MEDICARE EXPANSION OF TELEHEALTH WITH 1135 WAIVER:
Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 1, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. The telehealth waiver will be effective until the public health emergency (PHE) declared by the Secretary of HHS on January 31, 2020 ends.
Medicare Telemedicine and Virtual/E-Visits Billing Guide - for specifics on billing Medicare for these services. Medicare Advantage Plans do not have to comply with the Medicare waivers and may have telemedicine benefits that differ from traditional Medicare (FFS).
There are four main types of virtual services physicians and other professionals can provide to Medicare beneficiaries during the COVID-19 Emergency Declaration period: Medicare telehealth visits, virtual check-ins, e-visits, and telephone services:
1) Telehealth/Telemedicine Visits - Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.
Key points of the Medicare COVID-19 Waiver, Interim Final Rule 1, Interim Final Rule 2:
- These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits (see coding note below).
- Waive geographic restrictions, meaning patients can receive telehealth services in non-rural areas;
- Waive originating site restrictions, meaning patients can receive telehealth services in their home;
- Allow use of telephones that have audio and video capabilities;
- Allow reimbursement for any telehealth covered code, even if unrelated to COVID-19 diagnosis, screening, or treatment;
- Not enforce the established relationship requirement that a patient see a provider within the last three years (therefore patient may be new or established).
- HHS will not impose penalties for noncompliance with HIPAA. Providers can use any non-public facing remote communication product that is available to communicate with patients. Applications that are non-public facing include but are not limited to Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype. Public facing applications like Facebook Live, Twitch, TikTok, etc. are not allowed. Additional information can be found at this notice from Department of Health and Human Services (HHS).
- Removal of frequency limitations on Medicare telehealth for subsequent inpatient visits (CPT 99231-99233), subsequent skilled nursing visits (CPT 99307-99310), and critical care consult codes (CPT G0508-G0509).
- Physician supervision of nonphysician practitioners (NPP) can be provided virtually using real-time audio/visual technology for services requiring direct supervision by a physician or other practitioner.
CMS has developed a toolkit
with electronic links to reliable sources of information on telemedicine to help providers learn about the general concept of telehealth, choose telemedicine vendors, initiate a telemedicine program, monitor patients remotely, and develop documentation tools.
2) Virtual Check-Ins
- In all areas (not just rural), new (during the PHE) as well as established patients from their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. The communication cannot be 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. Find more information here
- In all types of locations including the patient’s home, and in all areas (not just rural), and for new (during the PHE) as well as established patients during the PHE, 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. Patients 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. Find more information here
4) Telephone (audio only)
- CMS has increased reimbursement rates for telephone evaluation and management services provided by a physician (CPT 99441-99443).
Payment for these codes are normally in the range of about $14-$41 and have increased to about $46-$110 to bring payments for these codes equal to Medicare’s established in person visit codes. This payment rate increase will be retroactive to March 1, 2020
. CMS will also reimburse telephone assessment and management services provided by a qualified nonphysician healthcare professional (CPT 98966-98968) but at the standard rate. These codes are available to new or established patients and may be furnished using audio-only devices. Corrected claims must be filed with modifier 95 and the place of service you normally would see the patient (usually POS 11) to receive the increased payment for claims filed prior to the waiver.
Find additional information on Medicare telehealth during COVID-19 here
TEXAS TELEMEDICINE EMERGENCY RULE WAIVERS:
Governor Greg Abbott waived certain regulations and directed that the Texas Department of Insurance (TDI) issue an emergency rule, all relating to telemedicine care for patients with state-regulated insurance plans to help doctors across Texas continue to treat their patients while mitigating the spread of COVID-19.
This waiver only applies to fully-funded plans (TDI or DOI will be on the insurance card):
- Pay in-network health professionals at least the same rate for telemedicine services as for in-person services, including covered mental health services.
- Cover telemedicine services using any platform permitted by state law (with the same HIPAA flexibilities mentioned in the Medicare waiver above) including the telephone (audio only telephone must be initiated by the patient).
- May establish a physician-patient relationship by telephone.
For additional information please review the TMB FAQs Regarding Telemedicine During Texas Disaster Declaration for COVID-19 Pandemic
- Effective March 20 and now extended through June 30
(payments were previously set to expire April 30), Medicaid, Medicaid managed care organizations (MCOs), and Healthy Texas Women Program
will pay for audio-only telephone consultations
as authorized by TMB. The Texas Health and Human Services Commission (HHSC) said covered evaluation and management CPT codes are 99201-05 and 99211-15 and should be billed with the -95 modifier. Medicaid and Medicaid MCOs also will pay for certain behavioral services provided over the telephone
. Additionally, effective immediately, HHSC will pay federally qualified health centers as telemedicine
and telehealth service distant site providers.
HHSC announced on 5/8/2020 it would temporarily allow payments for Texas Health Steps visits provided via telemedicine during May to children older than age 24 months. To be paid for the services, physicians must provide the services between May 7 to May 31, bill using the 95 modifier, document within the medical record reason why certain components of the exam could not be completed in person, and complete those components within 6 months of the telemedicine visit. Good-cause exceptions to the 6 month follow-up visit include the patient changing physicians, changing Medicaid managed care plans, moving, or losing Medicaid coverage, among others. More information can be found on the notice: Texas Health Steps Checkups Guidance Effective May 7 2020 to May 31 2020
Chronic Pain Patients
Prompt Payment Extension
- Governor Abbott approved TMB's request to temporarily suspend Title 22, Chapter 174.5 (e) (2)(A) of the Texas Administrative Code. This waiver allows telephone refill(s) of a valid prescription for treatment of chronic pain by a physician with an established chronic pain patient. This suspension is in effect until June 6, 2020
. For further guidance, please review the TMB’s telemedicine FAQs
, as well as the DEA’s COVID-19 website
for federal requirements.
- The prompt pay deadlines have been extended to allow an additional 15 days for timely claims payment. Read the bulletin
for additional information.
COVID-19 PAYER POLICY NOTICES:
Special Coding Advice
The Texas telemedicine waivers discussed above are specific to fully-insured plans (TDI or DOI on insurance card) and will dictate what plans are required to do during the COVID-19 crisis (despite what is stated on payer policy). Self-funded plans are not subject to the above waivers and will have separate telemedicine policy information outlined, please verify benefits for all self-funded plans. Consult the TMA billing chart and the TMA Practice Viability Toolkit for coding help. The MGMA also has developed a telemedicine chart of payer policies. This information is subject to change frequently. Please verify coding policy with the patient's plan.
- AMA has developed these coding scenarios
to assist in applying best coding practices during this public health crisis. Be sure to append the applicable modifier.
Standard Telemedicine Information (pre-COVID-19)
In general, most State telemedicine legislation only applies to fully-insured plans, thus coverage for telemedicine varies by plan and patients benefits. It is imperative to verify coverage prior to rendering telemedicine services.
Standard Policy Notices:
Below are links to standard payer telemedicine policies outside of the COVID-19 crisis. The TMA has developed Telemedicine Payers Quick Reference Chart to further assist in identifying payer requirements. This information is subject to change. Please verify with the patient's plan.
After reviewing and understanding payer policies and ensuring you will receive proper payment for conducting telehealth services, below are resources to help identify a vendor that fits your needs.
Rules & Legislation
Please review our HCMS Telemedicine Rules & Legislation Fact Sheet for links to and a review of Texas telemedicine rules and laws.
Note: The information provided on this factsheet does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available are for general informational purposes only. Information on this factsheet may not constitute the most up-to-date legal or other information.
American Telemedicine Association (ATA)
Texas Medical Association (TMA)
The American Telemedicine Association has many resources, educational courses and events. The ATA is a non-profit association with a membership network of thousands of industry leaders and healthcare professionals.
American Health Insurance Plans (AHIP)
American Medical Association (AMA)
Telehealth Connects Patients and Doctors in Real Time - A brief, November 2017.