Coding and Billing for Telehealth Services During COVID-19 Public Health Emergency

The revenue code selected should be the same as the revenue code that would be used if the patient was receiving services in the outpatient department of the hospital. The Centers for Medicare & Medicaid Services (CMS) has stated that items and services provided via telecommunications technology to a patient in a temporarily relocated off-campus provider-based department of the hospital, which may be the patient’s home, in accordance with the extraordinary circumstances policy are considered to be face-to-face visits and should be coded and billed as though the service was occurring in person in the outpatient department of the hospital. (05/05/2020)

Yes. CMS stated that hospitals may relocate part of their excepted provider-based departments to a new-off campus location while maintaining the original location.¹ (05/05/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 42 (April 30, 2020)

Yes. CMS is allowing both excepted off-campus and on-campus provider-based departments to provide services at temporarily relocated off-campus locations in accordance with the extraordinary circumstance exception outlined in the interim final rule, CMS-5531-IFC, to begin furnishing and billing for services in the new location(s) prior to submitting documentation to the CMS Regional Office in support of the extraordinary circumstances relocation request. Note that the request must be submitted to the Regional Office within 120 days of beginning to provide services at the relocated off-campus location(s).¹ (05/05/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 40 (April 30, 2020)

Yes. All hospitals that are applying for an extraordinary circumstance relocation exception in response to the COVID-19 public health emergency should notify their CMS Regional Office by email within 120 days of beginning to provide services in the new off-campus location(s) and include the following information: 1) The hospital’s CMS Certification Number (CCN); 2) the address of the current provider-based department (PBD); 3) the address(es) of the relocated PBD(s); 4) the date which they began furnishing services at the new PBD(s); 5) a brief justification for the relocation and the role of the relocation in the hospital’s response to COVID-19; and 6) an attestation that the relocation is not inconsistent with their state’s emergency preparedness or pandemic plan.¹ Additionally, CMS reiterated during the CMS Office Hours call on May 7, 2020, that addresses must be provided for each of the locations to which the hospital outpatient department is temporarily relocating. The email may contain multiple addresses or may be in the form of a spreadsheet, but hospitals are reminded that the information must be encrypted and should not include unnecessary protected health information (PHI), such as patient names. (05/05/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 41 (April 30, 2020)

No. Non-excepted off-campus departments will continue to be non-excepted during the COVID-19 public health emergency even if they relocate and will continue to be paid at the PFS-equivalent rate.¹ These non-excepted off-campus provider-based departments will therefore continue to bill for their services using modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, when services are provided in temporarily relocated departments of the hospital, which may include the patient’s home. (05/05/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 41 (April 30, 2020)

No. When therapy services are provided in a temporarily relocated off-campus provider-based department by the hospital’s clinical staff using telecommunications technology, the therapy services would be billed as though they were provided face-to-face. Note that services must be provided in accordance with the appropriate level of supervision and the hospital must ensure the location(s) meet all of the conditions of participation, except for the conditions of participation that have temporarily been waived during the public health emergency. Also, if therapy services are not provided by clinical staff of the hospital, the hospital would not bill for these services. If the hospital plans to seek an exception under the extraordinary circumstance relocation policy for their on-campus or excepted off-campus department, modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, would be appended to the Current Procedural Terminology (CPT®) or HCPCS procedure code(s) that describes the service(s) provided. If the therapy services are normally provided in a non-excepted off-campus provider-based department or if the facility does not plan to seek an exception under the extraordinary circumstance relocation policy, modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, would be appended to the procedure code(s). CMS has published a list of the outpatient therapy, counseling, and educational services that hospital clinical staff may furnish incident to a physician’s service during the COVID-19 public health emergency.¹ (05/05/2020)

¹List of Hospital Outpatient Services and List of Partial Hospitalization Program Services Accompanying the 4/30/2020 IFC (April 30, 2020)

CMS has not provided specific guidance on revenue codes that must be billed with HCPCS code G2025, Distant site telehealth services provided by an RHC/FQHC. CMS’ only guidance regarding revenue codes for services provided in an RHC is that an appropriate four-digit revenue code should be entered for each type of service provided to explain each charge. It should be noted that telehealth distant site services furnished between January 27, 2020 and June 30, 2020 are to be reported using modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System. For telehealth distant site services furnished between July 1, 2020 and the end of the public health emergency, RHCs will use HCPCS code G2025 to identify services that were furnished via telehealth.¹ (05/05/2020)

¹MLN Matters SE20016, “New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)”, page 2 (April 30, 2020)

Modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, would be assigned when items and services are provided to registered patients of a hospital on-campus department or to registered patients of an excepted hospital off-campus provider-based department that has temporarily relocated under the extraordinary circumstances policy outlined in the interim final rule. Modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, would be assigned when items and services are provided to registered patients of a hospital non-excepted off-campus provider-based department or when the hospital chooses not to pursue temporary relocation of the hospital department under the extraordinary circumstances policy.¹ Under the temporary relocation exception, hospitals may temporarily relocate a portion of each of their outpatient departments to multiple off-campus locations; these locations may include the patients’ homes. Hospitals that opt to temporarily relocate their outpatient departments, or a portion of each department, under this provision must submit a request to their CMS Regional Office no later than 120 days following the date they begin providing services at one or more of these off-campus locations. The temporary relocation sites will be considered excepted off-campus provider-based departments of the hospital for the duration of the public health emergency and will be reimbursed for services provided using telecommunications technology at a rate which is equivalent to the rate that would be received if the services were provided during a face-to-face visit in the hospital outpatient department. (05/05/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, pages 37-46 (April 30, 2020)

Yes. CMS has waived the requirements which specify the types of practitioners that may bill for their services when furnished as Medicare telehealth services from the distant site. The waiver of these requirements expands the types of healthcare professionals that can furnish distant site telehealth services to include all those that are eligible to bill Medicare for their professional services. This includes physical therapists, occupational therapists, and speech language pathologists.¹ (05/05/2020)

¹“Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19”, pages 1-2 (April 30, 2020)

CMS has not addressed this particular circumstance, although they do note in the final rule that therapy services can effectively be furnished using telecommunications technology. They do, however, address the use of audio only to provide partial hospitalization program (PHP) services remotely. Specifically, they state that their expectation is that PHP services would be provided using telecommunications technology that includes both audio and video but that these services may be provided using audio only in cases where both audio and video are not accessible.¹ They further note that audio-only services should not be provided in cases where the provider feels that the services cannot adequately be performed using audio-only communication. (05/05/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, pages 47-50 (April 30, 2020)

CMS stated during the CMS Office Hours calls of May 5, 2020, and May 7, 2020, that they expect hospitals to bill the most appropriate code(s) for the services they are providing.¹ In other words, if the hospital is using facility resources above and beyond the costs associated with the telecommunications technology, including using hospital auxiliary staff to obtain patient history, record available vital signs, coordinate the discharge instructions, provide patient education, or similar tasks, then it may be appropriate to report an E/M visit charge. If, however, the hospital is not expending facility resources outside of the resources utilized to initiate the telehealth visit, it is likely more appropriate to report HCPCS code Q3014, Telehealth originating site facility fee, to cover the costs associated with providing the visit utilizing telecommunications technology.² (05/05/2020)

¹CMS Outreach and Education, “CMS Office Hours,”

²CMS Outreach and Education, “Thursday, May 7, 2020 CMS Office Hours,”

Yes. CMS stated during the CMS Office Hours call of May 7, 2020, that hospitals who do not plan to seek an exception under the extraordinary circumstances relocation policy may bill for services provided to registered patients of the hospital using telecommunications technology by appending modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, to those services. The services will then be reimbursed at the PFS-equivalent rate, which is currently 40% of the OPPS rate. (05/05/2020)

Auxiliary staff of the hospital, which includes registered dietitians, may provide services incident to a physician’s or NPP’s services, as long as they are operating under their state scope-of-practice laws and under the appropriate level of supervision. State regulations may dictate what particular services may be provided. For a registered dietician, these services may include medical nutrition therapy, CPT® codes 97802-97804 or HCPCS codes G0270-G0271, or diabetes self-management training services, HCPCS codes G0108-G0109.¹ (05/05/2020)

CMS instructions for DSMT services indicates that revenue code 0942 – OTHER THERAPEUTIC SERVICES (ALSO SEE 095X, AN EXTENSION OF 094X) – EDUCATION/TRAINING should be used when reporting these services.²
(05/06/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, pages 46-47 (April 30, 2020)

²Publication 100-02 Medicare Benefit Policy Manual, “Chapter 15 Covered Medical and Other Health Services, Subsection 300.5.1 Payment for DSMT, Special Claims Processing Instructions”, pages 272-273 (July 2, 2007)

As a Critical Access Hospital (CAH) Method II facility, you may submit the charge for the E/M level, such as 99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family, with modifier GT, Via interactive audio and video telecommunication systems,¹ to report the physician’s professional service.

If you request an exception to temporarily relocate to an off-campus location (which may be the patient’s home) under the extraordinary circumstances policy outlined in the interim final rule, then you may submit the charges as you would have done had the patient come into your facility.² In this instance, you may also be using other modifiers and condition codes, such as Condition Code DR, Disaster Related, or modifier CR, Catastrophe/Disaster Related,³ etc. As a CAH, you are exempt from reporting modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, and modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments.⁴

To apply for the extraordinary circumstance relocation exception, the following information should be sent to your Centers for Medicare & Medicaid Services (CMS) Regional Office within 120 days of the date that services are first provided in the new off-campus location(s): 1) The hospital’s CMS Certification Number (CCN); 2) the address of the current provider-based department (PBD); 3) the address(es) of the relocated PBD(s); 4) the date which they began furnishing services at the new PBD(s); 5) a brief justification for the relocation and the role of the relocation in the hospital’s response to COVID-19; and 6) an attestation that the relocation is not inconsistent with their state’s emergency preparedness or pandemic plan.⁵ The email may contain multiple addresses or may be in the form of a spreadsheet, but hospitals are reminded that the information must be encrypted and should not include unnecessary protected health information (PHI), such as patient names.
(05/06/2020)

¹Transmittal R2095OTN, “Revisions to the Telehealth Billing Requirements for Distant Site Services” (June 20, 2018)

²Hospitals: CMS Flexibilities to Fight COVID-19, “CMS Hospital Without Walls Temporary Expansion Sites)”. Page 5 (April 29, 2020)

³“COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing”, page 10 (May 1, 2020)

⁴The Social Security Act, “Payment of Benefits, Section 1833(t)(21)”

⁵CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 41 (April 30, 2020)

Therapy services that are provided in a temporarily relocated off-campus provider-based department by the hospital’s clinical staff using telecommunications technology would be billed as though they were provided face-to-face. Note that services must be provided in accordance with the appropriate level of supervision and the hospital must ensure the location(s) meet all of the conditions of participation, except for the conditions of participation that have temporarily been waived during the public health emergency. Also, if therapy services are not provided by clinical staff of the hospital, the hospital would not bill for these services. If the hospital plans to seek an exception under the extraordinary circumstance relocation policy for their on-campus or excepted off-campus departments, modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, would be appended to the Current Procedural Terminology (CPT®) or HCPCS procedure code(s) that describes the service(s) provided. If the therapy services are normally provided in a non-excepted off-campus provider-based department or if the facility does not plan to seek an exception under the extraordinary circumstance relocation policy, modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, would be appended to the procedure code(s). CMS has published a list of the outpatient therapy, counseling, and educational services that hospital clinical staff may furnish incident to a physician’s service during the COVID-19 public health emergency.¹ (05/06/2020)

¹List of Hospital Outpatient Services and List of Partial Hospitalization Program Services Accompanying the 4/30/2020 IFC (April 30, 2020)

No. It would never be appropriate to report both a clinic visit and an originating site fee for the same patient. CMS stated during the CMS Office Hours calls of May 5, 2020, and May 7, 2020, that they expect hospitals to bill the most appropriate code(s) for the services they are providing.¹ In other words, if the hospital is using facility resources above and beyond the costs associated with the telecommunications technology, including using hospital auxiliary staff to obtain patient history, record available vital signs, coordinate the discharge instructions, provide patient education, or similar tasks, then it may be appropriate to report an E/M visit charge. If, however, the hospital is not expending facility resources outside of the resources utilized to initiate the telehealth visit, it is likely more appropriate to report HCPCS code Q3014, Telehealth originating site facility fee, to cover the costs associated with providing the visit utilizing telecommunications technology. (05/06/2020)

¹CMS Outreach and Education, “CMS Office Hours,”

During the May 7, 2020, CMS Office Hours Call (which was after this webinar), CMS stated that you could append modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, without seeking temporary relocation of the hospital department under the extraordinary circumstances exception outlined in the interim final rule, CMS-5531-IFC¹ Procedures that are billed with modifier PN appended will be reimbursed at the Physician Fee Schedule (PFS)-equivalent rate, which is currently 40% of the Outpatient Prospective Payment System (OPPS) rate. (05/06/2020)

¹CMS Outreach and Education, “Thursday, May 7, 2020 CMS Office Hours,”

When therapy services are provided in a temporarily relocated off-campus provider-based department by the hospital’s clinical staff using telecommunications technology, the therapy services would be billed as though they were provided face-to-face. Note that services must be provided in accordance with the appropriate level of supervision and the hospital must ensure the location(s) meet all of the conditions of participation, except for the conditions of participation that have temporarily been waived during the public health emergency. Also, if therapy services are not provided by clinical staff of the hospital, the hospital would not bill for these services. If the hospital plans to seek an exception under the extraordinary circumstance relocation policy for their on-campus or excepted off-campus department, modifier PO, Services, procedure and/or surgeries provided at off-campus provider-based outpatient departments, would be appended to the CPT® or HCPCS procedure code(s) that describes the service(s) provided. If the therapy services are normally provided in a non-excepted off-campus provider-based department or if the facility does not plan to seek an exception under the extraordinary circumstance relocation policy, modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, would be appended to the procedure code(s). CMS has published a list of the outpatient therapy, counseling, and educational services that hospital clinical staff may furnish incident to a physician’s service during the COVID-19 public health emergency.¹ (05/06/2020)

¹List of Hospital Outpatient Services and List of Partial Hospitalization Program Services Accompanying the 4/30/2020 IFC (April 30, 2020)

In this instance, the facility’s Intensive Care Unit (ICU) room & board rate will cover the facility’s resources. If the physician is providing telehealth services to an inpatient, there are several CPT®/HCPCS codes that could be used to report the professional service charges for the physician depending upon the services that are provided. Unless provided otherwise, services included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site, although there is a waiver for behavioral health counseling and educational services as long as the healthcare provider feels that services can be adequately performed using audio only.¹ (05/06/2020)

¹Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, page 1 (April 29, 2020)

CMS has given no indication at the current time that they will be providing an exception to this requirement. In fact, they may be unable to provide this exception as the law requires that hospitals may only bill for services provided at the hospital or at an authorized off-campus department of the hospital. The law further requires that addresses where services are provided must be on file with the CMS Regional Office. Hospitals that are seeking to temporarily relocate one or more of their departments under the extraordinary circumstance exception must provide the address(es) where services will be provided to meet this requirement of the existing law. (05/06/2020)

Audio/video would be a type of video chat functionality, and includes Facebook Messenger video chat, Google Hangouts, Zoom, or Skype. Services such as Facebook Live, Twitch or TikTok are public-facing and should not be used.¹ CMS has discovered that there are instances where video is unable to be used, and has increased the Relative Value Units (RVUs) for CPT® codes 99441-99443 which describe telephone services. CMS has additionally identified several other services that may be performed using audio-only communication for certain situations.² (05/06/2020)

¹“Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency,” (March 30, 2020)

²CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, pages 137-141 (April 30, 2020)

CMS stated during the CMS Office Hours calls of May 5, 2020, and May 7, 2020, that they expect hospitals to bill the most appropriate code(s) for the services they are providing.¹ In other words, if the hospital is using facility resources above and beyond the costs associated with the telecommunications technology, including using hospital auxiliary staff to obtain patient history, record available vital signs, coordinate the discharge instructions, provide patient education, or similar tasks, then it may be appropriate to report an E/M visit charge. Remember that Emergency Department E/M levels are assigned based on hospital-specific criteria, and the level assigned should directly correlate with the facility’s resource utilization. If, however, the hospital is not expending facility resources outside of the resources utilized to initiate the telehealth visit, it is likely more appropriate to report HCPCS code Q3014, Telehealth originating site facility fee, to cover the costs associated with providing the visit utilizing telecommunications technology.² The facility would submit codes for the services provided using modifier PO, Services, procedures and/or surgeries provided at off-campus provider-based outpatient departments, if you plan to temporarily relocate under the extraordinary circumstances exception as outlined in the interim final rule, CMS-5531-IFC. If your exception is denied by the CMS Regional Office, then you will be required to resubmit the claims with modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital, and they will be reprocessed at the PFS-equivalent rate, which is currently 40% of the OPPS rate.³

These policies apply specifically to services provided to Medicare beneficiaries. Each individual payor may have their own guidelines and reimbursement policies related to telehealth services. It will likely be necessary to check with each payor regarding their specific policies to ensure accurate reimbursement for these services. (05/06/2020)

¹CMS Outreach and Education, “CMS Office Hours,”

²CMS Outreach and Education, “Thursday, May 7, 2020 CMS Office Hours,”

³CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, pages 37-39 (April 30, 2020)

Partial Hospitalization Program (PHP) services by definition must be furnished by a hospital or by a community mental health center (CMHC).¹ That being said, mental health providers would fall under the category of auxiliary personnel who may provide services incident to a physician’s, NPP’s or clinical psychologist’s plan of care, as long as the supervision levels are appropriate, the provider is functioning under their state’s scope-of-practice laws, and are not in conflict with the state’s emergency preparedness or pandemic regulations.² (05/06/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 49 (April 30, 2020)

²CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 20 (April 30, 2020)

CMS has stated that providers may use the place of service code that would have been used if the service been provided outside of the current public health emergency. Patients who routinely received telehealth services prior to the public health emergency would not require any changes when submitting claims during the current pandemic. Many providers did not routinely see patients via telehealth, and those providers are allowed to submit claims with the place of service code that reflects the usual location where patients are seen, rather than submit claims using place of service code ‘02’ and receive the lower facility rate.¹ CMS requests that modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, be appended for services provided via telehealth in these cases. An exception to this is CAH Method II claims, which should have modifier GT, Via interactive audio and video telecommunication systems, appended. Of note, modifier G0, Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke, is used when the services are for treatment of an acute stroke patient.

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 21 (April 10, 2020)

CPT® codes for telephone services 99441-99443 and 98966-98968 are not on the list of covered telehealth services, as telehealth services require audio and video communications.¹ These codes should be billed using place of service code where the provider is located, or would be located if there were no public health emergency. Generally, this will be POS 11, Office, but may be another location.²

¹Covered Telehealth Services for PHE for the COVID-19 Pandemic (March 1, 2020)

²Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, Interim Final Rule, page 89 (April 6, 2020)

Modifier CR, Catastrophe/disaster related, is not required to be reported on telehealth services.¹

¹Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19), page 2 (April 10, 2020)

Unfortunately, there has been no specific guidance issued for your scenario. Because the descriptor for CPT® code 99443, Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an 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; 21-30 minutes of medical discussion, contains the phrase “evaluation and management”, it may be possible to use prolonged E/M codes, such as 99354-99359, but the provider must provide services for at least 30 minutes beyond the time listed in the primary code description. If less than 30 minutes of additional service time is provided beyond the primary E/M service, a prolonged services CPT® code would not be assigned, according to the Prolonged Services guidelines published by the AMA.

Telehealth services require both audio/video communication, while a virtual check-in or e-visit is reported when a beneficiary communicates with their healthcare provider through an online patient portal without audio or visual communication.¹

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 22 (April 10, 2020)

Yes, CPT® codes 99201-99215 for outpatient office visits are currently the only E/M services that allow for the flexibility to use time or medical decision making (MDM) without the need for a history and exam component. This is similar to the changes that will be taking place for calendar year 2021. This guidance is for Medicare at this time, and individual payers may or may not follow suit.¹

¹Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency”, Interim Final Rule, pages 19268-19269 (April 6, 2020)

CPT® code 90853, Group Therapy, has been temporarily added to the list of approved telehealth services, and therefore this service may be reported when it is provided using audio/video communication by a provider who is qualified to provide telehealth services.¹ There are currently no CPT® or HCPCS codes that describe telephone (audio only) group therapy services. However, clinical psychologists and clinical social workers were recently added to the list of approved providers who may bill for telephone services and e-visits.

¹Covered Telehealth Services for PHE for the COVID-19 Pandemic (March 1, 2020)

Yes, a Critical Access Hospital may bill Method II for inpatient telehealth services, as long as the facility provider enrollment has been set up to do so. The physician would use audio/video to provide telehealth services, and both the physician services and the originating site fee would be reported. In this instance, modifier GT, Via interactive audio and video telecommunication systems, would be reported. HCPCS codes G0406-G0408, G0425-G0427, G0459 and G0508-G0509 are available for the physician’s use, as well as the other inpatient CPT® codes.¹

If the patient is physically located at the facility, HCPCS code Q3014, Telehealth originating site fee, would also be reported with modifier GT appended to the HCPCS code.

¹MLN Booklet for Telehealth Services (March 2020)

CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes except in rare cases. Providers are instructed to report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.¹ At the current time, revenue codes would rarely be assigned for telehealth services since billing for telehealth services is limited to professionals and would be reported on a CMS-1500 billing form.² An exception occurs when billing telehealth services under CAH Method II or when reporting HCPCS code Q3014, Telehealth originating site facility fee. When billing for telehealth services in one of these circumstances, it will be necessary to determine the location of your telehealth-related costs on your facility’s cost report in order to appropriately assign a revenue code.

¹Medicare Claims Processing Manual (Pub. 100-04), Chapter 4, Section 20.5

²Medicare Telehealth Frequently Asked Questions, Question #13

The Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency Interim Final Rule with Comment Period (IFC), states that PTs, OTs, and SLPs are not recognized as distant site providers who are eligible to provide telehealth services. Although some of the services commonly performed by these providers were recently added to the list of Medicare telehealth services, the qualified providers who may provide telehealth services has not changed as a result of the public health emergency.

Online assessments and e-visits, including HCPCS codes G2010, G2012, and G2061-G2063 and CPT® codes 98966-98968 and 98970-98972, are not considered telehealth services. In the IFC, PTs, OTs, and SLPs were added to the list of qualified providers who may provide online assessments and e-visits, along with clinical psychologists and licensed clinical social workers. Unfortunately, these procedures may only be reported on a professional claim form and are not reimbursable when submitted on the facility claim form.¹

As you noted, there has been a lot of discussion regarding this topic during the regular CMS calls. It is unclear at the current time whether CMS will change the current policies and allow a facility fee for telehealth services or e-visits during the public health emergency, but at the current time there is no provision for PTs, OTs, or SLPs to be able to perform telehealth services and no facility reimbursement for telehealth services.

¹Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, Interim Final Rule, pages 79-81 (April 6, 2020)

Communication between a patient and provider through a patient portal are considered to be e-visits or virtual check-ins, and may be reported using CPT® codes 98970-98972 or HCPCS codes G2061-G2063. The registered medical assistant would be an appropriate provider as long as they are working according to your state scope of practice laws and under the direction of a nurse practitioner. It is important to note that online digital E/M services are reported once for the qualified nonphysician healthcare professional’s cumulative time during a seven-day period which begins with the qualified nonphysician healthcare professional’s initial, personal review of the patient’s initial inquiry. If the patient generates the initial inquiry within seven days of a previous procedure or E/M service and both services relate to the same problem, then the online digital E/M services are not separately reportable. Also, if a separately reportable E/M service occurs within seven days of the initial review of the online patient inquiry reported by the qualified nonphysician healthcare professional for the same problem, the online digital E/M service would not be reported.

A virtual check-in is a short, patient-initiated communication through audio or visual means of communication that Medicare has defined as a brief communication service with a practitioner via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. Medicare expects that these virtual services will be initiated by the patient, but the providers may need to educate patients on the availability of these services. E-visits are non-face-to-face patient-initiated communications with a practitioner through the use of an online patient portal.¹ (04/23/2020)

¹CMS Press Release, “Medicare Telemedicine Health Care Provider Fact Sheet

You are able to bill the code that would have been used if there were no COVID-19 Public Health Emergency, such as CPT® codes 99304-99306 for the initial nursing facility care.¹ As part of the flexibilities instituted by CMS for fighting COVID-19, 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 will allow for visits to be conducted via telehealth, as appropriate.² (04/23/2020)

¹COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, page 21

²Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19, page 4

CMS has hinted broadly that therapists will be allowed to provide telehealth services during this public health emergency. Unfortunately, no formal announcement has been made at the current time. We believe CMS will allow these providers to perform telehealth services, but we do not currently have details on this.¹ At the current time, CMS has not changed the list of distant site practitioners who are eligible to perform telehealth services, and this list does not currently include physical therapists, occupational therapists, or speech-language pathologists.² (04/23/2020)

¹CMS Outreach & Education Open Door Forums, “Podcasts and Transcripts, April 16, 2020 Office Hours, page 13

²CMS-1744-IFC, “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, pages 36-41

CMS has stated that providers may use the place of service code that would have been used if the service been provided outside of the current public health emergency. Patients who routinely received telehealth services prior to the public health emergency would not require any changes when submitting claims during the current pandemic. Many providers did not routinely see patients via telehealth, and those providers are allowed to submit claims with the place of service code that reflects the usual location where patients are seen, rather than submit claims using place of service code ‘02’ and receive the lower facility rate.[1] CMS requests that modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, be appended for services provided via telehealth in these cases. An exception to this is CAH Method II claims, which should have modifier GT, Via interactive audio and video telecommunication systems, appended. Of note, modifier G0, Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke, is used when the services are for treatment of an acute stroke patient.

(04/09/2020)

The hospital is not limited to codes on the CMS approved telehealth list of services when services are provided to a patient at home using audio/video communication and the hospital has chosen not to register the patient’s home as a provider-based department. Codes for the services provided should be reported with modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital. Due to the wording of the interim final rules, services provided through audio/video communication to a patient in an outpatient department of the facility – which can include the patient’s own home – are covered as if they are face-to-face and are not considered true telehealth services. When providing telehealth services, you must use the telehealth services list.[1]

(08/27/2020)

The telephone call is an audio only service, while the in-office E/M is conducted through audio/visual telecommunications. The CPT® codes for the telephone services, such as CPT® codes 99441-99443 should not be related to an E/M service provided seven days prior to the telephone contact, and the telephone call should not result in an E/M service within the next 24 hours (or next available appointment with the physician). If the telephone call is NOT related to the previous E/M visit, then it may be reported. There are instances where a good audio/visual connection cannot be made, or the patient does not have access to an internet connection and an in-office E/M is not possible.[1]

(08/27/2020)

During one of the Centers for Medicare & Medicaid Services (CMS) stakeholders ‘CMS Office Hours’ calls, CMS indicated that the quantity is based upon the number of connections. For example, if there is one meeting set up and the specialists “see” the patient one after the other, then this would be a quantity of one unit of service for HCPCS code Q3014. If there are two visits set up at separate times, then it would be appropriate to report two units of service for the originating site fee. [1]

The rationale behind this is similar to an on-site, face-to-face visit. If the patient is in one room, sees Dr. A, then Dr. B comes in, the facility would only charge for one visit. If the patient sees Dr. A, then has to go to Dr. B’s office for the next visit, then there would be two visits. The difference with the situation here is that the “room” is virtual.

(10/08/2020)

CMS has indicated that providers should be using the HCPCS code describing the services provided. If the service provided by the facility is supportive in nature, then HCPCS code Q3014, Telehealth originating site facility fee, may be reported. For Calendar Year (CY) 2020, the reimbursement rate is $26.65. This helps the facility to cover costs associated with activities such as patient registration, some pre-service and post-service work by hospital staff, covering the platform used for the audio/visual call, etc.[1]

(10/08/2020)

Yes, there are instances where you do not need to submit the patient’s home address and still be able to submit HCPCS code Q3014, Telehealth originating site facility fee. Both surround the usage of modifier PN, Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital. If you are a non-excepted provider-based department (PBD) or If you are an excepted PBD and are willing to receive the lower reimbursement of a non-excepted PBD, you may append modifier PN to the applicable services and not submit the patient’s home address to the CMS Regional Office.[1]

(10/08/2020)

You should be selecting the code which accurately describes the service provided. According to CMS, If the hospital staff provides administrative and clinical support when a distant site practitioner furnishes a telehealth service to a registered hospital outpatient, then HCPCS code Q3014, Telehealth originating site facility fee, would be appropriate. Typically, the hospital would bill HCPCS code G0463, Hospital outpatient clinic visit for assessment and management of a patient, when a professional is located in the hospital and furnishes an E/M outpatient service to a registered hospital outpatient in the hospital. Since the patient’s home is serving as a relocated outpatient department of the hospital, it would be appropriate to report HCPCS code G0463 in this situation.[1]

(10/08/2020)

The patient’s home can be designated as a provider-based department (PBD) of the hospital for emergency department (ED) services. HCPCS code G0463, Hospital outpatient clinic visit for assessment and management of a patient, would not be appropriate for this scenario. If the hospital staff provides administrative and clinical support for a physician located at a distant site, then HCPCS code Q3014, Telehealth originating site facility fee, would be appropriate. If the physician is located in the hospital and the patient’s home has been designated as a PBD, then the ED visit codes may be reported utilizing either CPT® codes 99281-99285 or HCPCS codes G0380-G0384. CMS expects 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.[1]

The facility would not need to use modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, but any other applicable modifiers would be necessary.

(10/08/2020)

For RHCs, HCPCS code G2025, Payment for a telehealth distant site service provided by a rural health clinic (RHC) or federally qualified health center (FQHC) only, was created on January 27, 2020 and would be used in place of HCPCS code Q3014, Telehealth originating site facility fee. Modifier CG, Policy criteria applied, should be appended. Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, may be appended, but is not required. Any other applicable modifiers, such as CR or CS, should also be appended. Additionally, CMS recommends a revenue code within range 052X, Freestanding Clinic.

Claims will be paid at the RHC’s all-inclusive rate (AIR) of $92.03. This rate was not in the claims processing systems until after July 1, 2020, so any claims submitted between January 27 and June 30, 2020 will be reprocessed beginning on July 1, 2020.

You may wish to review MLN Matters® article SE20016 ‘New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)’ to review additional flexibilities that are specific to RHC providers.[1]

(10/08/2020)