Medicare

CMS payment policies & regulatory flexibilities during COVID-19 emergency

Updated May 1, 2020

The AMA has been working constantly with the Centers for Medicare & Medicaid Services (CMS) 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.

Featured updates: COVID-19

Track the evolving situation with the AMA's library of the most up-to-date resources from JAMA, CDC and WHO.

Read the Latest

Below are key actions CMS has taken in response to AMA advocacy. Topics include financial assistance, telehealth, the Merit-based Incentive Payment System (MIPS), enrollment, elective surgery and regulatory relief. For the complete list of CMS payment and policy guidance related to COVID-19, please access the CMS website. For the latest information about Medicare coronavirus waivers and flexibilities, visit this CMS website.

CMS further expands Medicare telehealth and testing, clarifies EMTALA flexibilities

The Centers for Medicare & Medicaid Services (CMS) waived additional regulatory requirements and further expanded telehealth in Medicare in an interim final rule released on April 30, 2020. In response to efforts by organized medicine, CMS will be increasing payments for audio-only telephone visits between Medicare beneficiaries and their physicians to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110, and the payments are retroactive to March 1, 2020. This is a major victory for medicine that will enable physicians to care for their patients, especially their elderly patients with chronic conditions who may not have access to audio-visual technology or high-speed Internet.

During the COVID-19 public health emergency, CMS is forgoing the rulemaking process to add new services to the list of Medicare covered telehealth services, which will be updated on a sub-regulatory basis. CMS is now recognizing audio-only technology for payment for behavioral health services, as identified in their list of telehealth services. CMS also expanded the types of clinicians who can furnish Medicare telehealth services to include physical and occupational therapists and speech language pathologists.

Medicare will also pay physicians and practitioners to assess patients and collect laboratory samples for COVID-19 testing when that is the only service patients receive. Physicians and other clinicians may use CPT code 99211 to bill for services furnished incident to their professional services, for both new and established patients, when clinical staff assess symptoms and collect specimens for purposes of COVID-19 testing. CMS also created a new code, HCPCS code C9803, for hospital outpatient departments to bill for a clinic visit dedicated to specimen collection. Beneficiary cost-sharing is waived for COVID-19 testing and related services.

Finally, CMS issued additional FAQs clarifying Emergency Medical Treatment and Labor Act (EMTALA) requirements and flexibilities during the pandemic.

HHS Emergency Fund disbursement

On April 10, the Department of Health and Human Services (HHS) began disbursing the first $30 billion out of the $100 billion that Congress allocated to hospitals, physicians and other health care providers in the Public Health and Social Services Emergency Fund in the Coronavirus Aid, Relief and Economic Security (CARES) Act. CARES Act Provider Relief Fund disbursements are grants, not loans, and do not have to be repaid. The funds may be used either for health care related expenses or for lost revenues that are attributable to coronavirus.

The initial $30 billion tranche was directed to hospitals and physician practices in direct proportion to their share of 2019 Medicare fee-for-service (FFS) spending. All facilities and health professionals that billed Medicare FFS in 2019 are eligible for the funds. The funds went to each organization's taxpayer identification number which normally receives Medicare payments, not to each individual physician, via Optum Bank with "HHSPAYMENT" as the payment description. 

On April 22, HHS provided additional information about allocation of the remaining $70 billion funding, including:

  • An additional $20 billion for “general allocation” based on 2018 net patient revenue, not just Medicare fee-for-service.
  • $10 billion for targeted distribution to hospitals in areas that have been particularly impacted by the COVID-19 outbreak.
  • $10 billion to rural hospitals and rural health clinics.
  • $400 million to Indian Health Service facilities.
  • Some portion of the remaining funds is being used to cover the costs of caring for uninsured patients with COVID-19 based on Medicare payment rates.
  • An unspecified portion will be used for clinicians, including obstetricians-gynecologists, and facilities that rely more on Medicaid than Medicare revenues.

Medicare providers who have already received a payment from the Provider Relief Fund are now eligible to apply for additional $20 billion in “general allocation” funds by submitting data about their annual revenues and estimated COVID-related losses via the General Distribution Portal.

A portion of the $100 billion Provider Relief Fund will be used to reimburse healthcare providers, at Medicare rates, for COVID-related treatment of the uninsured. Physicians are eligible for this funding. Every health care provider who has provided treatment for uninsured COVID-19 patients on or after February 4, 2020, can request claims reimbursement through the program and will be reimbursed at Medicare rates, subject to available funding. Steps will involve: enrolling as a provider participant, checking patient eligibility and benefits, submitting patient information, submitting claims and receiving payment via direct deposit.

HHS resources

  • Physicians must attest to receipt of the funds and agreement to the fund terms and conditions within 30 days using this portal.
  • Additional details about the allocation are available.
  • Terms and conditions for receipt of the funds that each organization receiving the grants will need to attest to within 30 days of receiving the grant.
  • HHS addressed FAQs about the “general allocation” of $50 billion.
  • Physician can register for the uninsured funding program on April 27, 2020, and begin submitting claims in early May 2020.

AMA resources

AMA posts legislative and regulatory information: COVID-19 slide deck

The AMA has released a slide deck focused on the federal government’s response to the COVID-19 pandemic. It recaps legislative and regulatory milestones, discusses Medicare’s telehealth expansion and regulatory relief and outlines two financial assistance options available to practices facing financial hardship. The slides were last updated on April 26, and the information included is rapidly changing due to actions from Congress, HHS and CMS.

CMS resource provides additional guidance to physicians

In an MLN matters article (PDF), revised on April 10, CMS offers details about several new Medicare fee-for-service policies in response to the COVID-10 pandemic, including guidance on the appropriate modifiers and place of service codes for billing telehealth services and waiving cost-sharing for COVID-19 testing-related services. The AMA has developed special coding advice (PDF) during the COVID-19 public health emergency that includes step-by-step instructions for coding in 11 real-world scenarios.

HHS launches new telehealth website

To help physicians and patients get started with telehealth services, HHS launched the telehealth website with resources and best practices for accessing care virtually. For physicians, there are tips for getting starting, preparing patients for telehealth visits, billing and payment, and legal considerations. AMA resources, including the telehealth quick guide, are featured.

CMS updates FAQs about regulatory waivers and telehealth flexibilities

On April 9, CMS released answers to common questions (PDF) about the regulatory and telehealth flexibility available during the COVID-19 emergency, including:

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 social distancing and 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.

Medicare advance payments

To assist with cash flow challenges during the COVID-19 pandemic, CMS expanded its Advance Payment Program to provide qualifying physicians an emergency upfront payment of up to three months’ Medicare payments based on historical claims information from Oct to Dec 2019. Physicians will need to repay this advance, and CMS extended the repayment to give physicians 210 days from the date the Medicare Administrative Contractor issues the payment.

On April 26, CMS suspended the advance payment program for Medicare Part B suppliers, including physicians. We will share any updates on the Medicare Advance Payment Program as they are made available.

AMA resources

  • Fact sheet explaining the Advanced Payment Program
  • FAQs answer common questions about timing, interest and submitting a request

CMS resources

  • Fact sheet (PDF) on advanced payments during the COVID-19 pandemic

AMA releases special coding advice related to COVID-19

New guidance from the AMA provides special coding advice during the COVID-19 public health emergency. One resource outlines coding scenarios (PDF) to help health care professionals apply best coding practices.

The scenarios include telehealth services for all patients.

There is also a quick-reference flowchart that outlines CPT reporting for COVID-19 testing (PDF).

Medicare expands telehealth during COVID-19 emergency

The Centers for Medicare & Medicaid Services (CMS) lifted Medicare restrictions (PDF) on the use of telehealth services during the COVID-19 emergency. Key changes include:

  • Effective March 1 and throughout the national public health emergency, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19.
  • Medicare will pay physicians for audio-only telephone calls and has greatly expanded the list of covered telehealth services to include emergency department visits, for example.
  • Physicians utilize telehealth for both new and established patients.
  • Reporting and documentation for office visits performed via telehealth may be based on medical decision-making or time on date of encounter, utilizing 2020 definitions and CMS total time data.
  • Allowing medical screening exams (MSEs), a requirement under Emergency Medical Treatment and Labor Act (EMTALA), to be performed via telehealth.
  • Patients can receive telehealth services in all areas of the country and in all settings, including at their home.
  • CMS will not enforce a requirement that patients have an established relationship with the physician providing telehealth.
  • Consent for telehealth services may be obtained by staff or the practitioner at any time, required only once on an annual basis.
  • Physicians can reduce or waive cost-sharing for telehealth visits.
  • Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply.
  • Physicians can provide telehealth services from their home. Physicians do not have to add their home to their Medicare enrollment file.
  • HHS Office for Civil Rights (OCR) offers flexibility for telehealth via popular video chat applications, such as FaceTime or Skype, during the pandemic.

AMA tools and resources:

CMS and HHS guidance:

  • 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
  • HHS Office of Inspector General FAQs (PDF) clarify the Administration is allowing broad flexibility for physicians to reduce or waive Medicare beneficiary cost-sharing
  • OCR guidance on 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

2020 Merit-based Incentive Payment Program (MIPS) changes

CMS is evaluating options for providing relief around participation and data submission for the 2020 MIPS performance year. The agency created a new MIPS Improvement Activity to give physicians credit in 2020 for participation in a COVID-19 clinical trial conducted by the National Institute of Health (NIH) or by reporting through a clinical data repository.

CMS resources:

Medicare provider enrollment relief

During the national emergency due to COVID-19, CMS will:

  • Allow licensed physicians to provide services to Medicare beneficiaries outside their state of enrollment as long as the physician is licensed in another state. State licensure requirements still apply.
  • Temporarily suspend certain Medicare enrollment screening requirements, including criminal background checks and site visits.
  • Postpone all revalidation actions.
  • Expedite any pending or new enrollment applications.

CMS guidance:

  • CMS fact sheet (PDF) discusses the Medicare enrollment flexibilities in place during the public health crisis
  • CMS enrollment relief FAQs (PDF) clarify that physicians do not need to update their Medicare enrollment file with their home address in order to bill telehealth services

Medicare recommendation about elective surgeries and non-essential procedures

On April 19, CMS issued recommendations to guide practices as they consider safely resuming in-person care in regions with low incidence of COVID-19 disease and that have passed the gating criteria according to the Guidelines for Opening Up American Again. Considerations include clinical need, personal protective equipment, workforce availability, testing capacity, and supplies. CMS continues to urge the maximum use of telehealth modalities. Decisions should be consistent with public health information and in collaboration with state public health authorities.

CMS previously issued guidance on postponing non-essential adult elective surgery and medical and surgical procedures to conserve critical resources, such as ventilators and personal protective equipment (PPE), and to minimize the spread of COVID-19 to patients and physicians.

Decisions remain the responsibility of hospitals, surgeons and state and local officials.

CMS guidance:

CMS relieves regulatory burdens

CMS has also issued several regulatory burden waivers to provide additional relief, including:

  • CMS is temporarily waiving the requirement for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred or otherwise dislocated as a result of the effect of disaster or emergency.
  • For durable medical equipment and prosthetics, orthotics and supplies (DMEPOS) that is lost, destroyed or otherwise unusable, Medicare contractors may waive replacement requirements such as: a face-to-face visit, obtaining new order from a physician and new medical necessity documentation.

CMS guidance:

Medicare payment and coverage policies related to COVID-19