Coronavirus (COVID-19): new telehealth rules and procedure codes for testing

Editor's note: On March 17, the Centers for Medicare & Medicaid Services provided more context on these new rules, including that for services dated from March 6 and for the duration of the COVID-19 crisis, Medicare will pay for telehealth services provided to beneficiaries "in any healthcare facility and in their home" and won't enforce the established-relationship rule. For more information, see the CMS Fact Sheet. The following post has been updated.

On March 6, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act. The legislation will allow physicians and other health care professionals to bill Medicare fee-for-service for patient care delivered by telehealth during the current coronavirus public health emergency.

In particular, the legislation gives the U.S. Department of Health and Human Services (HHS) secretary the authority to waive or modify certain telehealth Medicare requirements when the President has declared a National Emergency, or the HHS Secretary has declared a Public Health Emergency, as Sec. Alex Azar did in January. For instance, the legislation gives the HHS secretary the authority to waive the originating site requirement for telehealth services provided by a qualified provider to Medicare beneficiaries in any identified emergency area during emergency periods. The legislation also allows telehealth services to be provided to Medicare beneficiaries by phone, but only if the phone allows for audio-video interaction between the qualified provider and the beneficiary. This expansion was originally thought to be limited to qualified providers who have furnished Medicare services to the individual in the three years prior to the telehealth service (or another qualified provider under the same tax identification number that has provided services within three years). However, CMS has clarified that the established-relationship rule will not be enforced. The patient must initiate the service and give consent to be treated virtually, and the consent must be documented in the medical record before initiation of the service.

As noted, the waiver of the originating site requirement and expansion of telemedicine modalities is limited to emergency areas identified by the President and HHS Secretary during emergency periods. Accordingly, as a practical matter, this expansion of payment is very limited. (Update: On March 13 President Trump announced a national emergency declaration, and on March 17 CMS announced the official expansion of Medicare’s telehealth benefits.) Further, health care providers must still comply with state telehealth laws and regulations, including professional licensure, scope of practice, standard of care, patient consent, as well as other payment requirements for non-Medicare beneficiaries.

The codes that will be billed for what Medicare actually defines as Medicare “telehealth services” will typically be evaluation and management (E/M) codes (for example, 99213, 99214) along with a telehealth Place of Service (POS) code (02) and potentially a modifier (if required by commercial payer). However, there are additional services available for payment that are not ever restricted by originating site and other Medicare telehealth regulations. The Medicare “communications-based technology” codes (e.g. G2012) are not deemed by the Centers for Medicare & Medicaid Services (CMS) to be Medicare “telehealth services,” which means they are not subject to the statutory restrictions regarding originating site and rural geography. These services can be furnished even when patient are in their homes, regardless of a national emergency declaration. There are also time-based, online digital E/M codes (99421, 99422, 99423) for established patients. Similar codes (G2061, G2062, G2063) are available for online patient-initiated assessments provided by qualified non-physician health care professionals.

Last week CMS also announced that Medicare Part B would cover a test to determine if beneficiaries have coronavirus for dates of service on or after Feb. 4, 2020. But providers of the test will have to wait until after April 1, 2020, to submit a claim to Medicare for the test. Most physician offices will not have access to the test to perform it themselves, but may be ordering it for their patients or collecting specimens (e.g. nasal swab or sputum) for testing. In general, if the patient is in the office for an E/M service, the specimen collection is bundled in that service. Otherwise, many contracts don’t include specimen collection. You will need to check with the payers in your area on this point.

CMS has created two Healthcare Common Procedure Coding System (HCPCS) codes to report testing for coronavirus. Labs that test patients for the new coronavirus using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the new HCPCS code (U0001). This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. The second HCPCS billing code (U0002) allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19). On Feb. 29, 2020, the Food and Drug Administration (FDA) issued a new, streamlined policy for certain laboratories to develop their own validated COVID-19 tests. This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare or health insurers. Diagnosis coding for coronavirus is also available.

What is happening in the private health insurance sector remains unclear and may vary from payer to payer. An industry trade group, America’s Health Insurance Plans, issued its own statement last week. CMS also issued a fact sheet on “Information Related to COVID–19 Individual and Small Group Market Insurance Coverage.”

For more information, please see CMS’s frequently asked questions for health care providers regarding Medicare payment for laboratory tests and other services related to the 2019 novel coronavirus. CMS has also provided related fact sheets pertaining to Medicare and Medicaid and the Children’s Health Insurance Program.

Coverage, payment, and other aspects of getting paid for services related to the coronavirus are continuously evolving. Stay tuned to the “Getting Paid” blog for further updates. AAFP has more information about how to prepare for COVID-19 here: https://www.aafp.org/patient-care/emergency/2019-coronavirus.html

— Kent Moore, AAFP Senior Strategist for Physician Payment