RHCs and FQHCs
On April 17, the Centers for Medicare & Medicaid Services (CMS) published an MLN Matters® Special Edition Article on telehealth billing for rural health clinics (RHCs) and federally qualified health centers (FQHCs) during the COVID-19 PHE.
Prior to the passage of the CARES Act March 27, there was no legislative authority for CMS to pay Clinics for telehealth services. Section 1834(m) of the Social Security Act, the provision that defines the Medicare telehealth benefit, only provides coverage for services furnished under the Medicare Physician Fee Schedule (MPFS).
Section 3704 of the CARES Act now authorizes RHCs and FQHCs to furnish telehealth services to Medicare beneficiaries for the duration of the COVID-19 PHE. Congress directed CMS to develop payment rates for these services similar to the national average payment rates for comparable telehealth services under the MPFS.
According to the MLN article, RHCs and FQHCs will be paid different rates for telehealth services furnished before July 1, 2020, and after that date:
For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, [Clinics] must put Modifier “95” (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) on the claim. RHCs will be paid at their all-inclusive rate (AIR), and FQHCs will be paid based on the FQHC Prospective Payment System (PPS) rate. These claims will be automatically reprocessed in July when the Medicare claims processing system is updated with the new payment rate. RHCs and FQHCs do not need to resubmit these claims for the payment adjustment.
For telehealth services furnished on or after July 1 through the end of the COVID-19 PHE, RHCs and FQHCs are directed to use a Clinic-specific G code, G2025, to identify services that were furnished via telehealth. These claims will be paid $92, which is the average amount for all MPFS telehealth services on the telehealth list, weighted by volume for those services reported under the MPFS. This amount will be updated if the COVID-19 PHE continues into 2021.
Although the costs for furnishing telehealth services will not be used to determine the RHC AIR or the FQHC PPS rates, these costs must be reported on the appropriate cost report form:
RHCs must report both originating and distant site telehealth costs on Form CMS-222-17 on line 79 of the Worksheet A, in the section titled “Cost Other Than RHC Services.” FQHCs must report both originating and distant site telehealth costs on Form CMS-224-14, the Federally Qualified Health Center Cost Report, on line 66 of the Worksheet A, in the section titled “Other FQHC Services.” Since telehealth distant site services are not paid under the RHC AIR or the FQHC PPS, the Medicare Advantage wrap-around payment does not apply to these services. Wrap-around payment for distant site telehealth services will be adjusted by the MA plans.
Medicare Coverage for Communication Technology-Based Services
In the last few years, CMS has expanded coverage for several communication technology-based services (CTBSs). Although CTBSs are not furnished face-to-face, CMS does not consider these services to be subject to the restrictions in Section 1834(m). While telehealth services are a substitute for a face-to-face interaction, CTBSs are defined by the use of technology.
CMS has relaxed or clarified the rules regarding several CTBSs—including virtual check-ins, e-Visits, and remote patient monitoring—to afford providers more options to care for patients during the PHE.
Virtual Check-Ins. While telephone-only patient interactions do not qualify as telehealth services, they may be reimbursed as virtual check-ins under HCPCS G2012 if specific requirements are satisfied. Medicare pays approximately $15 for HCPCS G2012.
In a March 17 fact sheet, CMS advised as follows:
Medicare pays for these “virtual check-ins”…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 IFR I, CMS made two changes to these billing rules for virtual check-ins for the duration of the PHE. First, virtual services may be furnished to new patients as well as established patients. Second, CMS noted the OIG’s statement regarding reduction or waiver of beneficiary cost-sharing applies to virtual check-ins.
Also, CMS clarified that consent for virtual check-ins need only be obtained once annually, that it may be obtained at the same time that a service is furnished, and that it may be obtained by auxiliary staff under general supervision, as well as by the billing practitioner.
e-Visits. For other types of patient communications, a provider also may receive reimbursement for an e-Visit. As CMS explained in the March 17 fact sheet:
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.
In IFR I, CMS made the same modifications to the billing rules for e-Visits as it did for virtual check-ins regarding new patients, waiver of beneficiary cost-sharing, and consent.
CMS began reimbursing eVisits effective January 1, 2020. CMS requires the service be provided to patients via a HIPAA-compliant platform, such as an electronic health record portal, secure email, or other digital application. The level of service is based on the cumulative number of minutes the billing practitioner spends with the patient over a seven-day period (clinical staff time cannot be counted):
|CPT Code||Cumulative Time
(over 7-day period)
|CPT 99421||5-10 minutes||$15.52||$13.35|
|CPT 99423||21 or more||$50.16||$43.67|
E-Visits performed by qualified non-physician healthcare professionals are billed using the following codes:
|HCPCS Code||Cumulative Time
(over 7-day period)
|Facility and Non-Facility|
|G2063||21 or more||$33.92|
CMS explained in IFR I that these codes may be billed “as licensed clinical social worker services, clinical psychologist services, physical therapist services, occupational therapist services, or speech language pathologist services, so practitioners that report services in those benefit categories could also report these online assessment and management services.”
Unlike telehealth services, CMS does allow RHCs and FQHCs to participate in eVisits. In IFR I, CMS extended reimbursement for eVisits to RHCs and FQHCs under HCPCS G0071, with a payment rate of $24.76.
Remote Patient Monitoring. In 2019, CMS began reimbursing practitioners for remote patient monitoring (RPM) services furnished to patients with chronic conditions. PYA’s white paper, Providing and Billing Medicare for Remote Patient Monitoring, details the opportunity presented by this new reimbursement.
In IFR I, CMS clarified the rules regarding RPM, both during the PHE and beyond:
RPM codes can be used for physiologic monitoring of patients with acute and/or chronic conditions. The typical patient needing RPM services may have a chronic condition (for example, high blood pressure, diabetes, COPD). However, RPM can be used for other conditions. For example, RPM services allow a patient with an acute respiratory virus to monitor pulse and oxygen saturation levels using pulse oximetry. Nurses, working with physicians, can check-in with the patient and then using patient data, determine whether home treatment is safe, all the while reducing exposure risk and eliminating potentially unnecessary emergency department and hospital visits.
As with other virtual services, IFR I clarifies that the OIG’s statement regarding reduction or waiver of beneficiary cost-sharing applies to RPM services and relaxes the rules regarding consent for these services for the duration of the PHE for the COVID-19 pandemic.
In IFR II, CMS stated it will allow RPM monitoring services for periods of time that are fewer than 16 days out of 30 days, but no less than 2 days, for patients who have a suspected or confirmed diagnosis of COVID-19.
Telephone E/M Services
For years, CMS refused to reimburse for telephone E/M services, claiming such telephone calls were reimbursed as part of other face-to-face interactions. In IFR I, however, CMS announced Medicare would, for the balance of the PHE for the COVID-19 pandemic, reimburse the following telephone E/M services for new and established patients at the following national payment rates:
|99441||Telephone evaluation and management service by a physician or other qualified health care professional who may report E/M services provided to established patient, parent, or guardian 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||$46.19||$26.35|
|99442||Same, 11-20 minutes of medical discussion||$76.15||$52.33|
|99443||Same, 21-30 minutes of medical discussion||$110.43||$80.48|
|98966||Telephone assessment and management service provided by qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion||$14.44||$13.35|
|98967||Same, 11-20 minutes of medical discussion||$28.15||$26.71|
|98968||Same, 21-30 minutes of medical discussion||$41.14||$39.70|
Note CMS significantly increased the reimbursement for CPT 99441-99443 on April 30, effective retroactively to March 1. The rates for these services now are comparable with those for telehealth E/M services (i.e., using both audio and video).
Regarding CPT 98966 – 98968, CMS noted “that these services may be furnished by, among others, LCSWs, clinical psychologists, and physical therapists, occupational therapists, and speech language pathologists when the visit pertains to a service that falls within the benefit category of those practitioners.” Also, to facilitate billing by therapists, CMS designated these codes as “sometimes therapy” services, thus requiring the private practice occupational therapist, physical therapist, and speech-language pathologist to include the corresponding GO, GP, or GN therapy modifier on claims for these services. Note that CMS did not increase the reimbursement for CPT 98966-98968 when it increased the rates for CPT 99441-99443.
RHC and FQHC Payment for Telephone-Only Services
Also in the April 17 MLN article, CMS clarified that RHCs and FQHCs will be reimbursed for telephone-only services–including virtual check-ins (HCPCS G2012) and telephone evaluation and management services (CPT 99441-99443)–under G0071. Unfortunately, CMS still will not permit RHCs and FQHCs to bill for remote patient monitoring.
Effective March 1 and continuing for the duration of the COVID-19 PHE, the payment for G0071 will be $24.76, instead of the CY 2020 rate of $13.53. Medicare Administrative Contractors will automatically reprocess any claims with G0071 for services furnished on or after March 1 that were paid before the claims processing system was updated. While CMS increased the reimbursement for CPT 99441-99443 to the same level as telehealth services (i.e, using an audio and visual platform), it did not do the same for RHCs and FQHCs; telephone-only services still will be reimbursed at $24.76.
If you have questions related to this updated telehealth reimbursement information, or would like additional guidance related to COVID-19, visit our COVID-19 hub, or contact one of our PYA executives below at (800) 270-9629.
Disclaimer: To the best of our knowledge, this information was correct at the time of publication. Given the fluid situation, and with rapidly changing new guidance issued daily, be aware that some or all of this information may no longer apply. Please visit our COVID-19 hub frequently for the latest updates, as we are working diligently to put forth the most relevant helpful guidance as it becomes available.