Updated April 27, 2020
The AMA continues our work with the Administration to identify issues arising due to COVID-19 and to recommend specific actions to improve Medicare coverage of services and reduce regulatory burdens on physicians during this crisis.
When the outbreak began, the AMA immediately urged the Centers for Medicare & Medicaid Services (CMS) to expand Medicare coverage of telehealth services. This is especially important for patients on Medicare because seniors who get the coronavirus are at high risk of a severe impact.
On March 30, CMS announced a number of new policies to help physicians and hospitals during the COVID-19 pandemic, including coverage for audio-only telephone visits. The AMA released a statement applauding these actions, which are effective March 1, 2020.
On April 23, CMS released a toolkit for states (PDF) to help accelerate the adoption of telehealth coverage policies, which will aid the states in identifying its Medicaid and Child Health Insurance Program policies in place which may hamper the rapid deployment of telehealth. Coverage of telehealth varies by state under Medicaid and CHIP, but states have broad flexibility to use telehealth such as telecommunications technology commonly available on smart phones and other devices. The toolkit for telehealth includes several topics: patient populations eligible for telehealth, coverage and reimbursement policies, providers and practitioners eligible to provide telehealth, technology requirements and pediatric considerations.
CMS continues to update its policies and to provide clarification on the expansive ways telehealth may be used to protect patients and providers during the COVID-19 pandemic. Below is a summary of CMS and related federal government actions allowing physicians to utilize telehealth during the COVID-19 pandemic.
CMS and the federal government have lifted many restrictions on the use of telemedicine
Key changes to Medicare telehealth payment policies include:
- Effective March 1 and throughout the national public health emergency, Medicare will pay physicians for telehealth services at the same rate as in-office visits for all diagnoses, not just services related to COVID-19.
- Office-based physicians should use their usual place-of-service (POS) code to be paid at the non-facility rate for telehealth services and add modifier 95 to telehealth claim lines. Telehealth services billed using POS code 02 (telehealth) will be paid at the facility rate.
- Physicians can reduce or waive Medicare patient cost-sharing for telehealth visits, virtual check-ins, e-visits, and remote monitoring services.
- Code selection and documentation guidelines for office visits performed via telehealth will be based on physician time spent on the date of visit or medical decision-making (MDM). CMS will utilize the 2020 physician time and definitions of MDM.
Medicare greatly expanded access to telehealth
- Patients in all settings, including in their home, and across the entire country, not just in rural areas, can receive telehealth services.
- Physicians may provide telehealth services to new and established Medicare patients.
- Consent for telehealth services may be obtained by staff or the practitioner at any time, required only once on an annual basis.
- Physicians can provide telehealth services from their home. Physicians do not need to update their Medicare enrollment file with their home address. See FAQ #12 (PDF) for more information.
- Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply.
Medicare significantly expanded telehealth services
- Importantly for physicians caring for seniors and rural patients who may not have internet access or a smart phone, physicians can now provide audio-only telephone evaluation and management visits for new and established patients
- Physicians can now provide more services to beneficiaries via telehealth, including emergency department visits. The services can be provided to either new or established patients. View a complete list of telehealth services (PDF).
- CMS is allowing medical screening exams (MSEs), a requirement under Emergency Medical Treatment and Labor Act (EMTALA), to be performed via telehealth.
- CMS removed frequency limitations on a number of Medicare telehealth services. For example, subsequent skilled nursing facility visits can be furnished via telehealth without the limitation that the visit is once every 30 days.
- Physicians can provide remote patient monitoring (RPM) services to both new and established patients for both acute and chronic conditions and for patients with only one disease. For example, RPM can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.
- Practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists will have expanded access to telehealth, virtual check-ins, e-visits and telephone calls during the crisis.
Rural health clinics & federally qualified health centers: Telehealth and virtual communications flexibilities
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) had slim margins before COVID-19. The pandemic has stretched the Centers and their providers even further. Congress and CMS have made changes to requirements and payments during the COVID-19 which allow RHCs and FQHCs greater flexibilities in using telehealth to reach their patients (PDF):
- Telehealth services can be provided by physicians and health professionals working for the FQHC or RHC and there are no restrictions on where the service is provided, meaning physicians or practitioners may provide the service from their homes.
- CMS will pay RHCs and FQHCs $92 for telehealth services provided by physicians and other practitioners.
- Expansion of virtual communication services.
- Consent for care management and virtual communication services.
Prescribing controlled substances
- The U.S. Drug Enforcement Administration (DEA) will permit physicians to prescribe controlled substances based on telehealth visits during the pandemic. State laws apply.
- DEA will allow physicians treating patients with opioid use disorder who have a waiver allowing them to prescribe buprenorphine to issue these prescriptions based on a telephone visit.
Use of technology for telehealth services
- Physicians don’t have to use fancy technology, any two-way audio-visual device will do- such as Facetime, Skype, or Zoom. However, the Office for Civil Rights (OCR), which enforces HIPAA, has stated that physicians should not use Facebook Live, Twitch, TikTok or other public facing communication services.
- OCR helpfully announced that it will use its enforcement discretion for physicians using telehealth, so that—for example—if they do not have time to conduct a security risk analysis or enter into a business associate agreement (BAA), they can still use telehealth to see patients during the crisis without fear of HIPAA penalties.
- While OCR hasn’t confirmed such statements, the agency stated that Skype for Business, Updox, VSee, Zoom for Healthcare, Doxy.me, and Google G Suite Hangouts have said that their products will help physicians comply with HIPAA and that they will enter into a HIPAA BAA.
- The OCR guidance emphasized that physicians are encouraged, but not required, to notify patients of the potential security risks of using these services and to seek additional privacy protections by entering into BAAs.
Diagnoses from telehealth services will be included in risk adjustment in Medicare Advantage
- CMS allows Medicare Advantage organizations and other organizations that submit diagnoses for risk adjusted payment to include diagnoses from telehealth visits (PDF) when those visits meet all criteria for risk adjustment eligibility. Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication. The inclusion of diagnoses for risk adjusted payment when using telehealth will allow for a more accurate calculation of risk adjustment scores, which ultimately results in better payment.
AMA tools and resources
- Telemedicine quick guide has detailed information to support physicians and practices in expediting implementation of telemedicine.
- Coding scenarios (PDF) provide real-world examples of how to code for telehealth services.
- State policy options to address COVID-19 includes a section on telehealth.
- State executive orders and directives chart (PDF) includes a section on telehealth and licensure.
- Summary of Medicare payment policies and regulatory flexibilities, including MIPS extensions and hardship exceptions.
- COVID-19 state policy guidance on telemedicine (PDF) outlines the AMA’s policy recommendation for telemedicine in response to COVID-19.
- AMA’s COVID-19 resource center centralizes the latest information from AMA leadership, JAMA Network™, CDC, FDA and more.
HHS and DEA guidance
- HHS recently launched a website providing comprehensive information and resources for patients and providers on COVID-related telehealth policies.
- CMS interim final rule (PDF) and fact sheet (PDF) detail new regulatory flexibility, relaxed enrollment requirements, expanded telehealth services, and revised physician supervision policies to help physicians and patients during the COVID-19 pandemic.
- CMS updated the list of covered telehealth services, effective March 1, 2020.
- CMS emergency regulatory waivers fact sheet (PDF) explains the relaxed Medicare rules for enrollment and providing services outside of the state where a physician is licensed.
- OCR guidance outlines telehealth communication methods during the COVID-19 nationwide public health emergency.
- OCR issued FAQs (PDF) about its use of enforcement discretion related to HIPAA and telehealth.
- HHS Office of Inspector General FAQs (PDF) clarify the Administration is allowing broad flexibility for physicians to reduce or waive Medicare beneficiary cost-sharing for telehealth and other non-face-to-face services.
- DEA guidance discusses prescribing controlled substances based on telehealth visits and announcement (PDF) about flexibility for physicians managing patients with opioid use disorder.
- The Substance Abuse and Mental Health Services Administration (SAMHSA) issued FAQs about the provision of methadone and buprenorphine (PDF) for the treatment of Opioid Use Disorder in the COVID-19 emergency.
Federal Communications Commission COVID-19 telehealth program
- The Federal Communications Commission (FCC) announced a $200 million program that supports health care providers responding to the COVID-19 pandemic by providing eligible health care providers support to purchase telecommunications services, information services and devices necessary to enable the provision of telemedicine services during this emergency period.
- The program will provide selected applicants with full funding for these eligible telehealth services and devices. Tto receive funding, eligible health care providers must submit an application to the commission for this program, and the commission would award funds to selected applicants on a rolling basis until the funds are exhausted or until the current pandemic has ended.
- Note that the program is limited to nonprofit and public eligible health care providers.