COVID-19 Telehealth Reimbursement Update

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COVID-19 Telehealth Reimbursement Update*

Telehealth reimbursement for services delivered during COVID-19 has reportedly been variable. Practitioners across professions are voicing complaints about rejected billing. In this brief article, the Telebehavioral Health Institute (Telehealth.org) summarizes current events as reported from key associations and news outlets to help you better understand to be successful at telehealth reimbursement. This article also points to resources and concludes by inviting the Telehealth.org community to weigh in with their experiences to help shed some light on practical solutions.

3/31/2020 Update to COVID-19 Telehealth Reimbursement

On 3/31/2020, CMS changed regulations for the use of telehealth in the Medicare program, including the use of telephone, and licensure for Medicare providers. Those changes have repercussions for both Medicare and commercial payers. Both systems will be addressed below, along with resources for professionals wishing to learn more. Since then, a number of groups have been posting updates to their COVID-19 telehealth reimbursement information.

Background: On March 17, 2020, the Center for Medicare and Medicaid Services Administration (CMS) released guidance allowing patients to be seen via live, 2-way interactive videoconferencing in their homes. This change is a marked deviation from previous telehealth rules, which only allowed telehealth visits to be received by clients and patients who were required to travel to a qualifying “originating site” for telehealth encounters reimbursed by Medicare. Telehealth Reimbursement was only available to clinicians in specific professions, which in the behavioral community, in effect, excluded counselors, Couples and marriage therapists (MFTs), addiction professionals, and behavior analysts.

The article below is a summary of information found across guidance in the behavioral and medical professions. Key links are provided for your convenience.

Current COVID-19 Telehealth Reimbursement

Many private payers may ask for a billing standard that is similar to Medicare, including the use of the same modifier and Place of Service (POS) codes. Click here to read the release from the Center for Medicare and Medicaid Services (CMS), which provides detailed Fact Sheets and FAQs defining a telehealth encounter for telehealth reimbursement purposes. Summarizes are provided for you below.

On the 1500 claim form, use the same CPT codes as would be used for an in-person encounter.

Use the modifier “95” after each CPT code to indicate the care was provided through telehealth.

In conducting a telehealth encounter, professionals are to use the same CPT codes on the 1500 form as if the encounter were in-person.

Use the “11” Place of Service (POS) that aligns with the specific encounter, just as they would when seeing clients and patients in person.

The American Psychological Association published an article summarizing telehealth reimbursement and giving using 1500 forms for two Medicare case examples. See Billing for psychological services provided during the COVID-19 public health emergency

The American Psychiatric Association has developed a list of responses by individual commercial payors, which can be found at the bottom of this page: Telepsychiatry and COVID-19  They have also provided a model letter for providers to use when contacting these payors.

CPT Codes Allowed for Telephone-Only or Traditional Telehealth

Payments for telephone (audio) only services are retroactive to 3/1/2020.

Diagnostic Interview (90791, 90792)

Psychotherapy (90832, 90833, 90834, 90836, 90837, 90838)

Psychoanalysis (90845)

Group Psychotherapy (90853)

Family Psychotherapy (90846, 90847)

Crisis Intervention and Interactive Complexity (90839, 90840, 90785)

Neurobehavioral Status Exam (96116, 96121)

Psychological Evaluation (96130, 96131)

Neuropsychological Evaluation (96132, 96133)

Psychological and Neuropsychological Test Administration and Scoring (96136, 96137, 96138, 96139)

Health Behavior Assessment (96156)

Health Behavior Intervention, Individual (96158, 96159)

Health Behavior Intervention, Group (96164, 96165)

Health Behavior Intervention, Family with the patient (96167, 96178)

Behavioral Screening (96127)

CMS also announced they will be increasing payments for audio-only telephone visits (99441, 99442, 99443) between Medicare beneficiaries and their providers to match payments for similar office and outpatient visits.

Screening, Brief Intervention, and Referral to Treatment (G0396, G0397)

See American Psychological Association article: Phone only telehealth services for Medicare during COVID-19

Forensic and Other Assessment Specialists

The American Psychological Association issued guidance for assessment professionals that includes telehealth reimbursement in a number of articles:

Neuropsychological and psychological testing during COVID-19

Guidance on CPT codes, technical requirements and more for successfully providing neuropsychology services via telehealth: Teleneuropsychology: New resources for your practice

COVID-19 Telehealth Reimbursement for Medicare

For telehealth, use the same CPT codes as if the encounter were in-person, but with these factors considered:

For new telepsychiatry encounters provided to patients under the waiver that would have been office visits, psychiatrists should consider their office as the place of service (POS) and use the place of service code 11, just as you did when you were seeing your patients in person. If you are providing inpatient care, you should use the place of service you would ordinarily use for that place even though you are not actually there. You should use the same CPT codes you would use for an in-person encounter, and on the 1500 Claim Form you should add the modifier 95 after each CPT code to indicate the care was provided as telemedicine. These same directions should be applicable for most commercial payers as well. Please let APA know if your experience is different.

Those psychiatrists who were previously providing telepsychiatry under Medicare’s pre-waiver rules should continue to report this care as they always have, for example, with POS 02.

For more information on telepsychiatry during COVID, see our Telepsychiatry blog.

CMS guidance dated March 17, 2020, allows patients to be seen via live videoconferencing in their homes.  

The Office of Civil Rights (OCR) has indicated they will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through a variety of technologies, but providers must use as many safety precautions as possible, and clients and patients must be informed of potential risks. Examples of currently allowed technology that is otherwise non-HIPAA compliant are FaceTime or Skype. When possible, however, clinicians are encouraged to protect their clients and patients by using HIPAA-compliant services. (See Telehealth.org Buyer’s Guide for options.)  

While Medicare coinsurance and deductibles would normally apply to these services, but HHS Office of Inspector General (OIG) is allowing professionals to waive these payments. Of note is that these payments typically are collected by the provider. The OIG then, in essence, is allowing the provider to waive co-pays.

Ryan Haight Act

The Ryan Haight Act requires an initial, in-person assessment of a patient to establish a professional relationship prior to digitally prescribing a controlled substance. As of March 17, 2020, the DEA has suspended this requirement.

Inpatient Psychiatric Settings (ECT)

In response to the March 18 announcement by the Centers for Medicare & Medicaid Services (CMS) recommendations regarding adult elective surgeries, and non-essential medical, surgical, and dental procedures during the COVID-19 outbreak, the American Psychiatric Association has taken the position that ECT an essential procedure. For more information, see their statement here: Telepsychiatry and COVID-19

COVID-19 Telehealth Reimbursement: Substance Use Disorders (SUDs)

On March 31, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Agency (DEA) released guidance providing flexibility to prescribe buprenorphine to new and existing patients with opioid use disorder via telephone by otherwise authorized practitioners without requiring such practitioners to first assess the patient in person or via telemedicine.

Separate guidance has been provided for patients treated with methadone in an Opioid Treatment Program

Guidance and resources for treating patients with mental health and substance use disorders: COVID-19 webpage.

On March 19, SAMHSA released guidance on 42 CFR Part 2

CMS Recommendations – Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I (April 19, 2020)

On March 16, SAMHSA posted COVID-19 guidance providing potential flexibility for Opioid Treatment Programs (OTPs).

Includes approaches for providing pharmacotherapy for opioids use disorder patients exposed to infections and COVID-19, disaster planning, potential flexibility for take-home medication, OTP guidance for patients quarantined at home with the coronavirus, and Frequently Asked Questions.

COVID-19 Guidance for Opioid Treatment Programs

On March 16, the Drug Enforcement Administration released Use of Telemedicine While Providing Medication-Assisted Treatment (MAT)

Substance Abuse and Mental Health Services Administration (SAMHSA): FAQs for Opioid Use Disorder Prescribing and Dispensing in the COVID-19 Emergency(March 19, 2020)

Drug Enforcement Agency (DEA): Advisory Letter Authorizing Expanded MAT Permissions (March 31, 2020)

Substance Abuse and Mental Health Services Administration (SAMHSA): COVID-19 Guidance for Opioid Treatment Programs and Opioid Treatment Programs – Sample Frequently Asked Questions (FAQs)

COVID-19 Telehealth Reimbursement: State-Based Guidance

A variety of sources have published guidance for providers interested in following developments at their state level.

Center for Connected Health Policy COVID-19 Related State Actions

National Governors Association website, What Steps Have States Taken To Address Coronavirus?

American Psychiatric Association Telepsychiatry and COVID-19

American Psychological Association Telehealth guidance-by-state during COVID-19

COVID-19 Telehealth Reimbursement: E-Visits

An e-Visit is a patient-initiated communication using digital patient portals, which are websites that give patients 24-hour access to personal health information. The patient logs into a secured area from anywhere with an Internet connection, using a secure username and password. Portals can include communication technology for established patients to use to send secure messages to the provider or their staff. These digital assessment services allow the provider to make clinical decisions that otherwise would have been provided in the office. CPT codes are available to bill for such services, however, Medicare co-insurance and deductible amounts cannot be waived for such visits.

During COVID, CMS is not enforcing the requirement limiting E-Visits to established patients only. The service description for non-medical professionals to use when billing is: “Qualified nonphysician healthcare professional online assessment and management, for an established patient, for up to seven days.”

G2062: cumulative time of 11-20 minutes during the seven days

G2063: cumulative time of 21 or more minutes during the seven days

Getting Rejection Notices?COVID-19 Telehealth Reimbursement Other Resources

The American Professional Agency, Inc, a malpractice carrier that has been supportive of telehealth for over a decade, has developed these COVID-19 resources:

FAQ about Coronavirus and Telehealth

Coronavirus and Telehealth Resources

If you are having difficulty getting paid by any payor, including the commerical payors, consider taking these steps:

Contact your state Insurance Commissioner. They are empowered to intervene on your behalf with insurance companies who are ignoring the law. You can find email addresses for your state legislators and Insurance Commissioners by going to your state websites.

Write a letter to your members of Congress

Representatives

Senators

If you are not getting paid by Medicare, send a letter to CMS Administrator Seema Verma and HHS Secretary Alex Azar at the addresses below:

• The Honorable Seema Verma
• Secretary Administrator
• U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services
• 200 Independence Avenue, S.W. 200 Independence Avenue, S.W.
• Washington, D.C. 20201 Washington, D.C. 20201
• The Honorable Alex Azar
• SecretaryU.S. Department of Health & Human Services 
• 200 Independence Avenue, S.W.

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