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The 1135 Waiver and Telemedicine Services
Wednesday, April 1, 2020 11:30 AM
Practices are facing a multitude of challenges amid the ongoing COVID-19 pandemic. As a result, many of our clients are seeking solutions that will better equip them to continue providing high-quality patient care. Telemedicine technology represents an important opportunity to stay connected with patients and provide ongoing treatment. Below, I outline some key telemedicine considerations along with a summary of recent Centers for Medicare & Medicaid Services (CMS) guidelines that may prove helpful for practices.
Keeping Patients Safe
The highest priority lies in keeping all parties safe and avoiding exposing anyone to unnecessary risk in a field where provider-to-patient contact can sometimes be a necessity. Fortunately, we live in a time where telemedicine/telehealth is a viable option, allowing providers and patients to exchange medical information electronically in real-time.
Due to the coronavirus pandemic, and the resulting national emergency declaration by the president, many practices are responding by quickly turning to telemedicine. While practices offering telemedicine must adhere to stringent government regulations — just as they do with more traditional forms of medicine — the Health and Human Services (HHS) Secretary may, under Section 1135 of the Social Security Act, waive certain requirements for government health services so the needs of enrollees may be met.1,2
Implications of the 1135 Waiver
The 1135 waiver has been implemented in response to the coronavirus pandemic, relaxing regulations and facilitating several options for physicians to provide and code for telemedicine/telehealth services.3 Below, I explain how this impacts the regulations, delivery, and coding practices for those providing telehealth services.
1. Evaluation and Management (E/M) Codes
In 2019, CMS published telehealth guidelines listing traditional out-patient E/M codes (99201 – 99215) as an option.4 Under the generous provisions from the 1135 waiver, these telehealth guidelines will be impacted in the following ways:
- The originating site requirement is likely waived during this emergency.
- The exam limitations for certain procedures (e.g., dilated retinal exams and confrontation visual fields) will make it difficult to code above 99202 for new patients and above 99213 for established patients.
- Coding based on physician face-to-face time may have a different result.
Additionally, you should adjust the following items:
- For Medicare, use Place of Service (POS) “2” to represent care was delivered via telehealth.5
- Non-Medicare payers may prefer POS “12” to represent a patient’s home.
- Append modifier -95 “Synchronous Telemedicine Service Rendered via a Real-time Interactive Audio and Video Telecommunications System.”
Meanwhile, the usual Medicare geographic adjusted rates will apply, and E/M rules regarding the level of history, exam, and medical decision or the amount of time spent “face-to-face” with the physician will apply, as well.
2. Virtual Check-ins
A recent CMS press release and its associated fact sheet, “Coverage and Payment Related to COVID-19 Medicare,” discuss HCPCS code G2012 as a viable option for virtual check-ins.6,7 The code states: “Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion”.
Please note the following limitations associated with G2012:
- The national reimbursement rate is $14.80.
- CMS recently waived the established patient requirement during the emergency declaration.
- More than 7 days must have passed since the last visit.
- No additional E/M service can be provided within the next 24 hours.
3. Online Digital E/M Services
The same CMS press release and associated fact sheet mentioned in No. 2 (above) also lists the new digital E/M services 99421 – 99423. The new codes, which were released in January 2020, are as follows:
- 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes.
- 99422 - Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes.
- 99423 - Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.
Additionally, these codes stipulate that they:
- Are to be used for patient-initiated services with physicians or other qualified health care professionals (QHPs).
- Require the evaluation, assessment, and management of the patient (but are not to be used for test results, scheduling appointments, or other communication that does not include an E/M service).
- Require a secure Health Insurance Portability and Accountability Act (HIPAA) compliant platform.
- Can only be reported once every 7 days (the time being cumulative over that period).
- Cannot incorporate the physician/provider devoted to a digital E/M service within a separately reported E/M visit that occurs (in the office) within 7 days of the initiation of an online digital E/M service.
- Cannot be reported if the patient initiates an online digital inquiry for the same or a related problem within 7 days of a previous E/M service.
- Cannot be reported separately if the online digital inquiry is related to a surgical procedure and occurs during the post-operative period of a previously completed procedure.
If you plan on integrating telemedicine into your practice, you will need to keep the following in mind:
- Safeguarding Protected Health Information (PHI) remains critically important for all encounters, including those conducted digitally.
- Chart documentation needs to clearly identify the services delivered via telehealth. (Remaining sections of the exam documentation should be similar to a “typical” evaluation, including relevant history, exam, assessment/diagnosis, and plan.)
- Appropriate coding sequences for Medicare claims are as follows (at the time of publication):
- Outpatient E/M codes (99201- 99215) with modifier -95
- Virtual check-in (G2012)
- Online digital E/M codes (99421 – 99423)
While the new CMS guidelines certainly provide important opportunities for continued patient care in these challenging times, we urge practices to monitor telemedicine transactions closely. It is certainly possible that modifier -95 or other factors could result in claims processing challenges; therefore, it is highly recommended that practices proactively contact third-party payers directly to determine if they have any policies or guidelines related to telemedicine services.
HELPFUL RESOURCES: To learn more about telemedicine services, click on this flowchart/FAQ for eye care practices and this medical practice implementation guideline. Additional information can be found on our dedicated COVID-19 resource page.