MGMA – Medicare Telehealth Waivers During the COVID-19 Public Health Emergency

Medicare Telehealth Waivers During the COVID-19 Public Health Emergency -Last Updated March 31, 2020- The Department of Health & Human Services (HHS) has instituted several flexibilities that waive many of the generally applicable rules governing Medicare telehealth services in response to the COVID-19 public health crisis.

These flexibilities have been implemented incrementally, however this resource intends to provide a comprehensive overview of all telemedicine waivers issued to date. For more information, please contact MGMA Government Affairs at govaff@mgma.org or 202.293.3450. For the latest COVID19 developments impacting medical practices and information on waivers of other Medicare rules, visit the MGMA COVID-19 Action Center.

Under ordinary circumstances, the following rules apply to Medicare telehealth services:

1. The service must be furnished via an interactive telecommunications system (“modality”); • Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting twoway, real-time interactive communication between the patient and distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.

2. The service must be furnished by a physician or other authorized practitioner (“distant site practitioner”);

3. The individual receiving the service must be located in a telehealth originating site, which generally must be a clinical site of service, such as a physician office, critical access hospital (CAH), hospital, SNF, or community mental health center (“qualifying originating sites”);

4. The qualifying originating site must be located in certain geographic areas, such as a health professional shortage area within rural census track (“geographic limitation”); and

5. The service must be on the list of covered codes (“covered codes”). Waivers Modality: Telehealth services may now be furnished via telephone or other qualifying device so long as the device has both audio and video capabilities. While it appears that the Centers for Medicare & Medicaid Services (CMS) is continuing to require that devices/telephones have audio and video capabilities for the list of Medicare covered telehealth codes, the Agency is permitting audio-only communications through CPT codes 99441-99443 and 98966- 98968,which are telephone E/M visits. These codes were not previously covered by Medicare and MGMA is awaiting further billing guidance and valuation information on these newly covered codes.

Distant Site Practitioner: Qualified healthcare professionals may furnish telehealth services from their own home (i.e., they are not required to be at their office when furnishing telehealth to patients). Specifically, CMS states that: “There are no payment restrictions on distant site practitioners furnishing Medicare telehealth services from their homes.” While previous guidance required that providers furnishing telehealth services from their homes update their enrollment files to reflect their home address, CMS recently relaxed this requirement and now provides the following billing guidance: “The practitioner is not required to update their Medicare enrollment with the home location. The practitioner 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.”

Qualifying Originating Sites: Originating site restrictions are waived, permitting clinicians to furnish services to patients that are in their homes or other locations.

Geographic Limitations: Geographic limitations are also waived, permitting clinicians to furnish services to patients located in any geographic area of the country, regardless of whether it is rural, urban, etc. Covered Codes: CMS expanded the list of ordinarily covered codes to now include more than 80 additional codes during the public health emergency. The full list of codes eligible for telehealth are listed here. In addition to these codes, CMS will also cover CPT codes 99441-99443 and 98966-98968, which are telephone E/M visits, and may be furnished using audio-only modalities.

Additional Waivers Applicable to Medicare Telehealth Licensing: CMS has temporarily waived the requirement that physicians or other healthcare professionals hold licenses in the state in which they provide services if they have an equivalent license from another state and are enrolled in Medicare. This licensing waiver applies to Medicare and Medicaid billing and does not have the effect of waiving State or local licensure requirements or any other requirement specified by the State or a local government. HIPAA: The HHS Office for Civil Rights (OCR) will waive penalties under HIPAA violations against healthcare providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype. OCR advises that providers should not use modalities that are public facing, such as Facebook Live or Tik Tok.

Beneficiary Cost-sharing: Ordinarily, the routine reduction or waiver of costs owed by Medicare beneficiaries, including coinsurance and deductibles, potentially implicate the Federal Anti-kickback Statute, the civil monetary penalty rule, and exclusion laws. The HHS Office of Inspector General (OIG) issued guidance stating it not subject physicians and other practitioners to OIG administrative sanctions for arrangements regarding reduced or waived cost-sharing for telehealth or other non-face-to-face services (i.e., virtual visits or evisits) during the COVID-19 public health emergency.

Beneficiary Consent: Beneficiary consent should not interfere with the provision of telehealth services. Annual consent may be obtained at the same time (i.e., not necessarily before) the time that services are furnished.

Removal of Frequency Limitations: The following services no longer have limitations on the number of times they can be provided by Medicare telehealth:

• A subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233);

• A subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days (CPT codes 99307-99310); and

• Critical care consult codes may be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation (CPT codes G0508-G0509).

End Stage Renal Disease (ESRD) Services: For Medicare patients with ESRD, clinicians no longer must have one “hands on” visit per month for the current required clinical examination of the vascular access site. CMS is also exercising enforcement discretion on the following requirement so that clinicians can provide this service via telehealth: Individuals must receive a face-to-face visit, without the use of telehealth, at least monthly in the case of the initial 3 months of home dialysis and at least once every 3 consecutive months after the initial 3 months.

Nursing Home Residents: CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.

Additional Billing Guidelines Place of Service: Medicare telehealth services are generally billed as if the service has been furnished in-person. Meaning, the claim should reflect the designated Place of Service (POS) code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. However, for distant site practitioners billing under the CAH Optional Payment Method II on institutional claims, the GT modifier will be required. If you are performing telehealth services “through an asynchronous telecommunications system” you must use the GQ modifier.

Virtual Care Codes Virtual Check-ins, E-Visits, and Remote Patient Monitoring (RPM): Clinicians can provide virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. Virtual check-in services were previously limited to established patients.

Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits (HCPCS codes G2061-G2063). Clinicians can provide RPM services to both new and established patients. These services can be provided for both acute and chronic conditions and can now be provided for patients with only one disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry (CPT codes 99091, 99457-99458, 99473- 99474, 99493-99494). For billing requirements for these services, please see MGMA’s Medicare Communication-basedTechnology Codes resource (note this guidance does not reflect instituted waivers, but provides general information about use of these codes).

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