On March 17, 2020, the Centers for Medicare and Medicaid Services (CMS) CMS Telemedicine Fact Sheet announced broadened access to “virtual services” under the Medicare benefit to allow beneficiaries to receive a wider range of services without having to travel to an office or other healthcare facility. CMS expanded these benefits on a “temporary and emergency basis” during the current national Public Health Emergency (PHE) declared by the president. For the duration of the COVID-19 PHE, Medicare will make payment for these virtual services for beneficiaries in any location (in the patient’s home or in a facility/clinic) and in any area (rural or urban). And, in the case of e-visits, CMS has expanded the list of “approved practitioners” who are able to provide and bill for the service to include PTs, OTs and SLPs.
This expanded access applies to services covered under Medicare Part B. It does not apply to services billed to Medicare Part A or other payers, including Medicare Advantage. Providers must contact each payer directly to ascertain coverage of any and all virtual services, including telehealth and e-visits.
NOTE: State laws (i.e., each discipline’s State Practice Act) must be carefully reviewed to ensure remote/virtual/telehealth intervention or assessment is allowed by law before implementing any type of remote or virtual therapy program.
CMS’s March 17 declaration addresses three main types of virtual services: Medicare telehealth visits, virtual check-ins and e-visits.
- Telehealth visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. The provider must use an interactive audio and video telecommunications system that permits real-time (synchronous) communication. Telehealth services under Medicare are limited to the following practitioners (subject to state law): physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dieticians, and nutrition professionals. PTs, OTs and SLPs are not approved providers of telehealth visits under Medicare.
- Virtual check-ins are a way for an established Medicare patient to have a brief communication with their physician (or certain other practitioners – not including PTs, OTs and SLPs) to avoid unnecessary trips to the doctor’s office. Virtual check-ins cannot be related to a medical visit in the previous 7 days and cannot lead to a medical visit within the next 24 hours. Virtual check-ins can be accomplished using a variety of communication modalities, including a discussion over the telephone, secure texting, via a patient portal or even by email.
- E-visits are described by CMS in the 2020 Medicare Physician Fee Schedule final rule as “non face-to-face patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.” Under the waiver, e-visits can be conducted from all types of locations, including the patient’s home, and in all areas, not just rural. CMS expanded the list of clinicians who are able to provide and bill for E-visits under Medicare Part B to include PTs, OTs and SLPs. E-visits may only be reported for established patients, must be initiated by the patient, and under the original CPT code description, must be delivered via an online patient portal.
During this waiver, CMS has indicated they are granting providers flexibility regarding the platform used to deliver remote/virtual visits, including e-visits, such that other methods of communication – including “everyday communications technologies, such as FaceTime or Skype,” may be used during this nationwide PHE without fear of HIPAA violations or penalties from the HHS Office for Civil Rights (OCR). That being said, a HIPAA-compliant platform (such as Zoom for Healthcare or Skype for Business) is recommended.
An e-visit is not a telehealth service under the Medicare definition, and must be billed by PTs, OTs and SLPs using one of three HCPCS G codes based on the cumulative amount of time spent communicating and interacting with the patient over a 7-day period:
- G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
- G2062: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
- G2063: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
Only one e-visit G code can be billed per 7-day period based on total time during those 7 days. Reimbursement is based on the Medicare Physician Fee Schedule and varies by locality/region. In general, payment for G0261 is approximately $12, G0262 is $22 and G0263 is $34. Rates can be accessed via the Physician Fee Schedule Lookup Tool accessible on the CMS website. It is unclear at this time if these codes can be billed for consecutive 7-day periods – that is, more than once during a therapy episode of care. APTA has reached out to CMS for clarification on this issue, as the codes were initially developed to be used for 7 days after and before a face-to-face visit.
CMS has indicated that modifier “CR” should be appended to the e-visit G codes on both institutional and professional claims to signify the services are being provided and billed under the 1135 waiver. Condition code “DR” should be included on institutional claims in addition to the CR modifier. Guidance from the APTA indicates that the GP, GO and GN modifiers are not required when billing the e-visit G codes.
The place of service (POS) code on the claim for e-visits should correspond to the location of the rendering provider – that is the location of the treating therapist. If the therapist is conducting the e-visit from the therapy clinic or office, POS code 11 should be used. If the therapist is conducting the e-visit from a mobile or home office, POS code 12 should be used. Because e-visits are not telehealth services, POS code 02 should not be used.
Documentation to support an e-visit should indicate that the patient initiated the e-visit, that the patient consented to the e-visit, and the service(s) provided (e.g., assessment, instruction, management, progression), including the clinical decision making of the therapist.
APTA emphasizes that e-visits are not “regular” therapy treatment visits, and as such, they do not count toward the patient’s Medicare tenth visit progress report period, and do not take the place of “regular” treatment intervention. E-visits are a way for the patient to reach out to their therapist with any questions or concerns about their ongoing, established treatment regimen and for the therapist to assess and manage the patient’s plan during the PHE.
Ongoing advocacy with CMS is critical at this time to ensure PTs, OTs and SLPs are included in the list of qualified professionals that are able to provide telehealth.
Remember, this policy applies to services billed to Medicare Part B only. Contact other non-Medicare payers and ask about their coverage of virtual services – both e-visits and telehealth.
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