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; will expire with the end of the PHE.
- Waive originating site restrictions, meaning patients can receive telehealth services in their home; will expire with the end of the PHE.
- 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.
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.
However, these codes will no longer be covered when the PHE ends. Therefore, for CY 2021, on an interim basis, G2252 (virtual check-in) has been established with payment equivalent to CPT code 99442. 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. 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. These services will only be covered through the duration of the PHE.
Find additional information on Medicare telehealth during COVID-19 can be found on the CMS letter to clinicians
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 emergency waivers were effective through September 12, 2020
This waiver only applied 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. However, payors agreed to continue this policy through the end of 2020.
- 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 TDI Emergency Rule FAQ
Some Medicaid and Children’s Health Insurance Program (CHIP) flexibilities
put in place during the COVID-19 pandemic have been extended through Sept. 30, 2021
. 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. 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.
The extension of the flexibilities includes allowing payments for Texas Health Steps visits provided via telemedicine to children older than age 24 months. To be paid for the services, physicians must 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.
Chronic Pain Patients:
Throughout the COVID-19 pandemic, the Texas Medical Board (TMB) has continuously issued an Emergency Rule allowing physicians to utilize telemedicine for issuing previous prescriptions for scheduled medications to established chronic pain patients, if the physician has, within the past 90 days, seen a patient in-person or via a telemedicine visit using two-way audio and video communication. The TMB has now updated Ch. 174.5
of the Texas Administrative code making the Emergency Rule permanent effective Oct. 7. For further guidance, please review the TMB’s telemedicine FAQs
, TMB COVID-19 page
, as well as the DEA’s COVID-19 website
for federal requirements.
Prompt Payment Extension:
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 PAYOR POLICY NOTICES
The Texas telemedicine waivers discussed above are specific to fully-insured plans (TDI or DOI on insurance card)/ They will dictate what plans are required to do during the COVID-19 crisis (despite what is stated on payor 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 Practice Viability Toolkit
for coding help. The MGMA also has developed a telemedicine chart
of payor policies. Consult the TMA Waiver Dates chart
for payor telemedicine policy waiver dates. This information is subject to change frequently. In addition, many health plans have extended their telemedicine waivers. Find additional information on this TMA resource,
but always verify with the patients plan as the information is subject to change.
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.
Policy and Procedures:
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.
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.
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.
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.
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 our HCMS Telemedicine Rules & Legislation Fact Sheet
for links to and a review of Texas telemedicine rules and laws. TMA also has a 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: