Billing Telehealth Services to Medicare
Please see the updated information on telehealth services provided in institutional settings.
Update on 05/05/2020
During the Centers for Medicare & Medicaid’s (CMS’) weekly office hours call on May 5, 2020, they provided clarification on the telehealth waiver for occupational therapy (OT), physical therapy (PT), and speech language pathology (SLP) in response to questions posed by audience members.
- Can OTAs and PTAs perform telehealth services for Medicare beneficiaries?
CMS’ answer was yes, provided all requirements for billing are met. This includes the direct supervision requirement. CMS also stated that all state supervision requirements would still apply.
CMS went on to state that in the Interim Final Rule released on March 30, 2020, CMS did provide a physician flexibilities waiver in regards to direct supervision, which would now apply. Under the waiver, CMS confirmed that having the therapist available immediately by telephone would meet the supervision requirement under the waiver. However, further research into the waiver indicates that the supervision flexibilities were approved for outpatient hospitals only, so the direct supervision requirement is still in effect for private practice. AOTA is seeking additional clarification from CMS.
- Can OT, PT, and SLP perform telehealth services in the outpatient hospital setting?
CMS’ answer was yes. Under the “Hospitals Without Walls” flexibility, hospital-employed therapists can provide services to patients via telehealth when the patient is in a temporary expansion location, such as their home, as long as the patient is registered as a hospital outpatient. CMS made it clear, however, that these services are not considered true telehealth and should be coded as if they were performed in the hospital. Although not required, condition code DR and modifier CR could be used to designate care provided under the flexibility.
Any outpatient hospital services performed outside of this waiver would fall under institutional services, and telehealth cannot be performed.
Can OT, PT, and SLP perform telehealth services in institutional settings such as a skilled nursing facility (SNF)?
CMS’ answer was not at this time. The telehealth waiver was meant specifically for Part B services billed on a 1500 form. CMS is continuing to look into this issue. AOTA will provide an update if CMS issues additional guidance. AOTA supports expansion of telehealth services to institutional providers and is part of a coalition advocating for this change.
- Can OT, PT, and SLP perform telehealth services in a Home Health Agency?
CMS’ answer is that a telehealth visit cannot replace an in-person visit due to statutory requirements. CMS has allowed flexibilities where they can, but they do not have the authority to change the statute. AOTA will provide an update if CMS issues additional guidance.
Original article on 5/1/20
The Centers for Medicare & Medicaid Services (CMS) announced on April 30, 2020, that it was using its waiver authority to allow occupational therapists, as well as physical therapists and speech language pathologists, to perform telehealth services for Medicare beneficiaries. The waiver is retroactive to March 1, 2020, and will remain in effect for the remainder of the public health emergency (PHE). AOTA actively advocated with CMS for this change, which ensures clients can safely receive medically necessary therapy services.
Here are the CMS guidelines to help with billing telehealth to Medicare:
- Patient consent is required for telehealth services. For the duration of the PHE, CMS is allowing this consent to be obtained annually. Written consent is preferable to verbal, but regardless of the method, documentation of the consent must be a part of the patient’s record.
- CMS requires the use of modifier 95 with all telehealth services.
- The place of service (POS) on the claim should be the same as the place where the service would have been rendered in person—11 for office or 12 for home.
- CMS has relaxed the requirements for a HIPAA-compliant platform for telehealth services. If possible, a HIPAA-compliant solution is the best option, but if it is not available, Skype and Face Time are acceptable during the PHE. Do not use public-facing applications such as Facebook Live.
- The following is the list of therapy CPT® codes covered for use as telehealth provided by occupational therapists. Following AOTA advocacy, CMS has added codes 97530, 97542, and 97150 as billable telehealth services using a newly approved sub-regulatory process.
Note: CPT code 97535 is designated for use with audio-only if the patient does not have access to video technology. All other services must be delivered via synchronous audio visual technology.
|
97110 |
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility |
|
97112 |
Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
|
97116 |
Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) |
|
97150 |
Therapeutic procedure(s), group (2 or more individuals) |
|
97165 |
Occupational therapy evaluation, low complexity |
|
97166 |
Occupational therapy evaluation, moderate complexity |
|
97167 |
Occupational therapy evaluation, high complexity |
|
97168 |
Occupational therapy re-evaluation |
|
97530 |
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
|
97535* |
Self-care/home management training (e.g., activities of daily living [ADLs] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact, each 15 minutes (*audio only allowed) |
|
97542 |
Wheelchair management (e.g., assessment, fitting, training), each 15 minutes |
|
97750 |
Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes |
|
97755 |
Assistive technology assessment (e.g., to restore, augment, or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes |
|
97760 |
Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes |
|
97761 |
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes |
|
96110 |
Developmental screening (e.g., developmental milestone survey, speech and language delay screen) with scoring and documentation, per standardized instrument |
|
96112 |
Developmental test administration (includes assessment of fine and gross motor, language, cognitive level, social, memory, and/or executive functions by standardized developmental instruments when performed) by physician or other qualified health professional, with interpretation and report; first hour |
|
96113 |
Developmental test administration (includes assessment of fine and gross motor, language, cognitive level, social, memory, and/or executive functions by standardized developmental instruments when performed) by physician or other qualified health professional, with interpretation and report; each additional 30 minutes |
|
96127 |
Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument |
An occupational therapist can perform telehealth services across state lines for a Medicare beneficiary if the following criteria are met:
- The OT must be enrolled as such in the Medicare program;
- The OT must possess a valid license to practice in the state that relates to his or her Medicare enrollment;
- The OT is furnishing services—whether in person or via telehealth—in a state in which the emergency is occurring in order to contribute to relief efforts in his or her professional capacity;
- The OT is not affirmatively excluded from practice in the state or any other state that is part of the 1135 emergency area.
State licensure requirements continue to apply unless waived under an 1135 waiver, so it is important to check state guidelines in both states before performing services across state lines.
Communication Technology Based Services (CTBS) such as e-visits and telephone assessments continue to be billable services. These services do not meet telehealth requirements.
The waiver states that telehealth is now available to “all that are eligible to bill Medicare for their professional services.” While strictly speaking this language excludes occupational therapy assistants, AOTA has asked for clarification from CMS and will continue to advocate for OTAs to be able to perform telehealth services.
CMS is now paying for telehealth performed in rural health clinics and federally qualified health clinics. However, these are the only additional settings outside of private practice where the rule is clear. Although the rule states that “hospitals may bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients,” it does not clearly state that therapy is included in these covered services. The rule also provides no guidance on services performed in a skilled nursing facility, inpatient residential facility, or home health setting. AOTA is seeking clarification from CMS and will provide updated information as it is received.