April 28, 2020

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On April 21, Dr. Anna Loengard, Chief Medical Officer with Caravan Health, hosted a COVID-19 educational webinar to share the anticipated clarification from CMS regarding telehealth flexibilities for rural health care clinics and federally qualified health centers.

With the fast pace of changing rules, it is important to stay attuned to the changes and be prepared to adapt. Technology-assisted visits, for example, for the provider and patient who are in the same location but are separated to reduce the amount of potential exposure, are not to be billed as telehealth – there is no need for a modifier.

Telehealth is specifically designated for the provider and patient who are in different locations, using real-time audio-video. Telehealth can be used in all geographies and now, the originating site (the site where the patient is located), can be the patient’s home. Prior to these changes, the originating site for RHCs and FQHCs had to be those clinic locations.

There is an expanded list of telehealth services available on the COVID-19 Resource page which provides details on how telehealth can be deployed. It is important to understand the scope of the varying visits and to be able to distinguish all elements of billing and coding. Direct supervision requirements still apply but can now be fulfilled virtually.



The Annual Wellness Visit (AWV), can be performed via telehealth and by using nurse-led models, offices can utilize nursing staff much like before as long as a face-to-face component with the physician is included in the visit. Advance Care Planning is optional during the AWV – but it’s not optional for patient care.




Co-insurance is often referred to as a barrier to care management in rural areas and this public health emergency presents an opportune time to introduce rural patients to telephonic care management, which could potentially encompass 60% of our Medicare patients who have two or more chronic illnesses. It is important to proactively contact patients to make sure they are getting the care they need – including patients with known depression and anxiety.

There are numerous opportunities and flexibilities that are expected to only be in effect for the duration of the public health emergency, which is for now, through this calendar year. Caravan Health is continuing to advocate to Congress on behalf of rural providers and respond to CMS to broaden the telehealth parameters for patients who do not have access to a video-component.
 

Questions & Answers:

Please discuss the state of the rule that billable visits must be patient initiated.
Most of the guidance that CMS has given us is that most of these services, because they have a co-insurance, need to be patient initiated. But we can share very specific language from a CMS document that states that they understand that patients may need to be educated on these services and therefore, the consent can be obtained at the time of service.

We understand that you want to have assurance. Below is a response taken from the CMS COVID-19 FAQ from April 17, 2020, regarding the virtual check-in:
“We expect that these services will be initiated by the patient, especially since many beneficiaries would be financially liable for sharing in the cost of these services. This means that the patient must consent to the service before or at the same it takes place and does not prohibit practitioners from educating, on their own initiative, beneficiaries on the availability of the service prior to, or at the same time it takes place.

What is a BAA agreement?
This refers to a Business Associate Agreement and is signed with any contractor when you’re going to share data with them. It relates to HIPAA privacy requirements and being able to share data with anyone, including conversations that are had in the context of a patient provider that you’d want to have assurances of what they’re doing and what their security is to assure you there is privacy.
Many videoconferencing platforms, even those not specifically designed for telehealth, offer BAAs with certain contract agreements.
 
Are pure telephone visits with no video available billable?
They are in fee-for-service, they are not to our knowledge a part of RHCs and FQHCs although we think they should be. We will be providing feedback to CMS on this and we encourage you to do the same in the comments that are open until June 1, on the interim final rule. We believe rural areas are exactly where they need this.
As a reminder, virtual services, G0071, provides coverage of the virtual check-in which is a brief telephone-only visit but it’s not the same as a telephone E/M. It is now a blended code, reimbursed at $34.76, and provides coverage for a 5-10-minute provider telephone visit. Is something that certainly should be considered when you don’t have the option for the expanded telephone-only visits.
 
Can we reach out and schedule an annual wellness visit or does a patient need to call and request one?
I think it’s fine to reach out and let patients know that you are providing annual wellness visits through telehealth and ask if they would like to schedule that. For those people who’ve had an annual wellness visit in the past, hopefully they’ll understand what that is. But letting them know that this, out of an abundance of concern for their health and well-being, is something you are providing would be completely allowable in getting their buy-in.
 
What if we perform the annual wellness visit after July 1st, how will Medicare know the patient received their annual wellness visit if we are only reporting G2025?
We will ask CMS for guidance on this. However, you can set up your billing software to add these codes along with G2025 so you can have this data. There is additional information that addresses this on our COVID-19 Resource page.

Beginning July 1st, are we to use the G2025 for all telehealth services?
That is my understanding of the way this was directed, and I have not seen any direction that you would use this in addition to. This may be something that we want to provide feedback to CMS on with our comments and I’ll add that to our letter to CMS. It seems like it would be beneficial to have an understanding of what specific services were being supplied via telehealth rather than just one global this is the number of telehealth services being provided. There is additional information that addresses this on our COVID-19 Resource page.
 
If we have patients who don’t have internet, so videos are not an option, our only billing option is CCM or G0071?
Yes, right. In our RHCs and FQHCs, if there’s no video option- the care management or the global virtual services code is the one that would be most feasible.
 
Is CMS currently set up to receive telemedicine claims with the new codes and if the patient also has MCD as secondary - as the two often utilize different codes for the same services, how are these kinds of claims being processed?
Right now, they are not set up for telemedicine claims and they won’t be until July 1st, in this setup of claims. I assume that this will always be processed in the same way that whatever Medicare would cover will be covered and the secondary insurance will cover the rest. In terms of whether or not secondary insurance plans recognize this code – I think that’s something we’ll have to take into consideration, if they will pay that as an authorized service.  There is additional information that addresses this on our COVID-19 Resource page.
 
For clarification during the public health emergency for an RHC not in a home health care shortage area, can they bill for the visiting nurse through telehealth?  Is the shortage area requirement waived?
They are saying that you can provide visiting nurse services to patients who are in your normal catchment area. You don’t have to apply for the shortage area designation in the way that you have in the past. Their assumption is that whatever your normal catchment area is for the purposes of visiting nurse services during the emergency would be defined in that way. You do need to make sure that they’re not receiving home health services from a home health agency before beginning services. However, these would be in-home services for patients, and are not provided via telehealth.
 
What specific codes are available for RHC telephone-only behavioral visits?
The BHI chronic care management is part of the general care management code which is telephonic support. You could also do the collaborative care model. So the first is the G0511, which is the general care management service code and the G0512 which is the collaborative care model so it would be a telephonic support of the patient with an added psychiatrist providing some counsel to the nurse or social worker who’s providing that support to the patient and in conjunction with the PCP. Those would both be ways to provide behavioral health through the telephone only.
 
For care management services the patient must have had a face-to-face visit within the last 12 months. Does a virtual visit qualify for that?
Yes, a telehealth visit will qualify. You can use a telehealth visit for that - establishing the visit for those services.
 
We need lobbying from Caravan regarding limitation on not submitting HCCs via telephone visit – this will present quite a challenge to capture all the HCCs for the rest of the year.
This is something we are providing feedback to CMS on. We think that there definitely needs to be as broad of an opportunity as possible to be able to document and have these codes on a claim.

G0071 will be used for risk adjustment, so your HCCs will be captures on a G0071 encounter. General care management, G0511, also contributes to HCC capture. We have a document for common codes contributing to risk adjustment on the COVID-19 Resource page. For those of you who are wondering which services will actually count towards and we’re not totally sure if the telephone-only E/M will be included, if that was an oversight or if it was deliberate.
 
Is the G0071 code to be billed along with the E/M or the standalone for telehealth services?
Now, the G0071 is actually a virtual check-in code that should not be billed if you’ve had an E/M visit in the last seven days or if it results in an E/M visit, whether or not the E/M visit is in-person or by telehealth. The G0071 is a blend of three distinct services in the FFS world and  can be billed in three circumstances: 1.) the virtual check in by phone when there has not be an E&M in seven days prior and it does not result in a visit (telehealth or in person) in 24 hours, 2.) asynchronous digitally assisted communication – i.e. the patient sends a photo of a rash and you communicate back, and 3.) a digital E/M (i.e. through the portal) for up to seven days.

There is much more detailed information on how these virtual services work on our website and if you want to learn more on what the limitations are, that information is available there.
 
With the telemed visits, what is the productivity merit goal for our clinics?
That would be specific to your clinic – I can’t answer that specifically for your site.
 
For VNS, are you saying that homebound can now be linked to patients who are high risk for COVID-19?
With the public health emergency, yes. They’ve stated that the patient may be homebound now because of significant risk of leaving home. They have provided language around this in the interim final rule that a broader variety of patients will be homebound because you may want to monitor them. Maybe they’re sick, maybe they’re at high risk of infection. I think we need to be careful around this that if there really is no infection in your community or very little infection, it’s just a matter of documenting why you think the patient is homebound. I think as long as it’s reasonable everything that CMS has put forth is around protecting beneficiaries and maintaining access to care. I think that needs to be your guiding light in all of this – are we doing this in an effort to give the highest quality of care and access.
 
Is there any clarification of audio-only business being able to be billed as telehealth?
Medicare Telehealth by definition is audio and video, so, no. There are telephone E/M visits that are available on fee-for-service. The GOO71 is a brief telephone check-in and that is available in that environment.
 
What is the payment rate for the visiting nurse service?
Looking at these services across our claims for 2019, there was significant variability but the average reimbursement per claim was approximately $200.
 
We have RHC providers charging only G0071 for Medicare and Medicaid patients for telehealth and telephone business. Is this correct?
No, not for a telehealth visit with real –time audio and video. You should now be billing your regular AIR/PPS depending on where you are. As of July, you’ll need to start billing the new telehealth code for telehealth visits. There is only one opportunity for telephone visits to be charged in the RHC and FQHC unless it’s for care management, and that is G0071.

So, to be clear, provider calls patient to see how they’re doing with their diabetes. During the call the provider goes over how telemedicine works with respect to the clinic. Is this a billable call?
I think that there needs to be more education to let the patient know your practice now has virtual check-ins. These are brief telephone calls to assess patients and their chronic illness.  

In terms of workflow, educating the patient about the option for the virtual check-in and obtaining consent should come before the provision of the care. Consent for billable virtual services should never be “after the fact.”

Dr. John Findley has talked about, “showing your patients your new front door”. You are changing your business model and how you provide care to them and it’s something that’s done up front with the patient in terms of education around what services you’re providing and getting consent.
 
If you use the GOO71 for the brief telephone visit, does it still need to be initiated through the patient portal or can we bill for a brief phone visit without the involvement of the patient portal?
What gets confusing about the GO071 is that it’s a blended service code for RHCs and FQHCs, so in fee-for-service it’s three distinct codes that are blended into one. You could be billing for the brief telephonic check-in, or the digital E/M through your portal – it doesn’t have to be both of them. But you could also be billing for a patient who has sent you a picture of their rash and you got back to them about that. In fee-for-service those are three distinct codes, but they’ve been blended together for RHCs and FQHCs.
 
Can you discuss the difference between G2012 and G0071?
The G2012 is the virtual check-in and fee-for-service and one of the service codes that has been blended into the GOO71 for RHCs and FQHCs.
 
How are folks identifying services that are COVID-related versus not for the various modifier and waiving of co-insurance deductible?
I want to clarify that this is a fairly narrow bunch of services, it needs to be a service that is directly related to a COVID-19 test. So, it’s really that the COVID-19 test has no co-insurance with it. I think there was a recognition that there are services around testing and the intent of this was to make sure that patients did not avoid getting tested because of a fear of medical bills. This is around both outpatient services, ER visits, observation stays in hospital although I don’t believe it extends to entire hospitalizations. The intent was to not have people avoid being tested because of fear of medical bills.
Specific guidance for how to code these services can be found on our COVID-19 Resource page which includes the following:

When waiving coinsurance, use modifier CS on the service line and do not collect the co-insurance from the patient. For claims with the CS modifier, the service will be paid with the co-insurance applied. Medicare Administrative Contractors (MACs) will automatically reprocess these claims beginning July 1, 2020
 
Can RHCs bill for remote patient monitoring CPT codes?
My understanding of the remote patient monitoring in the RHC and FQHC is actually considered part of the AIR/PPS. So no, this is something that cannot be billed separately.

They’ve stated that they will not be ready for claims for telemedicine with the code setup until July. Hence, why are they offering the preemptive payment option?
My understanding is they won’t be ready to process claims with the new code and that’s why they are instructing people to put these claims through as though it were AIR or PPS type payment. And, that they will retroactively reprocess those claims, but my understanding is that you should still be getting paid on those claims now, but they will have to be reprocessed in July. This will help keep cash flowing for now while making volume may be low and practices may be struggling to make this shift to their new “virtual front door.”
 
Will the G code be effective based on service date or billing date?
It will be the service date.
 
If RHC opts to hold claims until July rather than deal with the recoupment can we bill prior dates of service with the G code?
I am assuming that the way that I read the instructions are that the service dates through June 30 should be billed with an AIR/PPS and then service dates beyond need the G code.

It very specifically says for services furnished on a date of service. So, no you can’t, you won’t be able to bill a G code for a service date before July 1st.
 
Can you expand a little more on the consent from for telehealth?
The consent is that they are simply consenting to have an audio-video rather than in person service. It’s really about making sure the patient is aware of the services and that they are not the traditional office services that they are used to and that this is a service being provided to them that that there will be a bill involved.

To clarify, the consent can be obtained verbally, it just needs to be documented in the records – the patient doesn’t have to fill out a form per se.
  
How does a clinic choose to waive the copay for CCM or is this automatically done right now during the public health emergency? How does this affect reimbursement from CMS for this service?
This is not done automatically. For services related to a COVID-19 test and related services – these need to be waived. And there’s a modifier, -CS, and CMS will give you 100%. For all other services, you have the option for telehealth services and care management/virtual services to waive the co-insurance, and this can be done on a patient basis or on a service basis – which probably makes more sense. You’re going to need a logical process for when you waive the CCM or other co-insurance and when you don’t. This needs to be documented so you can’t waive it for friends or certain patients and not others.

From the Billing Consultant:
What I would do is in my practice management software, I’d set up a specific adjustment code for these claims that delineate that the Part B co-insurance copay or cost sharing obligations have been waived and when you waive those, that would be the adjustment code I would use. It would allow for a practice to know and understand what the cost to them was and secondarily if there was any question that adjustment code would be linked directly back to each service where the cost sharing was waived.
 
Can virtual visits be billed in the same month with home health services?
I have not seen any limits here. These are totally separate services so to my knowledge, there would be no crossover there.
 
What do you understand regarding the codes for coronavirus specimen collection?
I don’t have any particular knowledge of them. They have given clarity that you can’t send a nurse to somebody’s home – there won’t be any additional reimbursement. But if you were doing home health services this could be collected there. We have guidance in our HIM document about when and how to use the codes, and what specific codes should be used based on the type of the test.
 
Can Part B bill for fee-for-service telephone-only?
Yes, there are a series of telephone E/M codes both for physicians and advanced practice providers and other providers as well. There is a very clear documentation of this on our website.
 
How are other practices getting paperwork completed on new patients with current HIPAA waivers through the phone portal email?
I’m not sure that people are sending it. We now have the ability to see new patients as well as existing, but this is probably happening through mail, through scanning and emailing.
 
If the government announced that encounters should be processed as would face-to-face encounters in order to keep providers whole, regular E/M would need to be billed with 95 modifier. Do you agree or disagree with this approach at this time?
That is correct. In fee-for-service there has been a big push to keep the reimbursements as much as possible the same as pre-COVID. So, for example you can bill home visits and ER visits via telehealth with normal reimbursements. Providers use the normal place of service and the 95 modifier. This has not been translated into RHC/FQHC payments for telehealth. Depending on your current AIR/PPS, in many cases it may be less than what you normally would get paid. We will have feedback to CMS in our comments on the IFR.

To learn more, visit our COVID-19 resources page.

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