Navigating the boundaries of Medicare telehealth expansion

Thursday, March 26, 2020

CMS lifted some restrictions on telehealth coverage in a bid to keep non-critically ill patients out of clinics and hospitals to slow down the spread of the novel coronavirus (COVID-19), the agency stated in a March 17 press release.

Under the waiver, a range of providers, including physicians, nurse practitioners, clinical psychologists, and licensed social workers, are able to bill Medicare for telehealth encounters for any patient in any location, including the patient’s home. Previously, Medicare would pay for telehealth services only when specific originating site and distant site requirements were met. The waiver is retroactively effective to March 6.

Facility perspective

But what does this mean for the facilities where these visits may otherwise have taken place? First, ensure that all staff, from clinical to coders, are aware of the changes. Clinical staff should document that the visit was conducted via telehealth. Professional fee coders and revenue integrity staff should be on the lookout for an increase in telehealth visits and be prepared to offer tipsheets and resources for clinical staff as needed. In addition, the Office of Inspector General announced that organizations may waive the cost-sharing amounts for telehealth visits.

However, the waiver does not extend to permitting a facility fee for telehealth visits unless the patient is in the hospital. Consider this example: a physician at a hospital outpatient department provides telehealth services to a patient who is self-isolating in his home. The physician submits a 1500 claim form and is paid for her services. The hospital outpatient department cannot submit a UB-04 claim form and does not receive a separate facility payment for the use of its EHR.

What if the patient is already an inpatient or outpatient at a hospital? That changes things, says Valerie Rinke, MPA, CHRI, regulatory specialist with HCPro.

“If the patient is in a hospital location/department, whether inpatient or outpatient when receiving the telehealth service, then the site origination fee can be billed when the service is telehealth – but not e-visits or other communication-based technology services,” she says.

Outside of that circumstance, hospitals aren’t able to bill for telehealth services on hospital claims.

That holds true even when a nurse practitioner (NP) or other advanced practice provider (APP) who is employed by the hospital is providing the service. Claims for telehealth services must be submitted under the NP or APP’s National Provider Identifier (NPI) on a 1500 claim form using the applicable place of service code. In order for the hospital to bill for its employed NPs’ or APPs’ services, the NPs and APPs would have to be enrolled with Medicare, have an NPI, and reassign their benefits to the hospital. These steps are required to allow the hospital to submit a 1500 claim form on behalf of these clinicians.

Hospitals may be registering accounts in their patient accounting systems to allow clinicians to document the telehealth services in the hospital’s EHR. These accounts will have to be tracked for management purposes and to support cost reporting or in case CMS announces other changes enabling hospital billing. Hospitals will have to consider adding all the telehealth services in their chargemaster to track the facility services, and then determine how to adjust these if they cannot be billed on 1500 claims, Rinkle says. One possibility would be to use a new, unique COVID-19 adjustment code.

Editor's note: On March 31, CMS released an interim final rule, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-10 Public Health Emergency, to ease restrictions during the COVID-19 public health emergency. The interim final rule adds new telehealth codes, guidance, and definitions. Practitioners providing telehealth services under the 1135 waiver are instructed to use their actual location place of service code -- “the POS code that would have been reported had the service been furnished in person” – for telehealth claims rather than the 02 POS called for in previous guidance. Click here for more information.

NAHRI members can share information and ask questions about COVID-19-related revenue integrity concerns on our dedicated COVID-19 forum. Nonmembers may use HCPro’s COVID-19 forum by registering free of charge. Visit our Coronavirus Resource Center for additional guidance and education. Email NAHRI Director Jaclyn Fitzgerald at with requests for additional COVID-19 resources and news.