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MLNMattersSE20016RelatedCRN/APage1of9New&ExpandedFlexibilitiesforRHCs&FQHCsduringtheCOVID-19PHEMLNMattersNumber:SE20016RevisedArticleReleaseDate:February23,2021RelatedCRTransmittalNumber:N/ARelatedChangeRequest(CR)Number:N/AEffectiveDate:N/AImplementationDate:N/ANote:WerevisedthisarticletoprovidetheupdatedrateeffectiveJanuary1,2021forG2025.
You'llfindsubstantivecontentupdatesindarkredfont(seepages2,3,and6).
WealsoupdatedtherateforG0071onpage6.
PROVIDERTYPESAFFECTEDThisMLNMattersSpecialEditionArticleisforRuralHealthClinics(RHCs)andFederallyQualifiedHealthCenters(FQHCs)duringtheCOVID-19PublicHealthEmergency(PHE)forservicesprovidedtoMedicarebeneficiaries.
WHATYOUNEEDTOKNOWToprovideasmuchsupportaspossibletoyouandyourpatientsduringtheCOVID-19PHE,bothCongressandwe(CMS)havemadeseveralchangestotheRHCandFQHCrequirementsandpayments.
ThesechangesareforthedurationoftheCOVID-19PHE,andwe'llmakeotherdiscretionarychangesasnecessarytomakesurethatyourpatientshaveaccesstotheservicestheyneedduringthepandemic.
Formoreinformation,pleaseseetheRHC/FQHCCOVID-19FAQsathttps://www.
cms.
gov/files/document/03092020-covid-19-faqs-508.
pdf.
BACKGROUNDNewPaymentforTelehealthServicesOnMarch27,2020,CongresssignedintolawtheCoronavirusAid,Relief,andEconomicSecurityAct(CARESAct).
Section3704oftheCARESActauthorizesRHCsandFQHCstofurnishdistantsitetelehealthservicestoMedicarebeneficiariesduringtheCOVID-19PHE.
Medicaretelehealthservicesgenerallyrequireaninteractiveaudioandvideotelecommunicationssystemthatpermitsreal-timecommunicationbetweenthepractitionerandthepatient.
Ifyouhavethiscapability,youcannowprovideandbepaidfortelehealthservicestoMedicarepatientsforthedurationoftheCOVID-19PHE.
Anyhealthcarepractitionerworkingforyouwithinyourscopeofpracticecanfurnishdistantsitetelehealthservices.
Practitionerscanfurnishdistantsitetelehealthservices(approvedbyMedicareasadistantsitetelehealthserviceunderthePhysicianFeeSchedule(PFS))fromanylocation,includingtheirhome,duringthetimethatthey'reworkingforyou.
Alistoftheseservicesisavailableathttps://www.
cms.
gov/files/zip/covid-19-telehealth-services-phe.
zip.
MLNMattersSE20016RelatedCRN/APage2of9ThestatutorylanguageauthorizingRHCsandFQHCsasdistantsitetelehealthprovidersrequiresthatwedeveloppaymentratesfortheseservicesthataresimilartothenationalaveragepaymentratesforcomparabletelehealthservicesunderthePFS.
YoumustuseHCPCScodeG2025,thenewRHC/FQHCspecificGcodefordistantsitetelehealthservices,tofindservicesfurnishedviatelehealthbeginningonJanuary27,2020,thedatetheCOVID-19PHEbecameeffective(seehttps://www.
phe.
gov/emergency/news/healthactions/phe/Pages/2019-nCoV.
aspx).
Notethatthechangesineligibleoriginatingsitelocations,includingthepatient'shomeduringtheCOVID-19PHEareeffectivebeginningMarch6,2020.
EffectiveJanuary1,2021,thepaymentratefordistantsitetelehealthservicesisupdatedto$99.
45(seepage3).
ForservicesbetweenJanuary27,2020,throughDecember31,2020,yourrateissetat$92.
03.
TheseratesaretheaverageamountforallPFStelehealthservicesonthetelehealthlist,weightedbyvolumeforthoseservicesreportedunderthePFSduringthegiventimeframes.
Becausewemadethesechangesinpolicyonanemergencybasis,weneedtoimplementchangestoclaimsprocessingsystemsinseveralstages.
ClaimsRequirementsforRHCsFortelehealthdistantsiteservicesfurnishedbetweenJanuary27,2020,andJune30,2020,youmustreportHCPCScodeG2025onyourclaimswiththeCGmodifier.
YoumayalsoappendModifier"95"(SynchronousTelemedicineServiceRenderedviaReal-TimeInteractiveAudioandVideoTelecommunicationsSystem),butitisn'trequired.
WepaidtheseclaimsattheRHC'sall-inclusiverate(AIR),andtheMACautomaticallyreprocessedtheseclaimsbeginningonJuly1,2020,atthe$92.
03rate.
Youdon'tneedtoresubmittheseclaimsforthepaymentadjustment.
BeginningJuly1,2020,youshouldnolongerputtheCGmodifieronclaimswithHCPCScodeG2025.
Table1.
RHCClaimsforTelehealthServicesfromJanuary27,2020,throughJune30,2020RevenueCodeHCPCSCodeModifiers052XG2025CG(required)95(optional)Table2.
RHCClaimsforTelehealthServicesstartingJuly1,2020RevenueCodeHCPCSCodeModifiers052XG202595(optional)ClaimsRequirementsforFQHCsFortelehealthdistantsiteservicesfurnishedbetweenJanuary27,2020,andJune30,2020thatarealsoFQHCqualifyingvisits,youmustreport3HCPCS/CPTcodes:MLNMattersSE20016RelatedCRN/APage3of9TheFQHCProspectivePaymentSystem(PPS)specificpaymentcode(G0466,G0467,G0468,G0469,orG0470)TheHCPCS/CPTcodethatdescribestheservicesfurnishedviatelehealthwithmodifier95G2025withmodifier95WepaidtheseclaimsattheFQHCPPSrateuntilJune30,2020,andtheMACautomaticallyreprocessedtheseclaimsbeginningonJuly1,2020,atthe$92.
03rate.
Youdon'tneedtoresubmittheseclaimsforthepaymentadjustment.
Whenfurnishingservicesviatelehealththataren'tFQHCqualifyingvisits,youshouldhaveheldtheseclaimsuntilJuly1,2020,andthenbilledthemwithHCPCScodeG2025.
YoumayappendModifier95butitisn'trequired.
(Seehttps://www.
cms.
gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-specific-payment-codes.
pdfforalistofFQHCPPSspecificpaymentcodes).
BeginningJuly1,2020,youwillonlyneedtosubmitG2025.
YoumayappendModifier95butitisn'trequired.
Table3.
ExampleofFQHCClaimsforTelehealthServicesJanuary27,2020,throughJune30,2020RevenueCodeHCPCSCodeModifiers052XG0467(orotherappropriateFQHCSpecificPaymentCodeN/A052X99214(orotherFQHCPPSQualifyingPaymentCode)95052XG202595Table4.
FQHCClaimsforTelehealthServicesstartingJuly1,2020RevenueCodeHCPCSCodeModifiers052XG202595(optional)PaymentRatefor2021EffectiveJanuary1,2021,yourpaymentfordistantsitetelehealthservicesissetat$99.
45.
TheMACwillautomaticallyreprocessclaimswithHCPCScodeG2025fordatesofserviceonorafterJanuary1,2021thatweprocessedbeforetheratewasupdatedinthesystem.
MedicareonlyauthorizespaymentfordistantsitetelehealthservicestoRHCsandFQHCsfurnishedduringtheCOVID-19PHE.
IftheCOVID-19PHEisineffectafterDecember31,2021,we'llupdatethisratebasedontheCY2022PFSaveragepaymentratefortheseservices,weightedbyvolumeforthoseservicesreportedunderthePFS.
CostReportingWewon'tusecostsforfurnishingdistantsitetelehealthservicestodecidetheRHCAIRortheMLNMattersSE20016RelatedCRN/APage4of9FQHCPPSrate,butthesecostsmustbereportedonthepropercostreportform.
RHCsmustreportbothoriginatinganddistantsitetelehealthcostsonFormCMS-222-17online79oftheWorksheetA,inthesectiontitled"CostOtherThanRHCServices.
"FQHCsmustreportbothoriginatinganddistantsitetelehealthcostsonFormCMS-224-14,theFederallyQualifiedHealthCenterCostReport,online66oftheWorksheetA,inthesectiontitled"OtherFQHCServices".
MedicareAdvantageWrap-AroundSincetelehealthdistantsiteservicesaren'tpaidundertheRHCAIRortheFQHCPPS,theMedicareAdvantage(MA)wrap-aroundpaymentdoesn'tapplytotheseservices.
MAplanswilladjustwrap-aroundpaymentfordistantsitetelehealthservices.
Cost-sharingRelatedtoCOVID-19TestingForservicesfurnishedonMarch18,2020,throughthedurationoftheCOVID-19PHE,we'llpayallofthereasonablecostsforspecifiedcategoriesofevaluationandmanagement(E/M)servicesiftheyresultinanorderfororadministrationofaCOVID-19testandrelatetothefurnishingoradministrationofsuchtestortotheevaluationofanindividualforpurposesofdecidingtheneedforsuchtest.
Thiswouldincludeapplicabletelehealthservices.
(SeeMLNMattersarticleSE20011formoreinformation.
)ForthespecifiedE/MservicesrelatedtoCOVID-19testing,includingwhenfurnishedviatelehealth,youmustwaivethecollectionofco-insurancefrombeneficiaries.
ForservicesinwhichMedicarewaivesthecoinsurance,youmustputthe"CS"modifierontheserviceline.
Wepaidyourclaimswiththe"CS"modifierwiththecoinsuranceapplied,andtheMACautomaticallyreprocessedtheseclaimsbeginningonJuly1,2020.
Don'tcollectcoinsurancefrombeneficiariesifthecoinsuranceiswaived.
ClaimsExamples:Table5.
RHCClaimsforTelehealthServicesfromJanuary27,2020,throughJune30,2020,whencostsharingiswaived:RevenueCodeHCPCSCodeModifiers052XG2025CG,CS(required)95(optional)Table6.
RHCClaimsforTelehealthServiceswithcostsharingwaivedstartingJuly1,2020RevenueCodeHCPCSCodeModifiers052XG2025CS(required)95(optional)MLNMattersSE20016RelatedCRN/APage5of9Table7.
FQHCClaimsforTelehealthServicesJanuary27,2020,throughJune30,2020,whencostsharingiswaivedRevenueCodeHCPCSCodeModifiers052XG0467(orotherappropriateFQHCSpecificPaymentCodeN/A052XG0446(orotherFQHCPPSQualifyingPaymentCode)CS,95(required)052XG2025CS,95(required)Table8.
FQHCClaimsforTelehealthServicesstartingJuly1,2020,whencostsharingiswaivedRevenueCodeHCPCSCodeModifiers052XG2025CS(required)95(optional)OtherTelehealthFlexibilitiesDuringtheCOVID-19PHE,youcanfurnishanyMedicare-approvedtelehealthserviceunderthePFS.
(Seehttps://www.
cms.
gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
)Also,effectiveMarch1,2020,theseservicesincludeCPTcodes99441,99442,and99443,whichareaudio-onlytelephoneevaluationandmanagement(E/M)services.
YoucanfurnishandbillfortheseservicesusingHCPCScodeG2025.
Tobillfortheseservices,aphysicianorMedicareproviderwhomayreportE/Mservicesmustprovideatleast5minutesoftelephoneE/Mservicetoanestablishedpatient,parent,orguardian.
Youcan'tbillfortheseservicesiftheyoriginatefromarelatedE/Mserviceprovidedwithintheprevious7daysorleadtoanE/Mserviceorprocedurewithinthenext24hoursorsoonestavailableappointment.
TelehealthServiceswithCost-SharingFortheCPTandHCPCScodesincludedinthelistoftelehealthcodesatthelinkabove,we'lladjustthecoinsuranceandpaymentcalculationfordistantsitetelehealthservicesyoufurnishedtoreflectthemethodusedtocalculatecoinsuranceandpaymentunderthePFS.
Thecoinsurancefortheseserviceswillbe20%ofthelesseroftheallowedamount($92.
03for2020claimsor$99.
45for2021claimsbasedondateofservice)oractualcharges.
Thepaymentwillbe80%ofthelesseroftheallowedamount($92.
03for2020claimsor$99.
45for2021claimsbasedondateofservice)ortheactualcharges.
Beforetheadjustment,thecoinsurancefordistantsiteservicesyoufurnishedwas20%oftheactualchargesandthepaymentwastheallowedamount($92.
03for2020claimsor$99.
45for2021claimsbasedondateofservice)minusthecoinsurance.
MACswillautomaticallyreprocessanyclaimswithHCPCScodeG2025forservicesfurnishedonorafterJanuary27,2020throughNovember16,2020,thatwepaidbeforeweupdatedtheclaimsprocessingsystemtopayHCPCScodeG2025basedonthe"lesserof"methodology,asdescribedabove.
MLNMattersSE20016RelatedCRN/APage6of9TelehealthServiceswithCost-SharingWaivedThelistoftelehealthcodesatthelinkaboveincludesseveralCPTandHCPCScodesthatdescribepreventiveservicesthathavewaivedcost-sharing.
Asstatedearlierinthisarticle,youshouldbilltelehealthservicesonthislistusingHCPCScodeG2025.
Todistinguishthosetelehealthservicesthatdon'thavecostsharingwaivedfromthosethatdo,suchascertainpreventiveservicesyoumustalsoreportmodifierCS.
We'vemodifiedthedescriptoroftheCSmodifiertoaccountforthisadditionaluseasfollows:CS-Cost-sharingwaivedforspecifiedCOVID-19testing-relatedservicesthatresultinanorderfororadministrationofaCOVID-19testand/orusedforcost-sharingwaivedpreventiveservicesfurnishedviatelehealthinRuralHealthClinicsandFederallyQualifiedHealthCentersduringtheCOVID-19publichealthemergency.
Forpreventiveservicesfurnishedviatelehealththathavecost-sharingwaived,RHCsmustreportG2025onclaimswiththeCGandCSmodifierandFQHCsmustreportG2025withtheCSmodifieronorafterJuly1,2020.
Pleaseseetheabove-referencedclaimexamplesforCost-SharingRelatedtoCOVID-19Testing.
Theseexampleswillalsoapplytopreventiveservicesthathavecost-sharingwaived.
ExpansionofVirtualCommunicationServicesPaymentforvirtualcommunicationservicesnowincludesonlinedigitalevaluationandmanagementservices.
Onlinedigitalevaluationandmanagementservicesarenon-face-to-face,patient-initiated,digitalcommunicationsusingasecurepatientportal.
TheonlinedigitalevaluationandmanagementcodesthatarebillableduringtheCOVID-19PHEare:CPTcode99421(5-10minutesovera7-dayperiod)CPTcode99422(11-20minutesovera7-dayperiod)CPTcode99423(21minutesormoreovera7-dayperiod)Togetpaymentforthenewonlinedigitalevaluationandmanagement(CPTcodes99421,99422,and99423)orvirtualcommunicationservices(HCPCScodesG2012andG2010),youmustsubmitanRHCorFQHCclaimwithHCPCScodeG0071(VirtualCommunicationServices)eitheraloneorwithotherpayableservices.
ForclaimssubmittedwithHCPCScodeG0071onorafterMarch1,2020,andforthedurationoftheCOVID-19PHE,paymentforHCPCScodeG0071issetattheaverageofthenationalnon-facilityPFSpaymentratesforthese5codes.
We'llpay$24.
76forclaimssubmittedwithG0071onorafterMarch1,2020throughDecember31,2020.
EffectiveJanuary1,2021throughDecember31,2021,we'llpaythenewrateof$23.
73forclaimssubmittedwithG0071.
RevisionofHomeHealthAgencyShortageRequirementforVisitingNursingServicesYoucanbillforvisitingnursingservicesfurnishedbyanRNorLPNtohomeboundindividualsunderawrittentreatmentplaninareaswithashortageofhomehealthagencies(HHAs).
MLNMattersSE20016RelatedCRN/APage7of9EffectiveMarch1,2020andforthedurationoftheCOVID-19PHE,wehavedeterminedthattheareatypicallyservedbytheRHC,andtheareaincludedintheFQHCserviceareaplanhaveashortageofHHAs,andthisdeterminationdoesn'trequirearequest.
YoumustchecktheHIPAAEligibilityTransactionSystem(HETS)beforeprovidingvisitingnurseservicestomakesurethatthepatientisn'talreadyunderahomehealthplanofcare.
ConsentforCareManagementandVirtualCommunicationServicesMedicarerequiresbeneficiaryconsentforallservices,includingnon-face-to-faceservices.
DuringtheCOVID-19PHE,youmaygetbeneficiaryconsentatthesametimeyouinitiallyprovidetheservices.
Thismeansthatsomeoneworkingunderyourgeneralsupervisioncangetbeneficiaryconsent.
Directsupervisionisn'trequiredtogetconsent.
Ingeneral,auxiliarypersonnelundergeneralsupervisionofthebillingpractitionercangetbeneficiaryconsenttoreceivetheseservices.
Thepersongettingconsentcanbeanemployee,independentcontractor,orleasedemployeeofthebillingpractitioner.
(See:https://www.
cms.
gov/files/document/covid-final-ifc.
pdf).
RevisionofBedCountMethodologyforDeterminingProvider-BasedRHCsExemptiontotheRHCPaymentLimitIfyou'reaprovider-basedtoahospitalwithfewerthan50beds,youareexemptfromthenationalper-visitpaymentlimitforRHCs.
DuetotheCOVID-19PHE,somehospitalshavebeenorareplanningtoincreaseinpatientbedcapacitytoaddresstheincreasedneedforinpatientcare.
Ifyou'recurrentlyexemptfromthenationalper-visitpayment,we'reworkingtopreventyoufromlosingyourexemptionduetotheCOVID-19PHEandtoencouragehospitalstoincreasebedcapacityifneeded.
We'llusethenumberofbedsfromthecostreportingperiodpriortothestartoftheCOVID-19PHEastheofficialhospitalbedcountfordecidingexemptiontothepaymentlimit.
Ifyouhadaprovider-basedstatusandwereexemptfromthenationalper-visitpaymentlimitbeforetheeffectivedateoftheCOVID-19PHE(January27,2020),youwillcontinuetobeexemptfromthenationalpaymentlimitforthedurationofthePHEfortheCOVID-19.
ExceptiontotheProductivityStandardsforRHCsWeuseproductivitystandardstohelpdecidetheaveragecostperpatientforyourMedicarereimbursement.
Physicians,nursepractitioners,physicianassistants,andcertifiednursemidwivesareheldtoaminimumnumberofvisitsperfulltimeemployee(FTE)thatthey'reexpectedtofurnishintheRHC.
Failuretomeetthisminimummayshowthatthey'reoperatingatanexcessivestaffinglevel,thus,generatingexcessivecost.
ManyRHCshavehadtochangethewaytheystafftheirclinicsandbillforRHCservicesduringtheCOVID-19publichealthemergency(PHE).
Asaresult,theseRHCsmayhavedifficultyinmeetingtheproductivitystandards.
TominimizetheburdenonRHCs,yourMACmaygrantexceptionstotheproductivitystandardduringtheCOVID-19PHE.
YourMACwillprovidefurtherdirection.
ADDITIONALINFORMATIONViewthecompletelistofcoronaviruswaivers.
MLNMattersSE20016RelatedCRN/APage8of9Reviewinformationonthecurrentemergencieswebpageathttps://www.
cms.
gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.
Ifyouhavequestions,yourMACsmayhavemoreinformation.
Findtheirwebsiteathttp://go.
cms.
gov/MAC-website-list.
DOCUMENTHISTORYDateofChangeDescriptionFebruary23,2021WerevisedthisarticletoprovidetheupdatedrateeffectiveJanuary1,2021forG2025.
You'llfindsubstantivecontentupdatesindarkredfont(seepages2,3and5).
WealsoupdatedtherateforG0071onpage6.
December3,2020Werevisedthisarticletoprovideadditionalguidanceontelehealthservicesthathavecost-sharingandcost-sharingwaived.
You'llfindsubstantivecontentupdates(seepages5-6).
Wealsomadeotherlanguagechangesforclarity,butthesechangesdidnotalterthesubstanceofthearticle.
July6,2020Werevisedthisarticletoprovide:-Additionalguidanceontelehealthservicesthathavecost-sharingwaivedandadditionalclaimexamples-AnadditionalsectionontheRHCProductivityStandardsAllotherinformationremainsthesame.
April30,2020Werevisedthisarticletoprovide:-Additionalclaimssubmissionandprocessinginstructions-Informationoncost-sharingrelatedtoCOVID-19testing-Additionalinformationontelehealthflexibilities-Informationonprovider-basedRHCsexemptiontotheRHCpaymentlimitAllotherinformationremainsthesame.
April17,2020Initialarticlereleased.
Disclaimer:PaidforbytheDepartmentofHealth&HumanServices.
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Theinformationprovidedisonlyintendedtobeageneralsummary.
Itisnotintendedtotaketheplaceofeitherthewrittenlaworregulations.
Weencouragereaderstoreviewthespecificstatutes,regulationsandotherinterpretivematerialsforafullandaccuratestatementoftheircontents.
CPTonlycopyright2019AmericanMedicalAssociation.
Allrightsreserved.
Copyright2013-2020,theAmericanHospitalAssociation,Chicago,Illinois.
ReproducedbyCMSwithpermission.
NoportionoftheAHAcopyrightedmaterialscontainedwithinthispublicationmaybecopiedwithouttheexpresswrittenconsentoftheAHA.
AHAcopyrightedmaterialsincludingtheUB-04codesanddescriptionsmaynotberemoved,copied,orutilizedwithinanysoftware,product,service,solutionorderivativeworkwithoutthewrittenconsentoftheAHA.
IfanentitywishestoutilizeanyAHAmaterials,pleasecontacttheAHAat312-893-6816.
MakingcopiesorutilizingthecontentoftheUB-04Manual,includingthecodesand/orMLNMattersSE20016RelatedCRN/APage9of9descriptions,forinternalpurposes,resaleand/ortobeusedinanyproductorpublication;creatinganymodifiedorderivativeworkoftheUB-04Manualand/orcodesanddescriptions;and/ormakinganycommercialuseofUB-04Manualoranyportionthereof,includingthecodesand/ordescriptions,isonlyauthorizedwithanexpresslicensefromtheAmericanHospitalAssociation.
TolicensetheelectronicdatafileofUB-04DataSpecifications,contactTimCarlsonat(312)893-6816.
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comTheAmericanHospitalAssociation(the"AHA")hasnotreviewed,andisnotresponsiblefor,thecompletenessoraccuracyofanyinformationcontainedinthismaterial,norwastheAHAoranyofitsaffiliates,involvedinthepreparationofthismaterial,ortheanalysisofinformationprovidedinthematerial.
Theviewsand/orpositionspresentedinthematerialdonotnecessarilyrepresenttheviewsoftheAHA.
CMSanditsproductsandservicesarenotendorsedbytheAHAoranyofitsaffiliates.
You'llfindsubstantivecontentupdatesindarkredfont(seepages2,3,and6).
WealsoupdatedtherateforG0071onpage6.
PROVIDERTYPESAFFECTEDThisMLNMattersSpecialEditionArticleisforRuralHealthClinics(RHCs)andFederallyQualifiedHealthCenters(FQHCs)duringtheCOVID-19PublicHealthEmergency(PHE)forservicesprovidedtoMedicarebeneficiaries.
WHATYOUNEEDTOKNOWToprovideasmuchsupportaspossibletoyouandyourpatientsduringtheCOVID-19PHE,bothCongressandwe(CMS)havemadeseveralchangestotheRHCandFQHCrequirementsandpayments.
ThesechangesareforthedurationoftheCOVID-19PHE,andwe'llmakeotherdiscretionarychangesasnecessarytomakesurethatyourpatientshaveaccesstotheservicestheyneedduringthepandemic.
Formoreinformation,pleaseseetheRHC/FQHCCOVID-19FAQsathttps://www.
cms.
gov/files/document/03092020-covid-19-faqs-508.
pdf.
BACKGROUNDNewPaymentforTelehealthServicesOnMarch27,2020,CongresssignedintolawtheCoronavirusAid,Relief,andEconomicSecurityAct(CARESAct).
Section3704oftheCARESActauthorizesRHCsandFQHCstofurnishdistantsitetelehealthservicestoMedicarebeneficiariesduringtheCOVID-19PHE.
Medicaretelehealthservicesgenerallyrequireaninteractiveaudioandvideotelecommunicationssystemthatpermitsreal-timecommunicationbetweenthepractitionerandthepatient.
Ifyouhavethiscapability,youcannowprovideandbepaidfortelehealthservicestoMedicarepatientsforthedurationoftheCOVID-19PHE.
Anyhealthcarepractitionerworkingforyouwithinyourscopeofpracticecanfurnishdistantsitetelehealthservices.
Practitionerscanfurnishdistantsitetelehealthservices(approvedbyMedicareasadistantsitetelehealthserviceunderthePhysicianFeeSchedule(PFS))fromanylocation,includingtheirhome,duringthetimethatthey'reworkingforyou.
Alistoftheseservicesisavailableathttps://www.
cms.
gov/files/zip/covid-19-telehealth-services-phe.
zip.
MLNMattersSE20016RelatedCRN/APage2of9ThestatutorylanguageauthorizingRHCsandFQHCsasdistantsitetelehealthprovidersrequiresthatwedeveloppaymentratesfortheseservicesthataresimilartothenationalaveragepaymentratesforcomparabletelehealthservicesunderthePFS.
YoumustuseHCPCScodeG2025,thenewRHC/FQHCspecificGcodefordistantsitetelehealthservices,tofindservicesfurnishedviatelehealthbeginningonJanuary27,2020,thedatetheCOVID-19PHEbecameeffective(seehttps://www.
phe.
gov/emergency/news/healthactions/phe/Pages/2019-nCoV.
aspx).
Notethatthechangesineligibleoriginatingsitelocations,includingthepatient'shomeduringtheCOVID-19PHEareeffectivebeginningMarch6,2020.
EffectiveJanuary1,2021,thepaymentratefordistantsitetelehealthservicesisupdatedto$99.
45(seepage3).
ForservicesbetweenJanuary27,2020,throughDecember31,2020,yourrateissetat$92.
03.
TheseratesaretheaverageamountforallPFStelehealthservicesonthetelehealthlist,weightedbyvolumeforthoseservicesreportedunderthePFSduringthegiventimeframes.
Becausewemadethesechangesinpolicyonanemergencybasis,weneedtoimplementchangestoclaimsprocessingsystemsinseveralstages.
ClaimsRequirementsforRHCsFortelehealthdistantsiteservicesfurnishedbetweenJanuary27,2020,andJune30,2020,youmustreportHCPCScodeG2025onyourclaimswiththeCGmodifier.
YoumayalsoappendModifier"95"(SynchronousTelemedicineServiceRenderedviaReal-TimeInteractiveAudioandVideoTelecommunicationsSystem),butitisn'trequired.
WepaidtheseclaimsattheRHC'sall-inclusiverate(AIR),andtheMACautomaticallyreprocessedtheseclaimsbeginningonJuly1,2020,atthe$92.
03rate.
Youdon'tneedtoresubmittheseclaimsforthepaymentadjustment.
BeginningJuly1,2020,youshouldnolongerputtheCGmodifieronclaimswithHCPCScodeG2025.
Table1.
RHCClaimsforTelehealthServicesfromJanuary27,2020,throughJune30,2020RevenueCodeHCPCSCodeModifiers052XG2025CG(required)95(optional)Table2.
RHCClaimsforTelehealthServicesstartingJuly1,2020RevenueCodeHCPCSCodeModifiers052XG202595(optional)ClaimsRequirementsforFQHCsFortelehealthdistantsiteservicesfurnishedbetweenJanuary27,2020,andJune30,2020thatarealsoFQHCqualifyingvisits,youmustreport3HCPCS/CPTcodes:MLNMattersSE20016RelatedCRN/APage3of9TheFQHCProspectivePaymentSystem(PPS)specificpaymentcode(G0466,G0467,G0468,G0469,orG0470)TheHCPCS/CPTcodethatdescribestheservicesfurnishedviatelehealthwithmodifier95G2025withmodifier95WepaidtheseclaimsattheFQHCPPSrateuntilJune30,2020,andtheMACautomaticallyreprocessedtheseclaimsbeginningonJuly1,2020,atthe$92.
03rate.
Youdon'tneedtoresubmittheseclaimsforthepaymentadjustment.
Whenfurnishingservicesviatelehealththataren'tFQHCqualifyingvisits,youshouldhaveheldtheseclaimsuntilJuly1,2020,andthenbilledthemwithHCPCScodeG2025.
YoumayappendModifier95butitisn'trequired.
(Seehttps://www.
cms.
gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-specific-payment-codes.
pdfforalistofFQHCPPSspecificpaymentcodes).
BeginningJuly1,2020,youwillonlyneedtosubmitG2025.
YoumayappendModifier95butitisn'trequired.
Table3.
ExampleofFQHCClaimsforTelehealthServicesJanuary27,2020,throughJune30,2020RevenueCodeHCPCSCodeModifiers052XG0467(orotherappropriateFQHCSpecificPaymentCodeN/A052X99214(orotherFQHCPPSQualifyingPaymentCode)95052XG202595Table4.
FQHCClaimsforTelehealthServicesstartingJuly1,2020RevenueCodeHCPCSCodeModifiers052XG202595(optional)PaymentRatefor2021EffectiveJanuary1,2021,yourpaymentfordistantsitetelehealthservicesissetat$99.
45.
TheMACwillautomaticallyreprocessclaimswithHCPCScodeG2025fordatesofserviceonorafterJanuary1,2021thatweprocessedbeforetheratewasupdatedinthesystem.
MedicareonlyauthorizespaymentfordistantsitetelehealthservicestoRHCsandFQHCsfurnishedduringtheCOVID-19PHE.
IftheCOVID-19PHEisineffectafterDecember31,2021,we'llupdatethisratebasedontheCY2022PFSaveragepaymentratefortheseservices,weightedbyvolumeforthoseservicesreportedunderthePFS.
CostReportingWewon'tusecostsforfurnishingdistantsitetelehealthservicestodecidetheRHCAIRortheMLNMattersSE20016RelatedCRN/APage4of9FQHCPPSrate,butthesecostsmustbereportedonthepropercostreportform.
RHCsmustreportbothoriginatinganddistantsitetelehealthcostsonFormCMS-222-17online79oftheWorksheetA,inthesectiontitled"CostOtherThanRHCServices.
"FQHCsmustreportbothoriginatinganddistantsitetelehealthcostsonFormCMS-224-14,theFederallyQualifiedHealthCenterCostReport,online66oftheWorksheetA,inthesectiontitled"OtherFQHCServices".
MedicareAdvantageWrap-AroundSincetelehealthdistantsiteservicesaren'tpaidundertheRHCAIRortheFQHCPPS,theMedicareAdvantage(MA)wrap-aroundpaymentdoesn'tapplytotheseservices.
MAplanswilladjustwrap-aroundpaymentfordistantsitetelehealthservices.
Cost-sharingRelatedtoCOVID-19TestingForservicesfurnishedonMarch18,2020,throughthedurationoftheCOVID-19PHE,we'llpayallofthereasonablecostsforspecifiedcategoriesofevaluationandmanagement(E/M)servicesiftheyresultinanorderfororadministrationofaCOVID-19testandrelatetothefurnishingoradministrationofsuchtestortotheevaluationofanindividualforpurposesofdecidingtheneedforsuchtest.
Thiswouldincludeapplicabletelehealthservices.
(SeeMLNMattersarticleSE20011formoreinformation.
)ForthespecifiedE/MservicesrelatedtoCOVID-19testing,includingwhenfurnishedviatelehealth,youmustwaivethecollectionofco-insurancefrombeneficiaries.
ForservicesinwhichMedicarewaivesthecoinsurance,youmustputthe"CS"modifierontheserviceline.
Wepaidyourclaimswiththe"CS"modifierwiththecoinsuranceapplied,andtheMACautomaticallyreprocessedtheseclaimsbeginningonJuly1,2020.
Don'tcollectcoinsurancefrombeneficiariesifthecoinsuranceiswaived.
ClaimsExamples:Table5.
RHCClaimsforTelehealthServicesfromJanuary27,2020,throughJune30,2020,whencostsharingiswaived:RevenueCodeHCPCSCodeModifiers052XG2025CG,CS(required)95(optional)Table6.
RHCClaimsforTelehealthServiceswithcostsharingwaivedstartingJuly1,2020RevenueCodeHCPCSCodeModifiers052XG2025CS(required)95(optional)MLNMattersSE20016RelatedCRN/APage5of9Table7.
FQHCClaimsforTelehealthServicesJanuary27,2020,throughJune30,2020,whencostsharingiswaivedRevenueCodeHCPCSCodeModifiers052XG0467(orotherappropriateFQHCSpecificPaymentCodeN/A052XG0446(orotherFQHCPPSQualifyingPaymentCode)CS,95(required)052XG2025CS,95(required)Table8.
FQHCClaimsforTelehealthServicesstartingJuly1,2020,whencostsharingiswaivedRevenueCodeHCPCSCodeModifiers052XG2025CS(required)95(optional)OtherTelehealthFlexibilitiesDuringtheCOVID-19PHE,youcanfurnishanyMedicare-approvedtelehealthserviceunderthePFS.
(Seehttps://www.
cms.
gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
)Also,effectiveMarch1,2020,theseservicesincludeCPTcodes99441,99442,and99443,whichareaudio-onlytelephoneevaluationandmanagement(E/M)services.
YoucanfurnishandbillfortheseservicesusingHCPCScodeG2025.
Tobillfortheseservices,aphysicianorMedicareproviderwhomayreportE/Mservicesmustprovideatleast5minutesoftelephoneE/Mservicetoanestablishedpatient,parent,orguardian.
Youcan'tbillfortheseservicesiftheyoriginatefromarelatedE/Mserviceprovidedwithintheprevious7daysorleadtoanE/Mserviceorprocedurewithinthenext24hoursorsoonestavailableappointment.
TelehealthServiceswithCost-SharingFortheCPTandHCPCScodesincludedinthelistoftelehealthcodesatthelinkabove,we'lladjustthecoinsuranceandpaymentcalculationfordistantsitetelehealthservicesyoufurnishedtoreflectthemethodusedtocalculatecoinsuranceandpaymentunderthePFS.
Thecoinsurancefortheseserviceswillbe20%ofthelesseroftheallowedamount($92.
03for2020claimsor$99.
45for2021claimsbasedondateofservice)oractualcharges.
Thepaymentwillbe80%ofthelesseroftheallowedamount($92.
03for2020claimsor$99.
45for2021claimsbasedondateofservice)ortheactualcharges.
Beforetheadjustment,thecoinsurancefordistantsiteservicesyoufurnishedwas20%oftheactualchargesandthepaymentwastheallowedamount($92.
03for2020claimsor$99.
45for2021claimsbasedondateofservice)minusthecoinsurance.
MACswillautomaticallyreprocessanyclaimswithHCPCScodeG2025forservicesfurnishedonorafterJanuary27,2020throughNovember16,2020,thatwepaidbeforeweupdatedtheclaimsprocessingsystemtopayHCPCScodeG2025basedonthe"lesserof"methodology,asdescribedabove.
MLNMattersSE20016RelatedCRN/APage6of9TelehealthServiceswithCost-SharingWaivedThelistoftelehealthcodesatthelinkaboveincludesseveralCPTandHCPCScodesthatdescribepreventiveservicesthathavewaivedcost-sharing.
Asstatedearlierinthisarticle,youshouldbilltelehealthservicesonthislistusingHCPCScodeG2025.
Todistinguishthosetelehealthservicesthatdon'thavecostsharingwaivedfromthosethatdo,suchascertainpreventiveservicesyoumustalsoreportmodifierCS.
We'vemodifiedthedescriptoroftheCSmodifiertoaccountforthisadditionaluseasfollows:CS-Cost-sharingwaivedforspecifiedCOVID-19testing-relatedservicesthatresultinanorderfororadministrationofaCOVID-19testand/orusedforcost-sharingwaivedpreventiveservicesfurnishedviatelehealthinRuralHealthClinicsandFederallyQualifiedHealthCentersduringtheCOVID-19publichealthemergency.
Forpreventiveservicesfurnishedviatelehealththathavecost-sharingwaived,RHCsmustreportG2025onclaimswiththeCGandCSmodifierandFQHCsmustreportG2025withtheCSmodifieronorafterJuly1,2020.
Pleaseseetheabove-referencedclaimexamplesforCost-SharingRelatedtoCOVID-19Testing.
Theseexampleswillalsoapplytopreventiveservicesthathavecost-sharingwaived.
ExpansionofVirtualCommunicationServicesPaymentforvirtualcommunicationservicesnowincludesonlinedigitalevaluationandmanagementservices.
Onlinedigitalevaluationandmanagementservicesarenon-face-to-face,patient-initiated,digitalcommunicationsusingasecurepatientportal.
TheonlinedigitalevaluationandmanagementcodesthatarebillableduringtheCOVID-19PHEare:CPTcode99421(5-10minutesovera7-dayperiod)CPTcode99422(11-20minutesovera7-dayperiod)CPTcode99423(21minutesormoreovera7-dayperiod)Togetpaymentforthenewonlinedigitalevaluationandmanagement(CPTcodes99421,99422,and99423)orvirtualcommunicationservices(HCPCScodesG2012andG2010),youmustsubmitanRHCorFQHCclaimwithHCPCScodeG0071(VirtualCommunicationServices)eitheraloneorwithotherpayableservices.
ForclaimssubmittedwithHCPCScodeG0071onorafterMarch1,2020,andforthedurationoftheCOVID-19PHE,paymentforHCPCScodeG0071issetattheaverageofthenationalnon-facilityPFSpaymentratesforthese5codes.
We'llpay$24.
76forclaimssubmittedwithG0071onorafterMarch1,2020throughDecember31,2020.
EffectiveJanuary1,2021throughDecember31,2021,we'llpaythenewrateof$23.
73forclaimssubmittedwithG0071.
RevisionofHomeHealthAgencyShortageRequirementforVisitingNursingServicesYoucanbillforvisitingnursingservicesfurnishedbyanRNorLPNtohomeboundindividualsunderawrittentreatmentplaninareaswithashortageofhomehealthagencies(HHAs).
MLNMattersSE20016RelatedCRN/APage7of9EffectiveMarch1,2020andforthedurationoftheCOVID-19PHE,wehavedeterminedthattheareatypicallyservedbytheRHC,andtheareaincludedintheFQHCserviceareaplanhaveashortageofHHAs,andthisdeterminationdoesn'trequirearequest.
YoumustchecktheHIPAAEligibilityTransactionSystem(HETS)beforeprovidingvisitingnurseservicestomakesurethatthepatientisn'talreadyunderahomehealthplanofcare.
ConsentforCareManagementandVirtualCommunicationServicesMedicarerequiresbeneficiaryconsentforallservices,includingnon-face-to-faceservices.
DuringtheCOVID-19PHE,youmaygetbeneficiaryconsentatthesametimeyouinitiallyprovidetheservices.
Thismeansthatsomeoneworkingunderyourgeneralsupervisioncangetbeneficiaryconsent.
Directsupervisionisn'trequiredtogetconsent.
Ingeneral,auxiliarypersonnelundergeneralsupervisionofthebillingpractitionercangetbeneficiaryconsenttoreceivetheseservices.
Thepersongettingconsentcanbeanemployee,independentcontractor,orleasedemployeeofthebillingpractitioner.
(See:https://www.
cms.
gov/files/document/covid-final-ifc.
pdf).
RevisionofBedCountMethodologyforDeterminingProvider-BasedRHCsExemptiontotheRHCPaymentLimitIfyou'reaprovider-basedtoahospitalwithfewerthan50beds,youareexemptfromthenationalper-visitpaymentlimitforRHCs.
DuetotheCOVID-19PHE,somehospitalshavebeenorareplanningtoincreaseinpatientbedcapacitytoaddresstheincreasedneedforinpatientcare.
Ifyou'recurrentlyexemptfromthenationalper-visitpayment,we'reworkingtopreventyoufromlosingyourexemptionduetotheCOVID-19PHEandtoencouragehospitalstoincreasebedcapacityifneeded.
We'llusethenumberofbedsfromthecostreportingperiodpriortothestartoftheCOVID-19PHEastheofficialhospitalbedcountfordecidingexemptiontothepaymentlimit.
Ifyouhadaprovider-basedstatusandwereexemptfromthenationalper-visitpaymentlimitbeforetheeffectivedateoftheCOVID-19PHE(January27,2020),youwillcontinuetobeexemptfromthenationalpaymentlimitforthedurationofthePHEfortheCOVID-19.
ExceptiontotheProductivityStandardsforRHCsWeuseproductivitystandardstohelpdecidetheaveragecostperpatientforyourMedicarereimbursement.
Physicians,nursepractitioners,physicianassistants,andcertifiednursemidwivesareheldtoaminimumnumberofvisitsperfulltimeemployee(FTE)thatthey'reexpectedtofurnishintheRHC.
Failuretomeetthisminimummayshowthatthey'reoperatingatanexcessivestaffinglevel,thus,generatingexcessivecost.
ManyRHCshavehadtochangethewaytheystafftheirclinicsandbillforRHCservicesduringtheCOVID-19publichealthemergency(PHE).
Asaresult,theseRHCsmayhavedifficultyinmeetingtheproductivitystandards.
TominimizetheburdenonRHCs,yourMACmaygrantexceptionstotheproductivitystandardduringtheCOVID-19PHE.
YourMACwillprovidefurtherdirection.
ADDITIONALINFORMATIONViewthecompletelistofcoronaviruswaivers.
MLNMattersSE20016RelatedCRN/APage8of9Reviewinformationonthecurrentemergencieswebpageathttps://www.
cms.
gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.
Ifyouhavequestions,yourMACsmayhavemoreinformation.
Findtheirwebsiteathttp://go.
cms.
gov/MAC-website-list.
DOCUMENTHISTORYDateofChangeDescriptionFebruary23,2021WerevisedthisarticletoprovidetheupdatedrateeffectiveJanuary1,2021forG2025.
You'llfindsubstantivecontentupdatesindarkredfont(seepages2,3and5).
WealsoupdatedtherateforG0071onpage6.
December3,2020Werevisedthisarticletoprovideadditionalguidanceontelehealthservicesthathavecost-sharingandcost-sharingwaived.
You'llfindsubstantivecontentupdates(seepages5-6).
Wealsomadeotherlanguagechangesforclarity,butthesechangesdidnotalterthesubstanceofthearticle.
July6,2020Werevisedthisarticletoprovide:-Additionalguidanceontelehealthservicesthathavecost-sharingwaivedandadditionalclaimexamples-AnadditionalsectionontheRHCProductivityStandardsAllotherinformationremainsthesame.
April30,2020Werevisedthisarticletoprovide:-Additionalclaimssubmissionandprocessinginstructions-Informationoncost-sharingrelatedtoCOVID-19testing-Additionalinformationontelehealthflexibilities-Informationonprovider-basedRHCsexemptiontotheRHCpaymentlimitAllotherinformationremainsthesame.
April17,2020Initialarticlereleased.
Disclaimer:PaidforbytheDepartmentofHealth&HumanServices.
Thisarticlewaspreparedasaservicetothepublicandisnotintendedtograntrightsorimposeobligations.
Thisarticlemaycontainreferencesorlinkstostatutes,regulations,orotherpolicymaterials.
Theinformationprovidedisonlyintendedtobeageneralsummary.
Itisnotintendedtotaketheplaceofeitherthewrittenlaworregulations.
Weencouragereaderstoreviewthespecificstatutes,regulationsandotherinterpretivematerialsforafullandaccuratestatementoftheircontents.
CPTonlycopyright2019AmericanMedicalAssociation.
Allrightsreserved.
Copyright2013-2020,theAmericanHospitalAssociation,Chicago,Illinois.
ReproducedbyCMSwithpermission.
NoportionoftheAHAcopyrightedmaterialscontainedwithinthispublicationmaybecopiedwithouttheexpresswrittenconsentoftheAHA.
AHAcopyrightedmaterialsincludingtheUB-04codesanddescriptionsmaynotberemoved,copied,orutilizedwithinanysoftware,product,service,solutionorderivativeworkwithoutthewrittenconsentoftheAHA.
IfanentitywishestoutilizeanyAHAmaterials,pleasecontacttheAHAat312-893-6816.
MakingcopiesorutilizingthecontentoftheUB-04Manual,includingthecodesand/orMLNMattersSE20016RelatedCRN/APage9of9descriptions,forinternalpurposes,resaleand/ortobeusedinanyproductorpublication;creatinganymodifiedorderivativeworkoftheUB-04Manualand/orcodesanddescriptions;and/ormakinganycommercialuseofUB-04Manualoranyportionthereof,includingthecodesand/ordescriptions,isonlyauthorizedwithanexpresslicensefromtheAmericanHospitalAssociation.
TolicensetheelectronicdatafileofUB-04DataSpecifications,contactTimCarlsonat(312)893-6816.
Youmayalsocontactusatub04@healthforum.
comTheAmericanHospitalAssociation(the"AHA")hasnotreviewed,andisnotresponsiblefor,thecompletenessoraccuracyofanyinformationcontainedinthismaterial,norwastheAHAoranyofitsaffiliates,involvedinthepreparationofthismaterial,ortheanalysisofinformationprovidedinthematerial.
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