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Health Law Monitor

Play it Again Sam—CMS Issues Round Two of Telehealth Changes

May 4, 2020

By: Alaina N. Crislip

CMS has issued more telehealth regulatory flexibilities in light of the COVID-19 public health emergency (PHE), including new blanket waivers,1 guidance for rural health clinics (RHCs) and federally qualified health centers (FQHCs) under the CARES Act, and a new interim final rule issued April 30, 2020 (IFC).2 

Additions to List of Eligible Providers

For the remainder of the PHE, physical therapists, occupational therapists, and speech-language pathologists, among others eligible to bill Medicare, may provide distant site telehealth Medicare services. Before this change, only specified providers, including physicians nurse practitioners and physician assistants could engage in the provision of covered Medicare telehealth services. These restrictions are now removed under the blanket waiver; provided that, applicable practitioners must still adhere to state law licensure and scope of practice requirements when providing telehealth services. Because these laws vary from state-to-state, and even from state licensing agency-to-state licensing agency, it is important for licensed professionals to consult their respective state licensure boards to determine whether the telehealth services now made reimbursable by CMS are an authorized form of practice. 

Audio-Only Telehealth Expanded

After receiving feedback from stakeholders over the last month, CMS has learned that the use of audio-only codes is more widespread than originally anticipated. Additionally, CMS has indicated that the audio-only visits are appropriate for a higher intensity level of service than originally thought.  As a result, CMS is:

  • Temporarily waiving the required use of video technology, and permitting audio-only equipment to furnish services described by the code for audio-only telephone evaluation and management services (E/M), and behavioral health counseling and educational services; and
  • Increasing reimbursement for CPY codes 99441, 99442, and 99443 to align with reimbursement for office visits.

The ability to utilize these codes is retroactive to March 1, 2020. Codes that may be billed without an interactive video requirement will have a notation in the specific telehealth code. Additionally, CMS is exercising its enforcement discretion during the PHE to relax the requirement that audio-only services be provided only to “established patients”. Unless otherwise appropriately waived by a practitioner, cost-sharing obligations are still applicable to these services. Again, it is important to emphasize that licensed professionals need to ensure these forms of telehealth practice are legally authorized in their own states.

Telephone Assessments Permitted for Opioid Treatment Programs (OTP)

The most recent IFC issued by CMS permits OTPs to provide periodic assessments via a two-way interactive video communication technology during the PHE. If such technology is not available, then periodic assessments may be provided using audio-only telephone calls, as long as all applicable requirements are met. OTPs should use clinical judgment to evaluate and determine whether the periodic assessment may be performed with audio-only phone calls. The format of the assessment chosen, along with the reason and substance of the assessment, should be documented in the medical record. 

RHCs and FQHCs Telehealth Coverage

Initially RHCs and FQHCs were not covered by Medicare for telehealth services as a distant site.

Medicare will now reimburse telehealth services provided by RHCs and FQHCs, including recognition as a distant site, from January 27, 2020. through the duration of the PHE. Key takeaways include:

  • Any telehealth services in the Medicare telehealth code list may be provided by an RHC/FQHC practitioner and the use of HCPCS G2025 must be used to identify the telehealth services being provided;
  • Effective March 6, 2020, patients may be at any site including their home;
  • The services may be furnished by any practitioner working for the RHC/FQHC as permitted within the practitioner’s applicable scope of practice under state law; and
  • The practitioners can provide telehealth services from any distant site location during the time they are working for the RHC/FQHC, including their homes.

CMS has issued additional subregulatory guidance on the following:3

  • Claims submission requirements for RHCs/FQHCs;
  • Process by which CMS will address reprocessing and payment of claims;
  • Timing of processing by CMS;
  • Special billing rules and requirements related to cost-sharing waivers; and
  • Additional billing information and requirements for any telehealth service offered by RHCs/FQHCs.

CMS has established the payment rate for these claims at $92.03 (the average cost reimbursement rate for all telehealth services on the telehealth services list, weighted by volume), and will continue to evaluate this payment rate should the PHE extend beyond the end of the year.  

Hospital Provider Based Billing and Reimbursement for Outpatient Settings

CMS clarifies that hospitals may now bill for telehealth services furnished by hospital-based physicians to outpatients, including when patients are at their homes; provided that, the home is serving as a temporary provider-based department of the hospital. The reasons for such visit must be documented in the patient medical record. This is significant because hospitals may now bill for both the distant site provider fee and the originating site facility fee for telehealth services provided by hospital-based practitioners.

Remote Physiological Monitoring (RPM) Requirements Modified

Prior to the PHE, CPT code 99454 for RPM services required monitoring for at least 16 days during a 30-day period.  As of the most recent CMS IFC, for the duration of the PHE, RPM services can be reported for periods of time with as few as 2 days during a 30-day period, subject to other billing requirements. Any such instance in which the RPM modification is utilized must be for patients who have a suspected or confirmed diagnosis of COVID-19.

What Does This Mean?

Clearly CMS is viewing telehealth services as an effective tool to aid in the fight against the public health threats posed by the spread of COVID-19.  Which of these changes will last beyond the PHE? Will consumerism help drive the need for telehealth to be on a more equal footing with other face-to-face health care services? The answers to these questions will continue to evolve with the ever-changing regulatory COVID-19 landscape.


1  https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

2  https://www.cms.gov/files/document/covid-medicare-and-medicaid-ifc2.pdf

3  https://www.cms.gov/files/document/se20016.pdf


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