Telemedicine and Telehealth

Delivering health care services using telecommunications or information technology.

Emergency Declarations
COVID-19 Payor Policies
COVID-19 Vendors
Implementing Telemedicine
Contract Language
Policy and Procedures
Vendors
Education/Webinars
Payor Policies
Rules and Legislation

COVID-19 Telehealth Emergency Declarations


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.  In addition, 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. This CMS Fact Sheet describes COVID flexibilities and CMS has also issued an FAQ to provide more instruction. Information on the various PHE waivers can be found on the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers resource.

The Consolidated Appropriations Act 2023 extends many of the prominent Medicare telehealth flexibilities through Dec. 31, 2024. The extended flexibilities include:
The ability to see a patient in their own home regardless of geographic location 
An expanded list of eligible practitioners 
The ability for federally qualified health centers and rural health clinics to be distant site providers 
The ability to provide audio-only visits to patients 
The delay of the in-person visit requirement before a patient receives mental health visits

Medicare Telemedicine and Virtual/E-Visits Billing Guide  - 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 Medicare virtual services physicians and other professionals can provide to Medicare beneficiaries during the COVID-19 Emergency Declaration period - 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;
  • 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  non-physician 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 geographical areas, not just rural,  new (during the PHE) and 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 seven 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. More information on Virtual Check-Ins is available from CMS. 

3. E-Visits: In all types of physical locations, including the patient’s home, all geographical areas, not just rural, and for new (during the PHE) and established patients, 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 seven-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. More information on E-Visits is available from CMS.

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 has increased to bring payments 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 non-physician 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. Claims must be submitted with modifier 95 and the place of service code you would normally have sees the patient (usually POS 11) to receive payment parity.

Find additional information on Medicare telehealth during COVID-19 on the CMS letter to clinicians.   

MEDICAID
Medicaid, Medicaid managed care organizations (MCOs), and the Healthy Texas Women Program continuously update their coverage polices. Consult their COVID-19 page for updates and guidance (note the Recent News column on the right side of the page for specific notices). Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

CHRONIC PAIN PATIENTS
The TMB updated Ch. 174 of the Texas Administrative code making the Emergency Rule permanent effective Oct. 7, 2021. For further guidance, please review the TMB COVID-19  page, and the DEA’s COVID-19 website for federal requirements.

COVID-19 PAYOR POLICY NOTICES
Please verify benefits, coverage, and coding guides for all plans prior to rendering telemedicine services. You may also consult the TMA Practice Viability Toolkit for coding help.


Special Coding Advice: 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.  

COVID-19 TELEMEDICINE VENDORS



Standard Telemedicine Information (pre-COVID-19)

 

IMPLEMENTING TELEMEDICINE IN YOUR PRACTICE

If your organization is considering implementing a telemedicine program but you currently have limited experience with telehealth systems, please review the following information to assist you and your practice in this process. 

Contract Language:
Contracts are a necessary part of any telemedicine venture. A telemedicine service contract will share many of the same contracting concerns as an EHR, such as who owns the equipment, who owns the data, and expectations around service call timing, up-time, software updates and turnaround times. Agreements made with telemedicine providers or technology vendors should be reviewed to ensure that insurance provisions include mutual hold-harmless and indemnification language and that adequate insurance coverage is required. Confer with legal counsel to determine which state laws apply to the organization’s telemedicine services, monitor changes in applicable regulations and take steps to ensure that procedures for education and compliance are in place. The American Society for Health Care Risk Management has developed a white paper discussing Telemedicine Risk Management Considerations

The Coker Group offers TMA/HCMS physician members free technology contract review services. Coker Group is a member of TMA-approved Group Discount Programs.

Policy and Procedures:
Although telemedicine has the potential to improve several aspects of medical care, such as facilitating physician-patient communication and monitoring treatment of chronic conditions, telemedicine poses unique challenges in ensuring patient-safety and privacy of health information. Therefore, it is prudent for telemedicine providers to develop a comprehensive set of policies and procedures (P&P).

The TMA has developed templates to assist practices in developing their own P&P. These can be found under the section titled “Policies, Procedures and Forms for Telemedicine Services” on their own P&P. These can be found under the section titled “Policies, Procedures and Forms for Telemedicine Services” on their Telemedicine web page.  

Additionally, organizations considering telemedicine or adding new telemedicine technologies to an already existing panel of services must consider how the new or added services will be incorporated into privacy and security policies, procedures, and workflows. For example:
  • Incorporate telemedicine into the Notice of Privacy Practices. 
  • Include telemedicine equipment in the organization’s Security Management Plan and annual Security Risk Assessment. 
  • Ensure all staff and providers who participate in telemedicine services have received telemedicine specific healthcare privacy and security training. 
  • Determine the need for Business Associate Agreements. Evaluate all parties, including any vendors involved in the provision of services, for compliance with federal and state privacy and confidentiality regulations, and require the ability to provide proof compliance if asked. Require telemedicine vendors to hold their subcontractors accountable as well.
Vendors:
After reviewing and understanding payor policies (see above for COVID policies and below for standard policies) and ensuring you will receive proper payment for conducting telemedicine services, below are resources to help identify a vendor that fits your needs. 

Educational Resources/Webinars:
The TMA has developed a comprehensive web page of resources to assist in the implementation of telemedicine including a Getting Started Guide.

Additionally, the TMA has a multitude of telemedicine webinars which offer CME credit and are free to members: 

The AMA has developed a Quick Guide to Telemedicine in Practice  which includes a Telemedicine Implementation Playbook (available for download) designed to support physicians and practices in expediting the implementation of telemedicine. The AMA also offers resources “Digital Leadership” and a free Telemedicine Module within their Steps Forward program which provides 0.5 CME credits. 

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.

PAYOR POLICIES

In general, most State telemedicine legislation only applies to fully-insured plans (TDI or DOI on front of patients insurance card), 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 payor telemedicine policies outside of the COVID-19 crisis. 
RULES AND LEGISLATION

Please review TMA's white paper on Texas Laws and Regulations Relating to Telemedicine.

Note: The information provided on this fact sheet 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 fact sheet may not constitute the most up-to-date legal or other information. 

Below are the current TMA policies as related to telemedicine: