You know how the old line goes: If at first you do not succeed …

Keep justifying yourself until you get a Centers for Medicare & Medicaid Services win!

Such is the theme surrounding therapy providers, telehealth allowances, and the impacts of the pandemic on our ability to safely and effectively provide skilled care.

The timeline goes a little something like this.

March 17, 2020: Telehealth for MDs; E-visits for some therapy providers 

The success:

The Trump administration announced expanded Medicare telehealth coverage that enabled beneficiaries to receive a wider range of healthcare services from their doctors without having to travel to a healthcare facility. 

Beginning on March 6, 2020, Medicare — administered by the Centers for Medicare & Medicaid Services — announced that it would temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country.

The challenge:

As part of this declaration, CPT codes often used by therapists were included. However, at this point therapists were still statutorily excluded from providing telehealth.

What therapists in some settings did receive allowance for as part of this announcement was use of e-visits. 

An e-visit is considered a service furnished remotely using technology but is not considered a Medicare telehealth service. 

The 2020 Medicare Physician Fee Schedule describes e-visits as non-face-to-face “patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.” 

The Medicare G-codes for e-visits are G2061-G2063 and include very specific parameters to determine whether an e-visit can be included on a Medicare Part B (outpatient) claim for payment. 

  • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes 
  • G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11–20 minutes 
  • G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes 

April 8, 2020: CMS confirms use of technology to deliver ‘in-person’ services in the same building

The success:

Thanks to a thoughtful question posed on the CMS weekly COVID-19 provider calls, therapists received further clarification on how they can successfully provide care within the same building in a different location.

During this call CMS staff stated that therapists may provide evaluation and treatment services to patients in skilled nursing facilities via audiovisual devices, and that these services, for billing purposes, would be considered in-person services when provided in the same building as the patient.

Technology for this service was clarified to include smartphones or tablets to be used to provide evaluation and treatment, when clinically appropriate, and should be reported as in-person services, not telehealth, per Emily Yoder, an analyst with CMS’s Division of Practitioner Services.

This allowance permitted successful integration of therapy services in communities developing COVID-19 specific units thus promoting conservation of valuable personal protective equipment and clinically appropriate therapy service delivery.

Following this clarification CMS also updated its running Q & A document with the below.

Question: Should on-site visits conducted via video or through a window in the clinic suite be reported as telehealth services? How could a physician or practitioner bill if this were telehealth? 

Answer: Services should only be reported as telehealth services when the individual physician or practitioner furnishing the service is not at the same location as the beneficiary. If the physician or practitioner furnished the service from a place other than where the beneficiary is located (a “distant site”), they should report those services as telehealth services. If the beneficiary and the physician or practitioner furnishing the service are in the same institutional setting but are utilizing telecommunications technology to furnish the service due to exposure risks, the practitioner would not need to report this service as telehealth and should instead report whatever code described the in-person service furnished. New: 4/9/20 

The challenge:

This new flexibility was not considered an expansion of telehealth coverage or eligibility by CMS.

April 30, 2020: Further expansion of telehealth in Medicare announced

The success:

CMS announced this expansion in an April 30, 2020, press release and its COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

In response to the spread of COVID-19, CMS allowed audiologists and speech-language pathologists to provide telehealth services to Medicare Part B (outpatient) beneficiaries, retroactive to March 1, 2020, and for the duration of the public health emergency. 

Additionally, we received guidance on allowable CPT codes as noted below.

The challenge: 

Institutional billing allowances.

To say, can telehealth be billed on the 1500 form and on the UB-04? 

At this point therapists continued to seek clarity on setting specificity and allowance. 

May 27, 2020: CMS updates its FAQ’s

The success:

Medicare updated their FAQ documents to include the following:

  1. Question: Can outpatient therapy services that are furnished via telehealth and separately paid under Part B be reported on an institutional claim (e.g., UB-04) during the COVID-19 PHE? 

Answer: Yes, outpatient therapy services that are furnished via telehealth, and are separately paid and not included as part of a bundled institutional payment, can be reported on institutional claims with the “-95” modifier applied to the service line. 

This includes: 

  •  Hospital – 12X or 13X (for hospital outpatient therapy services); 
  •  Skilled Nursing Facility (SNF) – 22X or 23X (SNFs may, in some circumstances, furnish Part B physical therapy (PT)/occupational therapy (OT)/speech-language pathology (SLP) services to their own long-term residents);
  • Critical Access Hospital (CAH) – 85X (CAHs may separately provide and bill for PT, OT, and SLP services on 85X bill type); 
  •  Comprehensive Outpatient Rehabilitation Facility (CORF) – 75X (CORFs provide ambulatory outpatient PT, OT, SLP services); 
  • Outpatient Rehabilitation Facility (ORF) – 74X (ORFs, also known as rehabilitation agencies, provide ambulatory outpatient PT & SLP as well as OT services); and 
  • Home Health Agency (HHA) – 34X (agencies may separately provide and bill for outpatient PT/OT/SLP services to persons in their homes only if such patients are not under a home health plan of care). New: 5/27/20 
  1. Question: Can therapy services furnished using telecommunications technology be paid separately in a Medicare Part A skilled nursing facility stay? 

Answer: Provision of therapy services using telecommunications technology (consistent with applicable state scope of practice laws) does not change rules regarding SNF consolidated billing or bundling. For example, Medicare payment for therapy services is bundled into the SNF Prospective Payment System (PPS) rate during a SNF covered Part A stay, regardless of whether or not they are furnished using telecommunications technology. Therapy services furnished to a SNF resident, whether in person or as telehealth services, during a non-covered SNF stay (Part A benefits exhausted, SNF level of care requirement not met, etc.) must be billed to Part B by the SNF itself using bill type 22X, regardless of whether or not they are furnished using telecommunications technology. New: 5/27/20 

Where do we stand today?

Today, thanks to the diligence of our therapy associations, professional societies, groups including NARA and NASL, and a few persistent therapists who been successful in getting into the COVID-19 weekly calls cue (Thanks Mark, Bob, and Rick!- we are all cheering you on) we are making progress.

With that said, our advocacy efforts should continue to seek clarity specific to site location, payer and CPT code allowances.

We also need to be accountable for the care we provide under these new flexibilities.

With greater flexibility, we as therapists must continue to honor our responsibility to provide the highest level of evidenced based, person-centered, skilled care. 

Let us continue to advocate for those we serve, during this time of pandemic and for all the days that follow. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).