Normally, Medicare’s telemedicine policy is highly restrictive and it applies mostly to rural areas in Alaska and Hawaii. In the past, claims for telemedicine couldn’t be processed and paid except in those locales, and even then, only with certain guidance on “place of service” and with certain code modifiers. Under the current COVID-19 public health emergency, however, Medicare has significantly relaxed those rules to allow for the safety of our patients, doctors, office staff and the U.S. public-at-large under “shelter in place” provisions.
Additionally, the government gave Ambulatory Surgery Centers instructions to be open only for emergency surgery, but in a very recent change, also allowed them flexibility to “become” hospitals temporarily or to contract with a hospital for surgical services in order to keep the beds available in the hospital for those needing them in the event of a shortage.
(Note: The codes and modifier advice has been fluid since the emergency declaration began, but is correct at the time of this writing.)
Q: What rules did Medicare relax?
A: There are two main ones for us in ophthalmology. First, when the president declared the Public Health Emergency, it was made retroactive to March 6, 2020, and HHS Secretary Alex Azar issued a series of “1135 Waivers” (https://tinyurl.com/ybaks4z2). These 1135 waivers apply to corresponding numbered sections of the Social Security Act and temporarily changed the conditions of licensure, EMTALA regulations and Stark self-referral sanctions, as well as some HIPAA considerations. More on each of those below.
Q: How long will the rules remain relaxed?
A: CMS has noted that these will “end no later than the termination of the emergency period, or 60 days from the date the waiver or modification is first published unless the Secretary of HHS extends the waiver by notice for additional periods of up to 60 days, up to the end of the emergency period.” The waiver for EMTALA is worded slightly differently: It lasts until the “termination of the pandemic-related public health emergency.”
Q: What does the licensure waiver mean?
A: CMS will allow providers to essentially practice across state lines so that care can be given by any provider already credentialed under Medicare to protect patients who need care from having to travel for it at their own risk. Additionally, CMS issued a Fact Sheet on the Emergency Declaration (https://tinyurl.com/udfcczq) that allowed non-certified Part B providers to enroll and receive temporary Medicare billing privileges.
Q: What about providers who had “opted out” of the Medicare system and want to help care for patients during the emergency?
A: Even providers who had opted out of Medicare can terminate this status with Medicare, and they could thereby enroll in Medicare earlier than the normal period of disenrollment to be able to provide more care for the U.S. public. The termination provision of those providers remains once the disaster is over, however – they won’t be “opted out” any longer.
In the same document immediately above, CMS has also waived revalidation Medicare actions until the emergency is declared over. Once it is over, revalidation should begin again—but there is no guidance on how quickly that would ramp up.
Q: What about the relaxing of some of the Stark Law provisions? How does that affect me?
A: The U.S. Department of Health and Human Services Office of the Inspector General (OIG) on March 17, issued a Policy Statement that noted that “physicians and other practitioners will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations Federal health-care program beneficiaries may owe for telehealth services furnished consistent with the then applicable coverage and payment rules … .” This means you can (but don’t have to) waive coinsurance and deductibles for telehealth services during the emergency. If the diagnosis is COVID-19-related, CMS has already stated that copays and deductibles are waived in order to not have cost stand in the way of proper care for potential COVID-19 patients; other private payers followed suit almost immediately.
Q: What does the “1135 Waiver” mean with regards to HIPAA?
A: Normally, telemedicine must be delivered via a secure system in order to be considered a valid service in terms of billing but also to protect a patient’s “PHI” (protected health information). Under the 1135 Blanket waiver, for the duration of the emergency, the HHS Office of Civil Rights (OCR), which is normally in charge of HIPAA provisions, has noted in a press release that it will “exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health-care providers that serve patients through everyday communications technologies during the COVID-19 nationwide public health emergency. This exercise of discretion applies to widely available communications apps, such as FaceTime or Skype, when used in good faith for any telehealth treatment or diagnostic purpose, regardless of whether the telehealth service is directly related to COVID-19.” HHS notes the following as acceptable media for this use: “… popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom or Skype.”
They also note that offices are “encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications …” A consent (verbal) should be noted in the chart for the telemedicine exam.
HHS notes that the following are NOT acceptable for this purpose—even under the waiver because they are “public facing”: Facebook Live, Twitch and TikTok. Any similar technology would also be non-allowed.
Q: How can I protect myself, my staff and patients yet deliver care for them appropriately?
A: This is perhaps the biggest question of all. With social distancing and “stay at home” orders to shelter in place, some patients might actually need to be seen in the office. If this is a true ocular emergency that requires you to have the patient come to the office, your billing and coding is unaffected. Some patients you put off at first can’t wait indefinitely; as a result, there’s a new set of triage at play (who can wait and who can’t) given the risk to the elderly and those with underlying medical conditions. If you do need to see someone, you can use your usual codes for exams and file and be paid as usual. Don’t forget that first and foremost, your patients’ welfare is primary, but also be safe yourself and make sure that you and your staff use appropriate protective gear. The Centers for Disease Control and Prevention have good, continuously updated coronavirus guidance on such matters.
Q: If I determine that a patient needs care but it may not be safe to bring them into the office, how do I deliver care remotely?
A: There are multiple options available: live on the phone; simultaneous audio/video; “store and forward” (pictures with follow-up later); and e-visits (via email, for example). There are also codes for doctor-to-doctor consultations, but those may be less common in eye care.
Q: What billing codes apply to phone calls with patients made by doctors?
A: Some things are not covered services under Medicare (they weren’t before the emergency and remain so). For example, calling a patient to reschedule an appointment or merely to pass along a test result cannot be billed to Medicare or the patient. If your staff does these things, there is no mechanism for billing anyone.
In some cases, when your staff is reviewing the schedule and calls a patient, they may get the sense that a chat with the doctor is indicated. They should get consent for a telemedicine phone call and inform the patient that this will be billed. This should be documented in the chart; a written consent signed by the patient isn’t required (verbal notice is acceptable as long as it is documented). If you then speak with the patient and determine that he needs some minor care adjustment but can otherwise avoid a trip to the office, depending on the amount of time you as the provider spend with the patient, there are four possible codes: G2012; 99441; 99442; and 99443. On April 30, 2020, CMS raised the allowables for 99441-3. They noted that not all patients had the ability to do simultaneous audio and video. As a result of this change, 99441 has an allowable equal to 99212, 99442 equals 99213, and 99443 equals 99214.
Each of these codes imposes at least a five-minute provider time as well as other restrictions. (G2012 is not billable if there is a service related to the call rendered within 24 hours or at ‘next available’ appointment, for example or the service isn’t billable at all.) Document your time in case the phone visit is questioned later. (See your CPT and HCPCS code books for details.) It’s important to understand that CPT is created and revised by the AMA’s CPT Editorial Panel and HCPCS is maintained by CMS, so CMS may not always follow what AMA recommends as a code, and will instead create another code for Medicare use.
In CMS’ Interim Final Rule from March 30, 2020, CMS instructed to “report the POS code that would have been reported had the service been furnished in person.” Your claim to Medicare would normally use “02” for this but the instruction means that eye-care providers will use “11” as the Place of Service (POS) during the emergency. No modifier is needed or desired on these codes for Part B. Normally, CPT phone-call codes (99441 to 99443) aren’t paid by Medicare but coverage and payment is allowed under the pandemic emergency declaration. In this code series, 99443 has the highest time requirement for the provider to meet, so documenting that in the chart is key.
There’s a separate group of phone call codes for qualified health-care professionals (QHP) and non-physician providers (98966 to 98698) that Medicare covers as well. The term “QHP” in this setting means that a nurse practitioner or a physician assistant had the conversation and bills for it. Medicare covers the service here as well.
Q: What code applies if the doctor gets a digital image from a Medicare patient who asks for advice during this emergency?
A: For Medicare, code G2010 applies. To bill for the service, you would obtain consent for the service to be billed and the doctor (not staff) would then review the image and reply to the patient via the same methodology. As above, the claim would include POS “11.” No modifier is desired by Medicare.
Q: We have a secure patient portal. What if the doctors or QHP email back-and-forth with the patient? Is that billable during the COVID-19 emergency?
A: Yes. This was already payable before the emergency but it wasn’t something we typically thought of. Once the emergency is over, this might be something to consider as services are ramped up. CPT codes 99421 to 99423 apply here. Medicare covers and pays for the service. After consent for the service and billing, the doctor or QHP keeps track of how much time is involved in doing that over the next seven days and then tallies it up at the end of the week and bills one of the codes. 99421 has the lowest amount of time requirement and 99423 the highest. POS is “11.” No modifier is used for Medicare.
Q: I am a doctor and another doctor called me. She had an immunocompromised patient in the office with an eye condition. Rather than send the patient to me physically, she and I spoke with the patient present at her office. The other doctor felt we could minimize the exposure for the patient that way. After the discussion, I recommended some eye drops for the patient and didn’t need to see the patient physically. Can I get paid for that?
A: Yes. CPT codes 99446 through 99448 are for this service. You need the billing information, of course, but this is a payable service for Medicare during the emergency. Before billing, you should summarize your history and recommendations in a letter to the other doctor and send it for their files. Keep those notes in your records. Like the other codes, the time requirement varies: CPT 99446 has the lowest time and 99448 the highest. Be sure to document the consent and time, as above. On your claim, use POS “11”; no modifier is desired by Medicare.
Q: What if a patient can avoid coming in physically but I need to use both audio and video to check on her? Can I bill for that?
A: Yes. During the emergency declaration, when simultaneous audio and video are done and are medically supported, you can use Evaluation and Management codes 99212 to 99215 for established patients and 99201 to 99205 for new ones. On April 30, 2020, CMS changed the rules and made Eye codes (92002 to 92014) available to use for telemedicine. It’s not likely 92004 and 92014 could be met, but 92002 and 92012 are possible. Choose the appropriate code that pays best.
For the level of service, CMS notes you can use the normal 2020 rules (history, exam and decision making) or an option which is similar to the proposed rules for 2021. CMS noted in the Interim Final Rule above that, “On an interim basis, we are revising our policy to specify that the office/outpatient E/M level selection for these services … via telehealth can be based on medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record ... .”
Claims should use place of service code “11” as in the case above, however, to ensure proper payment, The Centers for Medicare and Medicaid Services are recommending that modifier 95 be used for these codes, only to note that the services were delivered during the emergency declaration. Those rules on POS and the 95 modifier will expire when the officially declared state of emergency expires.
Finally, on a personal note: Please stay safe, everyone. We’re all in this together. REVIEW
Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Atlanta. He welcomes any comments or questions on the topic of this month’s column. Please contact him at firstname.lastname@example.org.