On January 31st, 2020, Health and Human Services Secretary Azar declared a state of emergency across the entire United States. This means that under the now passed legislation, providers can bill for Medicare covered telehealth services nationwide without the originating site requirement (though services must still be via audio-video consultation).
Medicare beneficiaries may receive telehealth services as a Medicare covered service only in certain instances. The Bill gives the Secretary of US Department of Health and Human Services (HHS) the authority to Waive:
- The originating site requirement for telehealth services provided to Medicare beneficiaries located in any identified emergency area during emergency periods by a qualified provider.
- “Emergency area”- a geographical area in which, an “emergency period” is the period during which there exists: (a) an emergency or disaster declared by the president pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act and (b) a public health emergency declared by the secretary.
- Bill allows telehealth services to be provided to Medicare beneficiaries via phone, but only if the phone allows for audio-video interaction between the provider and the beneficiary.
- Allows Medicare beneficiaries to receive telehealth services from the comfort of their home (even via their smart phone) without risk of exposure.
- Healthcare providers MUST still comply with state laws and regulations that govern telehealth, including, but not limited to professional licensure, scope of practice, standard of care, patient consent and other reimbursement requirements for non- Medicare beneficiaries.
Please keep in mind, you still will need to submit the claim under the NPI number of a physician or NP and use POS Code “02”.
Three specific challenges the new legislation poses:
- The definition of a “qualified provider”
- Newly eligible Medicare patients are not eligible
- Free telehealth visits for Medicare patients may violate anti-kickback rules
Qualified Provider
To qualify as a medical provider who can receive payment for telehealth visits under the legislation, the provider must have a previous relationship with the patient and must have provided a service within three years prior.
Newly eligible Medicare patients are not eligible
Virtual check-ins and image/video evaluations are limited to established patients. An established patient is someone who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and sub-specialty who belongs to the same group practice, within the past three years.
The clinician must start an office visit with a look-back at claims data to determine eligibility. If the clinician doesn’t do this, they risk incurring a false claim.
The provider must identify under the same Tax ID Number (TIN) as the provider who is linked to the patient. The legislation stipulates the provider’s prior relationship with the patient a Medicare relationship. If the patient had commercial insurance and visited their PCP, the visit does not count toward the previous relationship due to it was not covered by Medicare.
Free telehealth visits for Medicare patients may violate anti-kickback rules
Hospitals may be able to provide Coronavirus-related care at no cost to an individual under patient – centered care. Hospitals are not able to give Medicare patients free visits. This is considered an incentive under Medicare rules, unless Medicare waived the rule. This would be a violation of the anti-kickback rules.
Access the MLN Booklet from CMS, here. The booklet details the regulations prior to COVID-19. The booklet reviews CMS guidelines for telehealth services providing the following information:
- Originating Sites
- Distant Site Practitioners
- Telehealth Services
- Telehealth Services Billing and Payment
- Telehealth Originating Sites Billing and Payment
Additional services available for payment that are not restricted by originating site and other Medicare telehealth regulations, “communications-based technology codes” (G2012). These codes are not deemed by CMS to be Medicare “telehealth services”, which means they are not subject to the statutory restrictions regarding originating site and rural geography.
These codes can be used when the patients are in their homes and regardless of a national emergency declaration. There are also time-based, online digital E/M codes for established patients:
- 99421- Online digital E/M services, for established patients, up to 7 days with a cumulative time of 5-10 minutes.
- 99422- Online digital E/M services, for established patients, up to 7 days with a cumulative time of 11-20 minutes.
- 99423- Online digital E/M services, for established patients, up to 7 days with a cumulative time of 21 minutes or more.
NOTE: The above codes are only for healthcare professionals who can bill E/M services.
HCPCS Codes for qualified non-physician healthcare professional:
- G2012- Virtual check-in by a physician or other qualified health care professional who can report E/M 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, 5-10 minutes of medical discussion.
- G2061- Qualified non-physician healthcare professional online assessment and management for established patients up to 7 days with a cumulative time of 5-10 minutes
- G2062- Qualified non-physician healthcare professional online assessment and management for established patients up to 7 days with a cumulative time of 11-20 minutes
- G2063- Qualified non-physician healthcare professional online assessment and management for an established patient up to 7 days with a cumulative time of 21 minutes or more
References
https://www.congress.gov/116/bills/hr6074/BILLS-116hr6074enr.pdf
https://www.nixonlawgroup.com/nlg-blog/2019/11/4/how-to-get-paid-for-patient-e-visits
https://www.aapc.com/blog/49520-get-paid-for-virtual-check-ins/