For several years, we’ve seen Medicare and the AMA’s Current Procedural Terminology (CPT) manual slowly approach the age of telehealth. With a lot of discussion and many headlines for each of the last few years in reality the codes and coverage embracing the modern age of medicine have lagged far behind the technology.
This isn’t limited to telehealth, or even coding and payments. The degree of penetration and utilization of the EHR in the last decade has left many of the regulations intended to govern the business of medicine in the dust. Rules written to govern the paper chart don’t really jibe with reality anymore. The old consult language of ‘communicated by written report’ hasn’t changed since those notes were typed on a typewriter and envelopes addressed by hand.
The Federal Documentation guidelines, a standard for the last twenty-five years, and the daily confinement of compliance for physicians, are the latest to show up in the rear-view mirror.
Fast-forward to the future in two short weeks, at least temporarily. Since the Public Health Emergency of COVID-19 has come to America in March and April of 2020 CMS has unleashed a series of changes intended to allow the codes and coverage to catch up with the newly imposed reality of telehealth.
Although specific e-service and telehealth type codes were in their infancy, both the CPT and the CMS systems are equipped to allow for Telehealth services and claims to be clearly identified, coded and billed. CPT had introduced the star symbol next to certain codes that were eligible for telehealth. Modifier 95 has been around for some time and identifies services performed via synchronous telemedicine with real-time audio/video communication.
The POS (Place of Service) codes, as CMS now uses them as of March 31, allow CMS to determine whether or not the service rendered was a traditional remote originating site (POS 2), or the new temporary version using office, hospital or other POS codes (11, 22 etc.).
Until late March 2020, the single largest obstacle to widespread adoption of telehealth for office services was the geographic limitations imposed by Medicare’s originating site geographic limitation—that the originating site be outside of a major metropolitan area. That was the elephant in the road, effectively blocking the use of the codes for any urban and many suburban areas, regardless of the practicality of it.
COVID-19 moved the elephant, at least for now. So welcome to the future.
Since late March CMS has taken extraordinary steps to allow providers to do what needs to be done, and to pay them for it. Here they are:
- Medicare will now pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
- After some initial back and forth Medicare has settled on paying physicians the standard office rate (POS ) payment for services provided via telehealth, and not apply the site-of -service differential associated with hospital clinic type encounters.
- HIPAA and Privacy Standards have been temporarily relaxed to allow the use of Facetime, Zoom, Skype and certain real-time two way telecommunications with patients for office visits.
- The April 6th Federal Register included detail on relaxed documentation requirements for COVID-19 telehealth office visit documentation: "On an interim basis, we are revising our policy to specify that the office/outpatient E/M level selection for these services when furnished via telehealth can be based on 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. "
This is truly a back to the future moment as this is the documentation standard that CMS and the CPT manual are moving to on January 1, 2021. The items listed above are just some of the larger moves. There is much more, payment for certain phone calls—things that CMS has never done. See the CMS website for the latest updates, they have been coming every few days.
So although all of this activity is unfortunately in response to the COVID-19 crisis, it is heartening to see CMS respond so appropriately, and relatively quickly. Who knew an elephant could move that fast? And once we are through the healthcare crisis facing us all CMS will face another challenge, perhaps more difficult in a way. How are they going to get the telehealth genie back in the bottle?
Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years.