In response to the novel coronavirus disease-2019 (COVID-19) public health emergency, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule to allow greater flexibility with regard to payment rules for clinicians and institutions that provide care to Medicare beneficiaries.1 These rules are aimed at improving access to telemedicine and remote monitoring services in an effort to circumvent unnecessary exposure to COVID-19 for clinicians, patients, and the greater community. The regulations, issued on March 30, 2020, are retroactively applicable to claims beginning March 1, 2020.1,2 The changes are applicable to the Medicare program only, and it should be noted that private insurers may adopt separate policies.
The key provisions that apply to the remote care of patients, particularly those with chronic conditions like diabetes, hypertension, and chronic obstructive pulmonary disease, are summarized below.
Expansion of Coverage for Telehealth Services
For CMS telehealth services, remote services that are similar to general consultations or office visits fall under Category 1. Services that do not fall into this category but demonstrate a clinical benefit to the patient, including improvement in diagnoses or reduction of complications, fall under Category 2.
The CMS has added >80 telehealth services to the list of eligible services in Category 2 for the duration of the public health emergency to reduce COVID-19 exposure risk. These include codes for home visits, initial and continuing intensive care services, group psychotherapy, end-stage renal disease care, and therapy services. The full list, including the new additions, can be found here.
Importantly, the CMS recognizes the benefits of remote access to certain services during the COVID-19 pandemic that were previously designated as noncovered services. “Under ordinary circumstances, we would expect the kind of [evaluation and management (E/M)] code reported to generally align with the physical location or status of the patient,” the CMS noted in the interim rule. In the context of the COVID-19 public health emergency, however, the relationship between care setting and patient status may depend on community and institution conditions, and practitioners should report the code that best describes the nature of the care they are providing had the service been performed in person.1,2 The CMS will assign the same payment rate that would have been paid under the Physician Fee Schedule as if the services were performed in person.2
Definitions and Exceptions for Telehealth Services
In the interim rule, the CMS clarified the definition of interactive telecommunication systems, which does not apply to telephones or digital mail services. Despite the fact that this definition, as interpreted by the CMS, does not apply to mobile devices that have audio and interactive, real-time video capabilities (eg, smartphones), the CMS believed it important to “avoid the potential perception that this language might prohibit use of any device that could otherwise meet the interactive requirements for Medicare telehealth, especially given that leveraging use of such readily available technology may be of critical importance.”1
As such, the expanded definition in the interim rule for telecommunication systems is “multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.”1
In addition, the use of Skype and FaceTime is permitted during the COVID-19 public health emergency. The Department of Health and Human Services Office for Civil Rights is waiving penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against healthcare providers who, in good faith, manage patients using these everyday communication technologies. Physicians will also not be subject to administrative sanctions from the Office of Inspector General if they reduce or waive cost-sharing obligations (eg, deductibles) owed by Medicare beneficiaries for telehealth services consistent with prior coverage and payment rules.3
Under the interim regulations, the CMS is allowing providers to select the level of the virtual office/outpatient visit when delivered via telehealth. Level selection is based on the time associated with the evaluation and management of the patient on the day of the visit or the CMS Master Data Management (MDM) program. Healthcare providers will not be required to document history or physical examination in medical records during these visits.2 Information about typical times associated with this type of in-person visit can be found here.
Changes to Remote Patient Evaluation and Monitoring Coverage
Codes for remote patient physiologic monitoring services can be applied to new patients during the COVID-19 public health emergency, whereas previously they were only applicable to established patients. Remote physiologic monitoring, typically used for patients with chronic conditions, may also be applied in situations for which remote monitoring would help determine whether at-home treatment is safe for acute conditions during the COVID-19 pandemic.1
The CMS has 7 existing codes for remote physiologic monitoring services. These cover collection and interpretation of data, initial setup and patient education, interactive management and communication with the patient/caregiver, and other services.1,2
During the interim period, verbal consent should be obtained from the Medicare beneficiary at least once annually, including at the time of the remote service, and it should be documented in the medical record that verbal consent was obtained.1
The CMS has also temporarily changed rules regarding audio-only communications. Telephone evaluation and management services were previously not covered by the CMS but will now be covered under the interim rule regulations. The CMS has recognized that during the COVID-19 public health crisis, there may be situations for which prolonged, audio-only communication is clinically appropriate. Codes for telephone assessment and management services conducted by either a qualified nonphysician healthcare professional (eg, clinical psychologists, physical therapists) or a physician to new or established patients, parents, or guardians should be used in these situations. Payment for these services is based on relative value units (RVUs) established during the 2008 Physician Fee Schedule final rule.1,2
Expanded or Altered Services Related to Diabetes Care
Continued coverage of insulin pumps and other infusion pumps requires in-person evaluations and re-evaluations under National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).2,4 These face-to-face requirements have been waived on an interim basis for both NCDs and LCDs until the conclusion of the public health emergency, a change advocated for by the Endocrine Society.2
In addition, provisions will be implemented to allow for temporary flexibilities for Medicare Diabetes Prevention Program (DPP) services. Guidance for suppliers of Medicare DPPs has been issued to provide alternative virtual delivery options for the duration of the public health emergency or to suspend in-person services and resume them at a later date. The number of virtual make-up sessions has been waived, but these sessions should only be held to achieve attendance goals and not weight-loss goals.2
In addition, Medicare beneficiaries are now allowed to obtain DPP services more than once per lifetime, a measure the CMS implemented to allow for continued eligibility despite potential disruptions in services, attendance, and weight loss. Under the interim rule, beneficiaries also have more flexibility in the number of acceptable virtual make-up sessions but are still required to attend the first core session in person. If DPP participants are unable to attend the first session in person, suppliers cannot start new cohorts until the conclusion of the COVID-19 public health emergency.2
1. Department of Health and Human Services. Medicare and Medicaid Programs; Policy and regulatory revisions in response to the COVID-19 public health emergency. Published March 31, 2020. Accessed April 8, 2020. https://www.govinfo.gov/content/pkg/FR-2020-04-06/pdf/2020-06990.pdf
2. Endocrine Society. Summary of key provisions of the COVID-19 public health emergency interim final rule relevant to endocrinology. Accessed April 8, 2020. https://www.endocrine.org/-/media/endocrine/files/membership/summary-of-cms-rule-42020.pdf
3. Office of Inspector General. OIG policy statement regarding physicians and other practitioners that reduce or waive amounts owed by federal health care program beneficiaries for telehealth services during the 2019 novel coronavirus (COVID-19) outbreak. Published March 17, 2020. Accessed April 8, 2020. https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-telehealth-2020.pdf
4. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for infusion pumps (280.14). Accessed April 8, 2020. https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=223&bc=AgAAQAAAAAAA&ncdver=2