On April 9, 2020, the Centers for Medicare and Medicaid Services (CMS) focused part of its “Office Hours on COVID 19” on answering providers’ questions on coding and payment challenges arising from new coverage of telehealth services during the pandemic.  Below are CMS’ responses on a number of the pressing concerns raised by providers during the call. ‘Questions and Answers’ have been rearranged to group similar questions and responses together.

As those responses indicate, many significant questions remain to be resolved by CMS with regard to telehealth service coding and payment, and providers are advised to keep posted on CMS’ progress in wading through these challenges.  Powers provides expert advice on new telehealth payment requirements.  If you have any questions, please contact Diane Millman (Diane.Millman@PowersLaw.com), Leela Baggett (Leela.Baggett@PowersLaw.com), or your regular Powers attorney.

RURAL HEALTH CLINICS

>> Participant: I’m calling representing the rural health clinics… Two weeks ago, the CARES Act was approved allowing our facility to bill as a site for telehealth, and it’s been almost two weeks and we’ve still not seen any regulations on how to bill for that….  When we do get these regulations out, if you guys would consider the types of patients that we are dealing with. We are not always going to be able to get audiovisual and telephone at the same time with a lot of our clients. Our patients in these rural areas that have several doctors call me today and say it’s really been a problem getting audio and telephone at the same time and, so we would like to see — I know we have virtual visits but if there was a way to build in some type of telephone type of telehealth reimbursement for rural health clinics during this time that would be great…

>>CMS: … We are actively working on the new authorities, and we are hopeful that we will be able to release something shortly, and as you probably know, the statutory provision does allow for both RHCs and FQHC to furnish telehealth services and it instructs us to create a mechanism for payment and that is what you are anticipating and we are certainly hard at work on making that happen as soon as we can. In terms of the audio-only, we certainly hear that and understand that. That is something we are taking into advisement as well, and I did want to point out since you mentioned the virtual check-in codes, the — in the Interim Final Rule that we released at the beginning last week, the payment rate under the systems for that virtual code has been increased as well, and I just wanted to make sure that you knew about that also. And those services can be done audio-only…

>> Participant: This kind of goes off of the other rural health questions. I wanted to make sure as of right now, there are no guidelines to bill for the telehealth services because we already bill on a UB form and the critical access hospitals were advised to bill with the “GT” modifier but looking for a little direction in billing.

>> CMS: Again, we are actively working on that, and we understand the idea is there for that guidance. We are — because the provision was passed two weeks ago, we are actively working on that. It would not be the exact same bill guidance for the critical access hospital because unfortunately the legal authorities are different, but we are again actively working on getting that an optimistic that will happen soon…

>> Participant: … I’m with the Kansas Medical Society, and we represent about 3,000 actively practicing physicians in the State of Kansas, many of whom are rural health care providers. We are anxious for some guidance on how to bill and how much — what reimbursement … will look like. Do we have an idea of when we can expect that … this week, early next week? Do we have a gauge on that?…

>>CMS: Rural health clinics. I don’t know that we have any more further answer than the one that Ryan so graciously gave.

TELEHEALTH PLACE OF SERVICE

>> Participant: … If you are say a physician and doing telemedicine from your home with a patient who is also in their home, I want to make sure I understand that physicians can put in box 32 on the claim form, their home address and they need not to update their file or their enrollment application with the contractor. Is that, correct?

>> CMS: So, that is correct. The other point to remember on that is that in term of the service location, like the place of service code, the same policy would apply in that visit would ordinarily have taken place in a practice location and the practice location could also be acceptable and we used both as reflected in the place of service code and in the service location information but even if the home — if the physicians, for example, would be used it would not necessarily as I understand the provider enrollment rules, that would not necessarily be updated.  That’s correct. So, no update needed.

>> Participant: … I know that physicians are to use the place of service where the service would have been provided, so if the service would have been provided in a hospital outpatient setting if it were in person then, of course, both the facility- the hospital- and the provider would be able to bill, so under this regulation, will the — can the hospital bill their portion of the E&M telehealth visit.

>>CMS: … Under the current rules, Medicare telehealth services are only billable by the professional who is furnishing the service from the business site unless any such cases where the patient is located within a hospital or other healthcare setting and then the original site facility can be reported. We are aware that there are a lot of additional questions surrounding that and we are actively taking a look at how the intersection of our existing payment rules works in the context of the changing environments at the public health emergency poses.

>> Participant: … The first [question] is regarding Q3014 for hospital billing. We all know that it is only applicable on a UB claim form regarding the situation with the pandemic and the professionals being at an existing site they are providing their services on the 1500. Some of these professionals are actually on-site at and within our hospitals, maybe at a nurse’s station and in one of the offices et cetera, so they are utilizing our staff… even though the provider is here and the patient is at home. We would like to know if CMS is going to consider making adjustments so the hospitals can still bill telehealth Q3014 on a UB to cover those resources being used. Thoughts there?

>>CMS: Yes, so that is a great question, and we are actively considering that sort of question. I think in the cases where the telehealth services are happening — when the services happening within the same location, we have not historically considered that to be telehealth and, therefore, not subject to the telehealth restrictions. I think in this case, as you are pointing out, that really is part of our broader consideration of the costs associated with the kinds of steps that the community is taking in response to the pandemic, and we are actively taking a look at that.

>>CMS: Sorry, if I could just add one clarifying point on your earlier question: If the patient and the practitioner are both in the institutional setting, say a hospital in the same location then the telehealth would not — you would not bill that professional service telehealth service, so it would not be limited to like the professional billing in that case if the nursing staff, for example, is providing service with the patient in-person in the same room and the professional is in a different room. I just wanted to make sure that was clear. …

>> Participant: … My question is about the face-to-face visit for hospice recertification, and we do understand that it must be an audio-visual telehealth visit, and I know you are taking it under advisement for the patients who do live in rural areas have no visual capacity because they don’t have a smart phone or a tablet or Internet access- only have a land line. What do you suggest, should hospice submit an individual waiver request if they can only do an audio-only telehealth visit for those patients who need to be recertified? …

>>CMS:  The face-to-face encounter requirement for hospice is a statutory requirement, so I think the agency is limited in its ability to waive that requirement either on a case-by-case basis or the blanket waiver. But as you mentioned, we are considering whether there is additional flexibility that should be in place, for example, you mentioned like patients in rural areas that may not have access to the two way audio-visual, so that is something we are taking another look at.

>>CMS: … It would not be a waiver though would it, if I understand the question. These are statutory authorities so it would be a policy change….

>>CMS: Yep, correct.

>> Participant: Hi. I have seen some information that we should be dealing with a modifier in the place telehealth would have originated from … Today, however, I saw an article admittedly not from CMS – but indicated they were quoting CMS to state we should be using now a “CS” modifier in order to ensure that we receive non-facility over facility reimbursement.

>>CMS:  … For all telehealth services during the public health emergency, we are asking to use the 95 modifier and the place of service code where the service would have been furnished where telehealth — were telehealth not needed. And the place of service code will be the driver of whether or not the non-facility or facility amount under the physician fee schedule is paid and so relative to telehealth services alone, there is no additional modifier needed except the 95. The other modifiers relate to COVID testing which could be furnished via telehealth visits associated with COVID testing, but those modifiers are not required in order for the appropriate payment to be made from telehealth itself. …

>> CMS: … Just for clarification, there is a “CS” modifier, and there’s some confusion around it because a long time ago it was used for claims related to an oil spill, but we’ve repurposed that and that’s the one you would use in the situations where there would be no cost sharing applicable and we — messaging was released … on that…. So everybody is probably aware that we put out a large amount of guidance on CMS.gov on the emergency preparedness and response operation page and while we are on the call today, we updated our frequently asked questions document, and it has a large number of FAQs related to the Interim Final Rule, so I urge everybody to go and look at that. I think a lot of your additional questions will be answered with that information and also to let you know we are working on updating the rest of the document, so we hope in the next day or so we have additional information updated on the FAQs.

>> Participant: Thank you, I had one other quick question on the claims we filed. Are we going to receive the facility rate on those, and will we have an opportunity to appeal those?

>> CMS: Those will be paid — those should be paid with the facility rate, and your second question, in terms of can that be changed or rectified, that’s a good question and what — we will have to take that back and we will issue some sort of guidance on that.

NON-PHYSICIAN CLINICAL STAFF AND TELEHEALTH

CMS: … At the moment, . . . therapists are not eligible to furnish telehealth services, and the services that are furnished with telehealth could not be reported. The virtual check-ins and the e-visits could be. I’m sorry, I should say the e-visits could be reported — actually believe the virtual check-ins could be as well. But, I’m not sure if that answers your question or are you asking about therapist that are employed in hospital in the hospital setting.

>> Participant: So, I have therapists that work in an outpatient hospital setting that bill usually so, for them, I understand they can’t do telehealth services but for the virtual check-ins and e-visits, are they able to go on the UB-04?

>>CMS: As long as they are employed at the hospital, then the hospital rules would continue to apply, so, whatever the billing rules under the hospital would be, those individuals would not — they would not be able to be billable on a professional claim. But I think we are certainly — we understand and have received a lot of questions along those lines that we are taking a look at what flexibilities we would have in that area.

>> Participant: Okay. And if my physical therapist do offer telehealth to Medicare patients letting them know that, giving them an ABN waiver before the service explaining it’s not eligible and not being an eligible service provider type and give them the total cost, is that something we can do right now since there are the quarantine issues that they can get that ABN over the phone?

>>CMS: That’s a great question. I can’t answer that. I don’t know if we have someone on the line who could and, if not, we can certainly take that and get back to you.

>> Participant: Okay. I’m sorry, I just have one more question about patients that are disabled, have dementia in a skilled nursing facility or assisted living that need the POA to be in charge of their healthcare. Right now, in Michigan, there is a lot of restrictions on visitation with anybody coming into those facilities, so would the POA be able to have a telehealth visit with the provider to discuss that beneficiary and be able to bill the telehealth services with the POA even though the patient may not be able to be in view of the provider?

>>CMS: That is another good question, and we should — we should take that back and make sure to get the right answer to you. …

>>CMS: On the ABN question, we have put out guidance that says that MOONS, ABNs, and several of the other documents required to be done can be delivered by telephone and otherwise so I don’t know if that is helpful, but it’s called “Waving Signatures for Beneficiary Notices Due to COVID-19.” …

>> Participant: I would like to say for the G2023, I’d love to have that answered because there are nurses and physicians going in and putting on PPE to run the specimen, so I applaud you for looking into that. I have a bigger question that has to do with hospital-based nonphysician services and not just PT, OT, SLP, but there are several other nonphysician providing services like audiologist and dietitians and social workers and wound care lactation nurses, and there is no guidance for them either, and so I think it would be very helpful if CMS could come up with some sort of guidance on behalf of hospital-based nonphysician practitioners, and … It does not make any sense why they can’t do the exact same services in the hospital-based setting especially, for example, like outpatient setting there is no difference. Is there a possibility that CMS could address the larger picture of nonphysician services, and I know there’s a lot of questions about telemedicine and there’s a lot of people that are actually providing services that could provide services via telemedicine, so I would love to hear your thoughts about the other individuals that I listed….

>>CMS: We are definitely aware of the question you are referring to in terms of the hospital-based services. We have gotten that question from many, many people, and it is clearly a circumstance that we could not speak to as readily as some of the other things we’ve already addressed.  Understanding very much why you are interested in it, and I assure you we are working on it, and we will be providing clarity as soon and we can.

>> Participant:  …You did talk about the “G” codes – the virtual check-in and telephone service codes- and in the Interim Final Rule on March 30th, it specifically mentions physical therapists and occupational therapist. … Can a physical therapist assistant and occupational therapy assistant provide telephone service visit and then to clarify the first question that was asked today, can a PT and OT on a claim from an institutional setting, can they bill those codes right now on a UB O4 claim form?

>>CMS: … The e-visit code, and those are reported for the services that are directly provided generally by the practitioners who are reporting them. And so generally, those are going to be reported on a professional claim and … in terms of professionals and others who are employed by the hospitals who services would be reported on the hospital claim and it would be paid under the OPPS then those codes, however, those codes would ordinarily — if they wouldn’t pay separately and that would continue to apply and, again, this is part of that answer just to put it in the context of what we’ve been saying about understanding a lot of these concerns and we are actively looking at all of those issues, and we certainly appreciate the importance of them.

>> Participant: Can you clarify a physical therapy assistant and occupational therapy assistant and — can they do the e-visit and the telephone service and — and the NPI of the therapist they have to be done by a therapist?

>>CMS: Under our current policy, those codes are for the services directly provided by the individual who is billing for those professional services. So, at the moment, I think the answer would be no, but it’s part of the question we are actively considering.

>> Participant: Just as you go back and consider, keep in mind in the hospital setting therapy is paid and billed under the physician fee schedule, not under the OPPS, if that makes a difference how you answer that we are still paid under the fee schedule not OPPS. …

>>CMS: Okay, so we are definitely looking at this, and it sort of really ties very much into some of these other questions about what constitutes a hospital and how to bill for hospital type services when the patient is outpatient service and provided they are not at the hospital and we are working to address that. ….

Since its April 9th “Office Hours,” CMS posted a new Q&A addressing some of the issues that were raised by participants, and this Q&A supersedes any conflicting guidance provided above.

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