CMS Interim Final Rule 2 COVID-19 Response: Telehealth

By Teri Bedard, BA, RT(R)(T), CPC

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a second Interim Final Rule in response to the COVID-19 pandemic. This ruling adds to and changes many of the recent expansions and waivers of the provisions previously outlined by CMS since the Public Health Emergency (PHE) was initiated.

The CMS Interim Final Rule 2 is located in its entirety online. Below is a summary of the finalized changes as they apply to the provision of telehealth. Note that due to the rapidly changing response to the PHE, modifications could be released by CMS that may impact or change regulations contained within this summary.

Telehealth Expansion Update

In response to stakeholder feedback to CMS related to the initial Interim Final Rule released on March 30, 2020, CMS has made additional adjustments to telehealth and telehealth services available during the public health emergency (PHE).  Stakeholders noted they are predominantly providing evaluation and management (E/M) services by telephone only. This is due to very few Medicare beneficiaries having the technology to do a visit with video capabilities or refusing to participate in a visit with video capabilities.  

The use of telephone visits is replacing care that CMS would otherwise expect to be in-person or by the defined telehealth visit requiring audio-video capability. Due to this, CMS indicated the audio-only or telephone E/M visits should be considered telehealth visits and added them to the list of Medicare telehealth services for the duration of the PHE. CMS also noted the use of billing or telephone visits are only to be used for medical discussions. They are not to be used for administrative or other non-medical discussions with the patient. In addition, these visits still have cost-sharing obligations, meaning there may be a copay for the patient for each visit depending upon payer guidelines.   

To account for the application of the telephone or audio-only visits, CMS has adjusted the Relative Value Units (RVUs) assigned to CPT® codes 99441-99443.  Codes 98966-98968 are used by practitioners who cannot independently bill for E/M visits. These codes are not used in place of the outpatient office visits, so the RVUs assigned by CMS have not been adjusted.

The updated RVU values crosswalk from the established values for codes 99212-99214 for both Work and Direct Practice Expense. The values for Direct Practice Expense will crosswalk as follows: 99212 to 99441, 99213 to 99442, and 99214 to 99443. The values of Work RVUs for the duration of the PHE for the audio-only codes are as follows: 99441 = 0.48, 99442 = 0.97, and 99443 = 1.50.

CMS also indicated in the Interim Final Rule 2 that they would be adjusting how codes are added to the telehealth list in response to the PHE. CMS stated they believe the table, as adjusted over the last two interim final rules, reflects the majority of services that would be appropriate to bill for services provided to Medicare beneficiaries during the PHE. There may be other services over the duration of the PHE which may need to be added related to infection control, patient safety, and other public health concerns. In the event new services need to be added, CMS is implementing a new practice that does not involve notice and comment rulemaking. Instead, a sub-regulatory process to modify the list of telehealth services will be conducted.

CMS has published a list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth. It is important to note that there are only a handful of codes that are considered telehealth that can be provided by audio-only.

Using Time to Select Appropriate Level of Telehealth Visit

Stakeholders submitted comments to CMS regarding the ability to use time as the basis for outpatient office E/M visits as part of the initial Interim Final Rule. CMS indicated in the initial ruling that the times, as identified in the CMS public use files, were the values to use; however, the values are not the same as those in the CPT® definitions for codes 99201-99215. CMS agreed these discrepancies can be confusing.  CMS is implementing, for the duration of the PHE, the use of the typical times associated with the levels of the outpatient office E/M codes as established as part of the CPT® definition. 

CMS is also clarifying, per the initial Interim Final Rule, when using time for the selection of the appropriate level of visit, the time is defined as all of the time associated with the E/M on the day of the encounter. All of the requirements for documenting the history and physical exam in the medical record do not apply for establishing the level of a telehealth provided visit.  

Technical Charges for Hospitals Related to Telehealth Services

As part of this second Interim Final Rule, when a patient is in the hospital outpatient department and the physician is at a distant site, not somewhere else in the hospital, there may be a technical charge billable by the hospital. Since the hospital is using resources for the patient to access the real-time audio-video technology, the room, and staff resources, there are expenses to be accounted for by the hospital.  

In these scenarios, a telehealth originating site facility fee would be paid by CMS to the hospital just as it would under telehealth services prior to the PHE. As part of the waiver, this is extended to the patient’s home as an originator site as well. Hospitals are reminded that services should only be provided to the patient in their home after the patient’s home is designated as PBD to the hospital for the provision of services. This would make the home an originator site and the location relative to the physician at a distant site, which is not in the hospital. Documentation of the service and location of the patient and physician are needed to support the telehealth visit provided.  

Comments to Second Interim Final Rule

CMS is moving forward without delay the implementation of the finalized provisions in the second Interim Final Rule. The rules as outlined are retroactive to March 1, 2020. CMS is providing a 60-day public comment period that can be accessed at http://www.regulations.gov.

Additional Links to CMS Transmittals and Resources

There are several transmittals by CMS that also summarize and provide additional information for providers. The following links will take stakeholders directly to these transmittals: 

• Coronavirus Waivers & Flexibilities
• COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
• Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19
• Hospitals: CMS Flexibilities to Fight COVID-19
• List of Telehealth Services
  

Teri Bedard, BA, RT(R)(T), CPC is the Director of Client Services at Revenue Cycle Coding Strategies LLC. In a previous blog post, Bedard answered questions about the details of the first CMS Interim Final Rule as it applies to the coverage of telehealth during the COVID-19 public health emergency. An archived webinar featuring Bedard further addresses the implications of the temporary CMS telehealth coverage decisions in response to the pandemic.

For resources on COVID-19 as it applies to the oncology community, visit ACCC’s continually updated Coronavirus Response page. ACCC members can also access ACCCExchange, a forum that allows them to communicate in real time with their colleagues about how the COVID-19 virus is affecting their communities and their patients.