Updates on Telehealth Coding and Billing Services under the COVID-19 Waivers

Written May 13, 2020 - information current as of this date

By Jackie King, MSHI, CPC, COC, RH-CBS Director of Clinical Informatics/HIM Consultant, ICAHN

These are unique times indeed.  With the onset of the COVID-19 pandemic, our country has seen the most unprecedented and sweeping changes to our healthcare reimbursement system in history.  These changes have taken place in such a rapid-fire manner that everyone who works in healthcare, including coding and billing professionals are becoming frazzled while trying to keep up.

One silver lining of this Public Health Emergency (PHE) has been the accelerated adoption of telemedicine services for treating patients.  We have opened up access to care, and the temporary ability to receive reimbursement for that care, in a manner and speed that would never have developed without the dire need for social distancing to slow the spread of the virus.

Telehealth vs. Telemedicine...is there a difference?  Telehealth refers to a broad range of technologies and services to provide patient care and improve the healthcare delivery system as a whole. Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. You will see these two definitions used interchangeably in literature and payer guidance, but it is good to have a high level understanding of the difference.  Telemedicine is a subset of telehealth that refers solely to the provision of health care services over a distance, through the use of telecommunications technology. Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit.  During the PHE, telemedicine has expanded to provide virtually all methods of patient care that can be performed without physical contact.

Technology requirements.  During the PHE, telemedicine technology requirements can include any non-public facing application (e.g. not social media) or software available to patients such as a telephone, computer, iPad, or cellular phone.    The OCR (Office for Civil Rights) at the Department of Health and Human Services (HHS) stated on March 17, 2020 that it will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered healthcare providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.  Some examples of allowable telemedicine technology during the PHE include: FaceTime, Zoom, and Skype. HIPAA compliant examples include, but are not limited to: Zoom for Healthcare, Doxy.me, Skype for Business, Updox, VSee, GoToMeeting, Amazon Chime, or Google G Suite Hangouts Meet. Examples of unacceptable telemedicine applications which are public facing include Tik Tok, Facebook Live, and Twitch.

Originating site. Although it may sound counterintuitive, the originating site for telemedicine is the location of the patient.  During the PHE, this can include the patient’s home both by CMS as well as most commercial payers.  The most recent set of changes included in the CMS-5531-IFC (interim final rule with comment period) released April 30, 2020, declares that hospitals may bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home.  This can be accomplished by requesting an extraordinary circumstances relocation exception that will designate the patient’s home as a provider based department (PBD) of the hospital.

Per CMS -55341-IFC Section II.E-.F. : To the extent that a hospital may relocate to an off-campus PBD that otherwise is the patient’s home, only one relocation request during the COVID-19 PHE is necessary. In other words, the hospital would not have to submit a unique request each time it registers a hospital outpatient for a PBD that is otherwise the patient’s home; a single submission per location is sufficient. Hospitals must send this email to their CMS Regional Office within 120 days of beginning to furnish and bill for services at the relocated on- or off-campus PBD.   We note that, during the COVID-19 PHE, a patient’s home would be considered a PBD of the hospital when the patient is registered as a hospital outpatient (as discussed in section II.F. of this CMS-5531-IFC 43 IFC) and is receiving covered OPD services from the hospital.

Billing the originating site fee: Use HCPCS code Q3014 for originating site fee to Medicare and Medicaid.

Distant site. The distant site is the location of the provider for telemedicine services.  With the April 30, 2020 update to  the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), CMS has expanded the types of healthcare professionals that are eligible to bill Medicare for their professional services.  This now adds in healthcare professionals who were previously ineligible to furnish and bill for Medicare telehealth services, and includes physical therapists, occupational therapists, speech language pathologists and others, to receive payment for Medicare telehealth services. These providers, in addition to physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, clinical social workers, and registered dietitians or nutrition professionals must all be acting within their scope of practice under state law.   This brings CMS more in line with most Medicaid and commercial plans who were allowing these practitioners to provide services via telehealth earlier in the PHE.

Telemedicine & Related Remote Communication Services Codes. Medicare has provided an expanded list of approved telehealth services that was updated on April 30, 2020 to include telephone (audio only) codes 99441-99443.  This list can be located at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.  Note that unless provided otherwise, other 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 physician or practitioner.   These visits can be performed for new or existing patients during the PHE for both Medicare and Medicaid beneficiaries.   If an audio only telephonic interaction cannot meet key components of a face-to-face encounter (10 or more minutes), the provider may instead seek reimbursement for virtual check-in services using CPT code G2012.

HCPCS code G2010 should be billed to Medicare for Virtual (not live) Check-ins, which include remote evaluation of recorded video and/or images submitted by an established patient (e.g., portal, email, text), including interpretation with follow-up with the patient within 24 business hours, 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.  (For commercial payers, use 99421-99423 depending on total cumulative time spent on the Virtual Check ins).

Billing distant site telehealth services under Medicare waivers (except for RHC/FQHC). Use the location where the patient would normally have been seen such as office (POS 11) on the claim to receive the higher non-facility payment rate during the PHE. Add  Modifier 95 (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) on these claim lines to indicate that the service was provided via telehealth per CMS 1744-IFC pages 13-15. Physicians and other practitioners are allowed to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location per COVID-10 Emergency Declaration Blanket Waivers for Health Care Providers.  Telehealth services rendered from a CAH Method II billing provider must add modifier GT to indicate the service was performed via telehealth (this CAH guidance is unchanged from before the PHE).

Billing distant site telehealth services under Illinois Medicaid and MCOs. All distant site providers billing for telehealth services must use modifier GT and Place of Service 02 on their claims, with two exceptions:  Community Mental Health Centers and Behavioral Health Clinics that have staff working remotely from home or another location during this health emergency should use their usual place of service (onsite/office). Services that are already allowed by telephone per the delivery modes identified by code in the Handbook for Community Based Behavioral Services, topic 208, should not be billed as telehealth and; Independent Practitioners (Psychiatrists, Licensed Clinical Social Workers and Licensed Clinical Psychologists) billing the Group A services from the Fee Schedule for Providers of Community-Based Behavioral Services.  HFS will allow medical/dental/behavioral health encounters with new or existing patients using audio only telephonic equipment to be reimbursed at the medical/dental/behavioral health encounter rate, as long as the encounter is of an amount and nature that would be sufficient to meet the key components of a face-to-face encounter.  For medical encounters the claim must include the GT modifier on all detail code service lines. For behavioral health encounters, the claim must include the GT modifier on all service lines, including the encounter service line. In order for behavioral health encounters to price correctly, the behavioral health modifier must be the first modifier appended to the encounter “T” code.  If an audio only telephonic interaction cannot meet key components of a face-to-face encounter, the provider may instead seek reimbursement for virtual check-in services or e-visit/online portal services. This guidance can be found in the HFS Provider Notice Telehealth Expansion Billing Instructions.

RHCs (and FQHCs) as distant site providers.  Another unprecedented waiver has authorized RHCs and FQHCs to furnish visits via telehealth as distant site providers.  These services can include telephone (audio only) visits lasting more than five minutes, in addition to two-way synchronous audio/visual visits. CMS has established a uniform RHC telehealth payment rate of $92.03 per visit for independent or provider-based RHCs.

Billing for RHC telehealth services. For telehealth distant site services furnished between January 27, 2020 and June 30, 2020, RHCs must report HCPCS code G2025 on their claims with the CG modifier. Modifier “95” (Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System) may also be appended, but is not required. These claims will be paid at the RHC’s all-inclusive rate (AIR), and automatically reprocessed beginning on July 1, 2020, at the $92.03 rate.  RHCs do not need to resubmit these claims for the payment adjustment.  Beginning July 1, 2020, RHCs should no longer put the CG modifier on claims with HCPCS code G2025.

When no live communication (telephone or audio/video) takes place between the provider and patient,  RHC’s will use HCPCS code G0071: Payment is for communication technology-based services for five minutes or more of a virtual (non-face-to-face) communication between a rural health clinic (RHC) or federally qualified health center (FQHC) practitioner and RHC or FQHC patient, or five minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner, occurring in lieu of an office visit; RHC or FQHC only.

Billing for FQHC telehealth services. For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, that are also FQHC qualifying visits, FQHCs must report three HCPCS/CPT codes for distant site telehealth services: the FQHC Prospective Payment System (PPS) specific payment code (GO466, G0467, G0468, G0469, or G0470); the HCPCS/CPT code that describes the services furnished via telehealth with modifier 95; and G2025 with modifier 95. These claims will be paid at the FQHC PPS rate until June 30, 2020, and automatically reprocessed beginning on July 1, 2020, at the $92.03 rate. FQHCs do not need to resubmit these claims for the payment adjustment. When furnishing services via telehealth that are not FQHC qualifying visits, FQHCs should hold these claims until July 1, 2020, and then bill them with HCPCS code G2025. Modifier 95 may be appended, but it is not required.  Beginning July 1, 2020, FQHCs will only be required to submit G2025. Modifier 95 may be appended, but it is not required. See MLN Matters SE20016 for complete details of RHC and FQHC telehealth billing.

The DR Condition Code: The title of the DR condition code is “disaster related” and its definition requires it to be “used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.” Use of the “DR” (disaster related) condition code is mandatory for institutional and non-institutional providers in billing situations related to the COVID-19 PHE for any claim for which Medicare payment is conditioned on the presence of a formal waiver, such as §1135 of the Social Security Act.  An example of this would be a patient that is placed in a Swing bed without a 3-day qualifying inpatient stay due to the waiver.

The CR Modifier: Both the short and long descriptors of the CR modifier are “catastrophe/disaster related.” The CR modifier is used in relation to Part B items and services for both institutional and non-institutional billing.  An example would be a retired provider/nurse has been reinstated to provide care. In this case, both the DR condition code and the CR modifier would be placed on the claim.  CMS is not requiring the CR modifier on telehealth services.   See MLN SE20011 for details.

The CS Modifier. The Families First Coronavirus Response Act waives cost-sharing (waives coinsurance and deductible) under Medicare Part B for patients for COVID-19 testing-related services. This rule is not specific to any place of service or code set and applies to all Part B charges included in an encounter only when the provider orders or administers the COVID-19 lab test.

For services furnished on March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.

For professional claims, physicians and practitioners who did not initially submit claims with the CS modifier must notify their Medicare Administrative Contractor (MAC) and request to resubmit applicable claims with dates of service on or after 3/18/2020 with the CS modifier to get 100% payment.

For institutional claims, providers, including hospitals, CAHs, RHCs, and FQHCs, who did not initially submit claims with the CS modifier must resubmit applicable claims submitted on or after 3/18/2020, with the CS modifier to visit lines to get 100% payment.

Physician or Practitioner Order for COVID-19 tests: Medicare will not require an order from a treating physician or non-physician practitioner as a condition of Medicare coverage of COVID-19 and other related diagnostic laboratory testing during the PHE. CMS similarly removed these requirements for an influenza virus diagnostic laboratory test and any other diagnostic laboratory test that is necessary to establish or rule out a COVID-19 diagnosis. See this link for an updated listing of codes associated with this waiver.

Payment for COVID-19 Diagnostic Testing: Practitioners can be paid for assessment and specimen collection for COVID-19 testing using the level 1 evaluation and management code CPT code 99211. In light of the public health emergency, Medicare will recognize this code to be billed for all patients, not just established patients. This approach helps physician practices to operate testing sites during the PHE. This does not apply to RHCs where specimen collection is part of the All Inclusive Rate (AIR) and is not separately billable.

Hospital outpatient departments can be paid for symptom assessment and specimen collection for COVID-19 using a new HCPCS code C9803 (Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19])), any specimen source retroactive to March 1, 2020. The service would be paid as conditionally packaged when furnished with another payable service under the OPPS. This approach helps hospitals to operate testing sites during the PHE. See Laboratories: Medicare Flexibilities to Fight COVID-19 for details related to the above items.

Telehealth documentation requirements. Providers should document medically necessary evaluation and management service the same as for any face-to-face patient encounter (history, exam, medical decision-making); with the addition of the following: A statement that the service was provided using telemedicine; the location of the patient; the location of the provider;  the names of all persons participating in the telemedicine service and their role in the encounter; total time spent communicating with patient (in case key components of an E&M aren’t met, time can be used for the level).

Coding for COVID-19: Coding Clinic and CDC Guidance. Guideline a: Code confirmed or presumptive positive cases of COVID-19 with U07.1 COVID-19 - for services on or after April 1, 2020 and B97.29, Other coronavirus as the cause of diseases classified elsewhere - for services on or before March 31, 2020.

Sequencing of codes: When COVID-19 meets the definition of principal diagnosis, code U07.1, COVID-19, should be sequenced first, followed by the appropriate codes for associated manifestations, except in the case of obstetrics patients as indicated in Section I.C.15.s. for COVID-19 in pregnancy, childbirth, and the puerperium.

Acute respiratory illness due to COVID-19:  Pneumonia: For a pneumonia case confirmed as due to the 2019 novel coronavirus (COVID-19), assign codes U07.1, COVID-19, and J12.89, Other viral pneumonia.  Acute bronchitis: For a patient with acute bronchitis confirmed as due to COVID-19, assign codes U07.1, and J20.8, Acute bronchitis due to other specified organisms. Bronchitis not otherwise specified (NOS) due to COVID-19 should be coded using code U07.1 and J40, Bronchitis, not specified as acute or chronic.  Lower respiratory infection: If the COVID-19 is documented as being associated with a lower respiratory infection, not otherwise specified (NOS), or an acute respiratory infection, NOS, codes U07.1 and J22, Unspecified acute lower respiratory infection, should be assigned. If the COVID-19 is documented as being associated with a respiratory infection, NOS, codes U07.1 and J98.8, Other specified respiratory disorders, should be assigned. Acute respiratory distress syndrome: For acute respiratory distress syndrome (ARDS) due to COVID-19, assign codes U07.1, and J80, Acute respiratory distress syndrome.

Exposure to COVID-19: For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, assign code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out. (Use this for preoperative screening for elective procedures).  For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. If the exposed individual tests positive for the COVID-19 virus, code U07.1 per guideline a.

Screening for COVID-19: For asymptomatic individuals who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign code Z11.59, Encounter for screening for other viral diseases. For individuals who are being screened due to a possible or actual exposure to COVID-19, see guideline d. for exposure to COVID-19. If an asymptomatic individual is screened for COVID-19 and tests positive, see guideline code U07.1 per guideline a.

Signs and symptoms without definitive diagnosis of COVID-19: For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.) but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as: R05 Cough, R06.02 Shortness of breath, R50.9 Fever, unspecified. If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, as an additional code. This is an exception to guideline I.C.21.c.1, Contact/Exposure.

Asymptomatic individuals who test positive for COVID-19. For asymptomatic individuals who test positive for COVID-19, assign code U07.1, COVID-19. Although the individual is asymptomatic, the individual has tested positive and is considered to have the COVID-19 infection.

This document is current at the time of writing, May 13, 2020 but we know that facts within it can change in the blink of an eye (and a CMS press release). There is no official end date to the PHE and associated waivers at this time.  The ongoing COVID-19 PHE crisis may indeed cause CMS to enact further waivers to protect our patients and healthcare providers, this remains to be seen. It is my hope that once the PHE has been rescinded, our expanded access to telehealth services remains at least partially intact.  This time can serve as an excellent data collection period to show the benefits both financially and clinically of being able to offer medical services remotely.