Telehealth Reimbursement Update

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

It is hard to believe that COVID-19 has been plaguing us for a year and the public health emergency (PHE) has once again been extended until April 21, 2021. It is also hard to believe that one year ago telehealth services were rarely offered by wound/ulcer management professionals. In fact, many professionals were emphatic that wounds/ulcers could not be managed via telehealth because “every patient requires a procedure every week.”

Then the unthinkable happened: stay-at-home orders were mandated throughout the country, elective surgeries were postponed, many hospital owned outpatient provider-based departments (PBDs) and physician offices were closed for an unspecified period of time, physicians and other qualified healthcare professionals (QHPs) could not visit their wound/ulcer patients in skilled nursing facilities, and a high percentage of patients (even those with chronic illnesses) chose to cancel appointments with their PBDs and/or physician offices. By the middle of the year, wound/ulcer management professionals were reporting that a high percentage of chronic wounds were quickly deteriorating and that the number of amputations that could have been prevented was rising at a rapid rate.

At that point, many wound/ulcer management professionals and PBDs determined that conducting telehealth assessments with their patients at home, in skilled nursing facilities, etc., was a good way to monitor their patients’ wounds/ulcers, to provide education to the patients and their caregivers, to educate staff nurses how to manage the wounds/ulcers, and to make the determination if an in-person visit with the physician/QHP was vital. These professionals revised their workflow, educated patients how to use the available telehealth platforms, and prepared their patients and themselves to participate in telehealth visits.

By the end of 2020, many physicians, QHPs, and therapists were facilitating telehealth visits from their homes, offices, and PBDs. Those professionals, who took the time to develop a workflow that educated patients how to participate in the telehealth visits, reported they were satisfied that they regained consistent assessment of their patients’ wounds/ulcers. When patients were queried about their participation in telehealth visits, a large percentage were happy that their wound/ulcer management professionals could assess their condition and could determine if in-person visits were necessary. Many patients reported that they preferred telehealth visits because 1) they did not have to risk COVID-19 exposure, 2) their professional was almost always “on time” for the telehealth visit, and 3) their professional spent more quality time with them. In fact, most wound/ulcer management professionals and patients express the desire to continue telehealth assessment visits after the COVID-19 PHE ends.

Now that the PHE has once again been extended, this author has received many questions about the relaxed telehealth regulations. The remainder of this article will share the most frequently asked questions (received in 2021) and answers about telehealth services.

Q:     

During the PHE, can all telehealth services be provided by audio only?

A:     

No, Medicare only covers audio-only interactions that they believe meet their requirements. Those telehealth services are easily identified, on the List of Medicare Telehealth Services for PHE, when “Yes” appears in the 4th column of the list:

Some examples of the allowed audio-only services, that may be pertinent to wound/ulcer management patients, are:
                 

Q:     

When the PHE ends, will the audio-only telehealth services still be covered by Medicare?

A:     

Because statute requires telehealth services to be provided via a two-way audio-visual communication technology, the CMS will not be able to reimburse, for audio-only services, when the PHE ends. Therefore, the CMS established a temporary communication technology based service (CTBS) code for audio-only assessment, which does not have to follow telehealth regulations. This new CTBS code should assist physicians/QHPs to assess their patients when they are not able to have audio-video assessment visits with them.  

G2252    Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, 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; 11–20 minutes of medical discussion.

Q:   

When the PHE ends, will the Centers for Medicare & Medicaid Services (CMS) reinstate the telehealth restrictions (geographic location of the originating site, originating site where patient receives the services, eligible distant site practitioner) that were relaxed during the COVID-19 PHE?

A:     

Yes, these restrictions will be reinstated because the CMS does not have the authority to eliminate them. It will take an act of Congress to make those relaxed telehealth services permanent. Once the PHE ends, professionals and patients should encourage Congress to address these important telehealth issues.

Q:     

The list of covered Medicare telehealth services has been dramatically expanded during the COVID-19 PHE. Will all the added telehealth services remain on the covered services list after the PHE ends?

A:     

Some of the added telehealth services will cease as soon as the PHE ends, some will remain in place until the end of the calendar year in which the PHE declarations ends, and some will become permanent (download PDF Table):
    
Telehealth Services That Will End When the PHE Ends (Partial List)

Telehealth Services That Will Remain in Place Until the End of the Calendar Year in Which the PHE Ends (Partial List)

Telehealth Services That Are Added to the Permanent List of Eligible Services

Q:    

When PBDs began supporting physicians/QHPs to perform telehealth visits, it appeared that they could not bill Medicare for that support. Are PBDs now allowed to bill for this service? If so, how will the PBD and physician/QHP be paid by Medicare?

A:     

On July 28, 2020, the CMS provided direction for on-campus PBDs or excepted off-campus PBDs to code for supporting physicians/QHPs to provide telehealth visits. Because PBDs cannot normally bill Medicare for services provided at home, the PBD must officially relocate the PBD (via the Temporary Extraordinary Circumstances Relocation Request) to the patient’s home, which must meet all PBD conditions of participation that were not waived for the PHE. The PBD must also register the Medicare beneficiary as a hospital outpatient. The telehealth service must be furnished by a physician/QHP who ordinarily practiced in the PBD. The PBD staff must provide administrative and clinical support for the professional telehealth service.

If all these criteria have been met, the PBD coding is then based on 1) the location of the physician/QHP when the telehealth visit is performed, and 2) the service provided by the physician/QHP. Following are the 3 main coding scenarios that may pertain to PBDs and physicians/QHPs who provide telehealth:

Scenario 1: Physician/QHP is in an on-campus PBD and provides a telephone E/M service

PBD            Report the clinic visit code G0463 with modifier PO.
                   Report condition code DR (disaster-related claim covered by a blanket waiver)
                   Payment will be the OPPS rate.

Physician/QHP    Report the phone telehealth visit with 99441–99443 and modifier 95.
                             Report place of service 22.
                             Payment will be the MPFS facility rate.

Scenario 2: Physician/QHP is in an on-campus PBD and provides an audio-video E/M service

PBD    Report the clinic visit code G0463 with modifier PO.
            Payment will be the OPPS rate.
            Report condition code DR.

Physician/QHP    Report an E/M code with modifier 95.
NOTE: Physician/QHP should not report a telehealth code because the patient is considered to be located in the PBD.
            Report place of service 22.
            Payment will be the MPFS facility rate.

Scenario 3: Physician/QHP is at a distant site, e.g., her/his home and is supported by an on-campus PBD.

PBD    Report the telehealth originating site code Q3014 with modifier PO.
           NOTE: PBD should not report G0463 because a clinic visit was not performed.
           Report condition code DR.
           Payment for the telehealth originating site facility fee is 80 percent of the lesser of the actual charge or $27.02.
Physician/QHP    Report the appropriate code for the telehealth service provided with modifier 95.
                              Report place of service 22.
                              Payment will be the MPFS facility rate.

Because the PO modifier designates an excepted off-campus PBD, you may be wondering why the PO modifier was added to the telehealth service codes of the on-campus PBD in the 3 scenarios above. It is because the PBD is required to temporarily relocate the PBD to the patient’s home (which is off-campus) so they can support the telehealth services provided by its physicians and QHPs. If the on-campus PBD or excepted off-campus PBD does not temporarily relocate to the patient’s home, it is a new non-excepted off-campus department that is not eligible for a Temporary Extraordinary Circumstances Relocation Request. Non-excepted PBDs are required to attach the PN modifier to every code on their claims and are always paid 40% of the Outpatient Prospective Payment System rate.
    
Summary

As you can see, physicians/QHPs and PBDs have several telehealth options for assessing wounds/ulcers during and after the PHE. In addition, the CMS has changed the regulations to allow some of the telehealth services to continue even after the end of the PHE is declared. All wound/ulcer management professionals should carefully review the entire list of Medicare eligible telehealth services to identify all the telehealth options available. The combination of telehealth, communication-based technology services (CTBS), and remote patient monitoring now offer additional ways to continue the digital services that patients with wounds/ulcers and their physicians/QHPs and PBDs have embraced during the PHE.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.