On January 11, 2023, HHS extended the PHE (Public Health Emergency) for another 90 days; many saw this coming as there was a rise in COVID-19 cases over the holiday season and with a new variant on the horizon. Others were annoyed over the extension; they; thought the PHE went on too long and should have already ended. The extension allowed providers, other qualified healthcare professionals, and practitioners to bill Medicare Part B for telehealth/telemedicine services following the waivers at the beginning of the PHEs.
But on January 30th 2023, the Biden Administration announced plans to let the coronavirus public health emergency expire in May 2023; the White House announced Monday that federal officials believe the pandemic has moved into a new, less dire phase.
In August, CMS, in preparation for the anticipated end of the PHE, developed a roadmap to help providers and healthcare facilities prepare for the future of waivers and flexibilities. This was always a part of my teachings when educating organizations that it was imperative to start putting a plan in place; since we knew the PHE would not last forever. In April, they revised and published their Roundup roadmap to further guide the end of the PHE. Medicaid has some additional COVID-19 waivers set to expire on May 11th; organizations and physicians’ offices will want to review their local Medicaid policies to ensure compliant documentation and coding of services post-PHE.
What is telehealth?
Telehealth, or Telemedicine, are in-person visits delivered virtually (online using HIPAA-compliant platforms with internet access). Per CMS, Telehealth is exchanging medical information from one site to another through electronic communication to improve a patient’s health. Examples of telemedicine included healthcare services delivered through videoconferencing, store-and-forward imaging, online patient portals, and audio communications.
Telehealth before PHE
Before the COVID-19 pandemic, telehealth/telemedicine was provided in most rural areas where patients did not have access to care, and there was a physician shortage. Some physician practices also utilize it on a limited basis, depending on the patient payer and geographic location. In addition, Medicare covered only a few services. For services they did cover, it was on a restricted basis and under limited circumstances. Still, they suspended/waived restrictions at the beginning of the PHE and added a significant amount of codes to the list. For example, audio-only calls were not considered telehealth services; new patient visits were prohibited, and only established patient visits were allowed.
During the PHE How many of you remember all the sleepless nights we had looking to see what other waivers and CPT codes CMS updated to give accurate guidance the following day? We stalked CMS’s newsroom, the local Medicaid website, CCHP(Center for Connected Health Policy), and many more. The changes were ever-changing; providers thought we were crazy as the guidance changed daily, hour to hour and minute to minute. CMS put our various fact sheets, FAQs, and a list of payable services to help guide organizations and practitioners. The constant change was also because the country had never been totally affected by a virus that caused limited access to healthcare in decades; therefore, flexibility to patient care needed to be thought through, revised and implemented.
CMS had added 144 telehealth services at the beginning of the PHE, such as emergency department visits, initial inpatient and nursing facility stays, and discharge day management services. Medicare will cover these services through the end of the PHE, which allows patients to receive telehealth services from providers eligible to bill Medicare Part B services. In addition, every year since the PHE started, CMS has revised the list of codes and made some services permanent after the end of the PHE.
There was a change to the Place of Service (POS) selection, which would now be equal to what it would have been had the service been provided in person (e.g. office 11 instead of 02); the provider would want to check individual payers to ensure which POS they require. Also, Modifier 95 was advised to be included in telehealth visits to show that services were utilized via telehealth during the PHE. Modifier CS, effective March 2020 until the end of the PHE, is a cost-sharing waiver modifier for COVID-19 testing, allowing Medicare and private payers to pay 100% of the claims; the patient is responsible for cost-sharing. CS modifier would be appended if the service results in an order for or administration of a COVID-19 test, the service is related to furnishing or administering the test, and the service is for the evaluation to determine if the patient needs a COVID-19 test.
Telehealth services allowed providers to care for their patients utilizing these services, allowing for exposure to COVID-19. CMS also allowed for audio-only calls, which benefited the elderly and mental health populations greatly, which may not have had access to real-time audio and visual capabilities. The waivers allowed:
- For HIPAA-compliant platforms such as Apple Facetime, Facebook Messenger video chat, Google Hangouts video, Zoom, Skype, Doxyme, GoToMeeting, ext. to be utilized temporarily. HHS also put out further guidance on the use of HIPAA-compliant platforms.
- Physician practitioners such as nurse practitioners and physician assistants can supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians.
- Physical and occupational therapists can delegate “maintenance therapy” – the ongoing care after a therapy program is established – to a therapy assistant.
- Virtual supervision was allowed for all teaching settings
- Primary Care Centers were allowed to see patients under the primary care exception, bill higher levels 4 and 5, and utilize telehealth services.
Below is a list of some services providers can provide with Telehealth Per CMS:
- An increase in continuity of care
- Limited physical contact reduces everyone’s exposure to COVID-19
- Screen patients with symptoms of COVID-19 and refer them as appropriate
- Help overcome clinician shortages, especially among rural and
- other underserved populations
- Provide support for patients managing chronic health conditions.
- Prescription drug management, including opioids
- Physical and occupational therapy
Permanent and Temporary Changes after PHE
On March 15, 2022, the Biden Administration enacted into law the “Consolidated Appropriations Act” and the Omnibus Bill, allowing the extension and flexibility of many of the services that fell under the 1135 waiver and the CARES ACT will be available for 151 days following the termination of the COVID-19 PHE and continuing Medicare’s expanded access to telehealth by extending COVID-19 telehealth flexibilities for an additional two years through Dec. 31, 2024. Below are some of HHS’s list of temporary and permanent changes after the PHE (See HHS website for the complete list):
- Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) can serve as a distant site provider for non-behavioral/mental telehealth services.
- Medicare patients can receive telehealth services authorized in the Calendar Year 2023 Medicare Physician Fee Schedule in their homes.
- There are no geographic restrictions for an originating site for non-behavioral/mental telehealth services.
- Some non-behavioral/mental telehealth services can be delivered using audio-only communication platforms.
- Behavioral/mental telehealth services can be delivered using audio-only communication platforms.
Temporary Changes through Dec 2024
- An in-person visit within six months of an initial behavioral/mental telehealth service and annually thereafter is not required.
- Telehealth services can be provided by a physical therapist, occupational therapist, speech-language pathologist, or audiologist.
- Behavioral/mental telehealth services can be delivered using audio-only communication platforms.
- SAMHSA announced it will extend this flexibility for one year from the end of the COVID-19 PHE, May 11, 2024, to allow time for the agency to make these flexibilities permanent as part of the proposed OTP regulations published in December 2022.
Place of Service (POS) & Modifiers CMS added a new Place of Service (POS) 10 effective January 1, 2022, and available to Medicare on April 1, 2022, for telehealth services provided in patients’ homes. POS 10 is where health services and health-related services are provided or received through telecommunication technology. POS 02, the patient is not located in their home when receiving health or health-related services through telecommunication technology. New modifiers have also been added:
- FQ – A telehealth service was furnished using real-time audio-only communication technology.
- FR – A supervising practitioner was present through a real-time two-way, audio/video communication technology
What is Expiring on May 11th
- The requirement for private insurance companies to cover COVID-19 tests without cost sharing, both for OTC and laboratory tests, will end. However, coverage may continue if plans choose to continue to include it.
- Anti-kickback statute waivers for COVID-19 purposes
- CPT code 99211 usage for specimen collection for COVID for new patients
- Visit frequency limitation
- RPM (Remote Physiologic Monitoring) for new patients
- Virtually Check-ins for new patients (CMS G Codes)
- Face to Face visits for ESRD patients
Now that we have an official end date for the PHE, it’s imperative for organizations utilizing telehealth services to review pre-PHE guidelines. As well as waivers during the PHE and new policies and guidelines set to take effect post-PHE. This will ensure that EHRs and practitioners’ documentation are accurate and compliant.
Here are some websites to help you start with your review; CMS 2023 final rule, CMS list of approved telehealth services, other payer policies, across-state line waivers, OIG (Office of Inspector General) website CPT book Category I and II codes, modifiers, CCHP website, CMS newsrooms for updates. Review EHR/templates to ensure the medical record captures the necessary elements for documentation and billing telehealth services. Also, ensure that the telecommunication technologies utilized will be considered HIPAA-compliant platforms.
The PHE caused an increased usage of telehealth services and showed many that care could be provided to patients safely and securely while not interrupting the continuity of care. In addition, they allowed patients to be monitored closely and assessed if escalation was needed. The next few months may be as hectic as the beginning of the PHE as we grasp the new changes, but I am elated to see what the future holds for telehealth.
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