Medicare Telehealth: An Updated Overview

Telehealth services are reimbursed off the Physician Fee Schedule (PFS), a $90 Billion payment system. The payments under the PFS are resource-based, and they take into account physician or other practitioner work, practice expenses (clinical staff, time, equipment, and disposable supplies), and malpractice insurance. Payment is made at the level of a hick picks (HCPCS) code (list is maintained on the CMS website), with each code generally describing a discrete service. For purposes of physician payment policy, CMS tends to divide the “world” of virtual services into those that CMS considers Medicare telehealth and those that are not Medicare telehealth. The internal and external processes for adding new codes for telehealth services are done through the PFS Notice and Comment Rulemaking Process. In the past, CMS has created Medicare-specific coding to describe a portion of service when they do not believe that the entire service could be furnished using Telecommunication Technology.

Payment Policy for Medicare Telehealth

These are services that would otherwise occur in person and are paid at the in-person rate. This point is essential because, as previously stated, the PFS is a resource-based payment system. Services used to furnish telehealth communication technology must be valued to account for the efficiencies of furnishing a service remotely. However, Medicare Telehealth Services are not described or valued as remote services. They are the same, for payment purposes, as an in-person service. These services are subjected to restrictions on geography, site of service, and practitioner type. The Medicare Telehealth benefit was made to improve access to care for beneficiaries in rural areas.
Section 1834(m) of the Social Security Act lays out the specific circumstances where Medicare will make payments for services that would otherwise occur in-person but are instead furnished using communication technology.
The beneficiary must be in a rural area, and they must be in a medical facility. There are a few exceptions—Congress has amended 1834(m) to remove the geographic and site of service restrictions for beneficiaries with end-stage renal disease, for diagnosis and treatment of an acute stroke, for beneficiaries with a substance use disorder and co-occurring mental health disorder, and most recently, services pertaining to mental health.
The statute also limits the range of practitioners who can bill for telehealth. There is a list of these practitioners in the statute.
This statute excludes therapists—physical therapists, occupational therapists, and speech-language pathologists. Therefore, they cannot bill for telehealth.
This statute specifies that telehealth must be furnished using Telecommunications technology. CMS has a longstanding regulatory interpretation of Telecommunications Technology: to be live, two-way audio communication technology. However, there is an exception—for asynchronous or stored-forward communication technology. This is explicitly limited to federal telemedicine projects in Alaska and Hawaii.

Payment for Non-Telehealth Medicare Services (Communication Technology Services)

These are not substituting for in-person services and are therefore valued accordingly (generally a lower payment rate). For example, virtual check-ins, inter-professional consultations (practitioner-to-practitioner consultation), and remote patient monitoring (remote physiologic monitoring services).
CMS has had a longstanding policy of paying separately for services of this type and not considering them subject to all the Telehealth restrictions in 1834(m). For example, CMS pays for remote interpretation of diagnostic tests, care management services, and even the global surgical packages could include communication technology as part of the furnishing of that service. There has been little by way of discrete coding to describe services provided using communication technology. However, even before the COVID-19 Pandemic, CMS had been working on changing this. Because Medicare Telehealth encompasses services that would ordinarily be furnished in-person, Telecommunication Technology services are defined as not being in-person at all, inherently not face-to-face, or as “preventing an in-person service.”

COVID-19 Public Health Emergency and CMS Waivers for Medicare Telehealth

In response to the pandemic, CMS attempted to quickly increase access to telehealth and other types of virtual services. This was done with a combination of statutory waiver authority provided by Congress as part of many relief acts (most significantly, the Cares Act) and CMS’s regulatory authority. CMS removed the restrictions in 1834(m) surrounding where the beneficiary must be located, the geographic area, and the service site using the waiver authority. Now, beneficiaries in rural and urban areas can receive telehealth services, and the beneficiary can remain in their home for the full range of services.
CMS waived the list of practitioners enumerated in the statute, waived the requirement that the technology be two-way audio-video for a subset of counseling and educational services, and began paying for audio-only evaluation and management. The waiver authority used to remove these restrictions is tied to the duration of the public health emergency so that these flexibilities will terminate with the PHE. To make these restrictions permanent, it would require an act of Congress. The first two acts of Congress in April and May of 2020, respectively, addressed telehealth services. CMS first expanded the range of services furnished as telehealth by adding over 135 new services to the Medicare telehealth list.

Audio-Only Telephone Evaluation and Management and Assessment/Management Visits

Six Codes- 3 for Physicians who Can Separately Report Evaluation and Management Visits, and 3 for Practitioners who Cannot Separately Report Evaluation and Management Visits.

CMS long considered these services non-covered under the physician fee schedule. In the first Interim Final Rule, CMS changed these codes from non-covered to covered and began making separate payments for purposes of the public health emergency. CMS also elected not to enforce the requirement that is in the code descriptor that these services only be provided to established patients. Following that rule, CMS began hearing from the stakeholder community that these codes were being used as stand-ins for office visits in instances when beneficiaries did not have access to or did not want to use the two-way audio-video telecommunications technology that would be required to be billed for those office visits. The payment rates for these audio-only visits were not accounting for all the actual resource costs associated with furnishing these services, so in the second IFC, CMS increased the payment rates for CPT codes 99441-99443 (codes for practitioners who can independently bill for EMS) and increased the payment rates to match the payment rates for the level two through four established patient office visit codes. For CMS to do this, they had to add these codes to the telehealth list and then waive the audio-only requirement for telehealth services.

For the communication technology-based services, CMS removed the requirements that these services be furnished only to established patients and expanded the eligibility to bill for these services from practitioners who could independently bill for EMS to those who could not.

Regarding remote physiologic monitoring (RPM) during the public health emergency, CMS began allowing consent for RPM services to be obtained once annually, including when the service is furnished.