Temporary Authorization of Telemedicine Services during COVID-19 State of Emergency

Dear Providers,

Throughout the COVID-19 state of emergency, Health First Colorado (Colorado’s Medicaid Program) is temporarily expanding its telemedicine policy to authorize the following:

1. Expanding the definition of telemedicine services to include telephone only and live chat modalities.
2. Authorizing Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services to bill encounters for telemedicine visits
3. Adding specified Physical Therapy, Occupational Therapy, and Home Health, Hospice and Pediatric Behavioral Therapy services to the list of eligible interactive audiovisual telemedicine services.

 

Existing Telemedicine Policy

Health First Colorado currently defines telemedicine as the delivery of medical services and any diagnosis, consultation, treatment, transfer of medical data or education related to health care services using interactive audiovisual communication instead of in-person contact. The list of CPT and HCPCS codes that are already allowed to be provided through telemedicine is available on the Telemedicine - Provider Information page.

  

For existing telemedicine policy information, including physician services, refer to the Telemedicine Billing Manual, located on the Billing Manuals web page under the CMS 1500 drop-down. The billing manual provides information on covered services, billing, reimbursement and confidentiality requirements.

 

Telemedicine does not include consultations provided by facsimile machines, text, email or instant messaging. 

 

COVID-19 State of Emergency Changes to Telemedicine Services

To facilitate the safe delivery of health care services to members throughout the COVID-19 state of emergency, the Department is authorizing three temporary changes to the existing telemedicine policy. 

1. Telephone and Live Chat Modalities - Services that are allowed to be provided by telemedicine under the existing policy will no longer be restricted to an interactive audiovisual modality only. Providers may deliver the allowable telemedicine services by telephone or via live chat. All other general requirements for telemedicine services, such as documentation and meeting same standard of care, still need to be met (see below for more details). 
2. Federally Qualified Health Centers, Rural Health Clinics, and Indian Health Services - For the duration of the COVID-19 state of emergency, Health First Colorado is allowing telemedicine visits to qualify as billable encounters for Federally Qualified Health Centers (FQHCs), Rural Health Clinic (RHCs), and Indian Health Services (IHS). Services allowed under telemedicine may be provided via telephone, live chat, or interactive audiovisual modality for these provider types.
3. Physical Therapy, Occupational Therapy, Home Health, Hospice and Pediatric Behavioral Health Providers - Health First Colorado has expanded the list of providers eligible to deliver telemedicine services to include physical therapists, occupational therapists, hospice, home health providers and pediatric behavioral health providers. Services delivered by these provider types require an interactive audiovisual connection to the member; they cannot be provided using telephone only or live chat.

 

Requirements for Telemedicine Services:

It is acceptable to use telemedicine to facilitate live contact directly between a member and a provider. Services can be provided between a member and a distant provider when a member is in their home or other location of their choice. Additionally, the distant provider may participate in the telemedicine interaction from any appropriate location. 

Other standard requirements for telemedicine services include:

• The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service. [C. R. S. 2017, 25.5-5-320(2)]. 
• Providers may only bill procedure codes which they are already eligible to bill. 
• Any health benefits provided through telemedicine shall meet the same standard of care as in-person care. 
• Providers must document the member’s consent, either verbal or written, to receive telemedicine services.  
• The availability of services through telemedicine in no way alters the scope of practice of any health care provider; nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law.  
• Services not otherwise covered by Health First Colorado are not covered when delivered via telemedicine. 
• The use of telemedicine does not change prior authorization requirements that have been established for the services being provided. 
• Record-keeping and patient privacy standards should comply with normal Medicaid requirements and HIPAA. Office for Civil Rights (OCR) Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

 

Billing Guidance:

To receive reimbursement for telemedicine services, providers must follow the following billing practices:

• UB-04 Institutional Claims - Providers must indicate that the service(s) were provided through telemedicine by appending modifier GT to the UB-04 institutional claim form with the service’s usual billing codes. This identifies the service as provided via telemedicine during the COVID-19 State of Emergency. 
• CMS 1500 Professional Claims - Place of Service code 02 must be indicated on all CMS 1500 professional claims for telemedicine. Only specific CPT/HCPCS are allowed. 

 

More communications will be sent as updates to the policy are available.

CMS Moves to Allow Digital Communications by PTs

The new regulatory waivers will allow PTs, OTs, and SLPs to engage in patient-initiated "e-visits" for purposes of assessment and management services.

In the federal government’s rapidly evolving response to the coronavirus pandemic, the U.S. Centers for Medicare and Medicaid Services has announced that it is easing Medicare telehealth restrictions in ways that could allow PTs to provide "e-visits," a limited type of service that must be initiated by the patient. Prior to this change CMS did not recognize PTs among the health care professionals allowed to bill codes associated with the visits.

The change, announced midday on March 17, is part of a set of loosened requirements that CMS has adopted to expand the provision of telehealth and patient-initiated digital communications, such as e-visits, to help blunt the spread of COVID-19. For the most part, PTs remain outside the reach of these so-called "1135 waivers" related to telehealth, with one exception: a type of remote interaction CMS calls an e-visit under Medicare Part B.

In its 2020 physician fee schedule final rule, CMS describes e-visits as “non face-to-face patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.” The code descriptors suggest the codes are intended to cover short-term (up to seven days) assessments that are conducted online or via some other digital platform, and include any associated clinical decision-making.

Under the waivers guidance issued by CMS, Medicare beneficiaries can qualify for e-visits no matter their geographic region or physical location, meaning that the provisions have been expanded to nonrural areas and can take place with patients in their homes. The big news for PTs and their patients is that, for the first time, PTs will be allowed to bill for e-visits under codes associated with online assessment and management services (codes G2061, G2062, and G2063). To determine the reimbursement rates for G2061-G2063, visit the CMS Physician Fee Schedule lookup tool. Medicare coinsurance and deductible would apply to the services.

To qualify as an e-visit, three basic qualifications must be met: the billing practice must have an established relationship with the patient, meaning the provider must have an existing provider-patient relationship; the patient must initiate the inquiry for an e-visit and verbally consent to check-in services; and the communications must be limited to a seven-day period through an "online patient portal."

Although the patient must initiate, CMS writes in a fact sheet that "practitioners may educate beneficiaries on the availability of the service prior to patient initiation." For example, if a patient cancels treatment because they can’t come to the clinic or are concerned about leaving home, then the PT may advise the patient that she or her can reach out to the therapists as needed.

Alice Bell, PT, DPT, APTA senior payment specialist, says that the waiver has some very practical implications for PTs, and offers a possible scenario in which the e-visit could be useful.

"Let's say that, as a PT, I've been seeing a patient for an orthopedic condition and I am progressing the patient’s exercises," Bell said. "The patient is unable to come into the clinic but calls me to say she's having difficulty with one of the exercises and that the other two seem to be too easy. I could arrange an e-visit with the patient and discuss her performance of the exercises. And I could then make a determination — maybe I find that the patient is performing one of the exercises incorrectly — and I could direct the patient on the correct performance. Perhaps I also determine that two of the exercises can be progressed because the patient is improving, so I could instruct the patient in the two new exercises. After that I could advise the patient to contact me for a follow-up e-visit as needed until the patient can return to the clinic."

The HHS Office of the Inspector General has also issued a policy statement that provides guidance on how it interprets the new telehealth waivers. APTA regulatory affairs staff will continue to monitor these waivers and other developments and share news with members.

"As we've seen over the past few weeks, and especially during the past few days, we're dealing with an extremely fluid situation in terms of response to the coronavirus pandemic," said Kara Gainer, APTA's director of regulatory affairs. "This waiver and other changes have the potential to make a difference, and we hope that CMS continues to take steps that can help providers and their patients stay healthy."

APTA has issued a statement on patient care and practice management during the COVID-19 outbreak, and offers a webpage to keep members up to date with the latest news on the pandemic.