| CCHP Medicare Fee-for-Service 2024 Billing Guide |
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Today, the Center for Connected Health Policy (CCHP) is releasing its 2024 Medicare Fee-for-Service Billing Guide. The 2024 edition is being released later in the calendar year in comparison to previous years in order to better capture the updates, clarifications and changes that were provided by the Centers for Medicare and Medicaid Services (CMS) in the preceding months.
As some readers may already know, many current Medicare telehealth policies are temporarily extended through the end of 2024. This updated billing guide focuses on billing under those temporary policies, though there are notations throughout the guide if permanent telehealth Medicare policies differ. CCHP also cautions that there could be additional clarifications or updates made by CMS after the publication of this guide, which will not be reflected. Therefore, CCHP always recommends readers to keep abreast of any changes by subscribing to the Medicare Learning Network Newsletter, as well as resources produced by CCHP and your regional telehealth resource center.
 In this edition of the Medicare Fee-for-Service Billing Guide, CCHP has streamlined and reorganized the content to make it more reader friendly and easier to navigate. As in past editions, it does still include billing examples to help break down both simple and complex telehealth billing scenarios in Medicare. In some instances, we provided examples of other payer’s telehealth policies, referencing California Medicaid specifically, though Medicaid policies will vary by state. CCHP stresses that this guide is provided for informational and educational purposes. It is not meant to be offered as legal advice nor a guarantee on reimbursement. CCHP is offering this guide as a tool & resource for the public.
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DEA Prepares New Regulations for Telemedicine Prescribing of Controlled Substances |
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The Drug Enforcement Administration (DEA) is on the verge of releasing their new regulations for prescribing controlled substances via telemedicine, which may introduce significant restrictions on virtual prescribing. In June, it was reported that the DEA’s telemedicine-controlled substance rule had been handed off to the Office of Management and Budget for review. With current pandemic-era flexibilities for telehealth prescribing expiring at the end of December 2024, the DEA is running out of time to release the rule and providing enough time for public comment. Last year, the DEA released their first attempt at a post-pandemic telemedicine prescribing controlled substance rule, prompting massive public feedback and forcing them to delay release of a revised rule until now. Since then, the DEA has conducted listening sessions to better understand stakeholder concerns, aiming to develop a rule that better accommodates the diverse needs of all parties involved. However, according to reports, the newly developed (yet to be proposed) rules may also be limiting, with speculation that it could limit providers to issuing no more than half of their prescriptions virtually, and require extensive checks through state prescription drug monitoring programs—posing challenges for telehealth providers, according to a recent Politico article [subscription required]. Concern about the impact of such a rule is mounting, especially in light of a recent study published in Health Affairs that found psychiatric care providers (who often prescribe controlled substances) were one of the most likely health professionals to use telehealth. The new rules could complicate the ability to deliver and receive psychiatric treatment in cases where the prescribing of controlled substances is involved. U.S. Senator Mark Warner has expressed deep concerns through a statement, alluding to the rule potentially falling short of maintaining access to certain prescriptions through telehealth. Senator Warner’s statement reads:
“As currently reported, the DEA’s proposal provides an even worse solution than the one put forth under the first proposed rule. This arcane approach would represent a significant step back for patients who rely on telemedicine for critical medications, and yet another failure by the DEA to establish a meaningful special registration, which Congress has repeatedly directed it to do for over a decade. The pandemic proved that the vast majority of health care providers can successfully provide quality health care through telehealth. We don’t need an arbitrary new set of regulations – we just need DEA to set up the minimum training requirements for providers and a special registration that allows the DEA to do its job to monitor telemedicine prescribing of these medications and catch bad actors. If the DEA is unable to work with health care providers and finalize a workable proposal soon, Congress should be prepared to take action so patients aren’t left without care on January 1st.”
Note that CCHP has not had access to the proposed text of the rule, and until we do, we are unable to make a definitive assessment of its potential impact. For more context on how we arrived at this pivotal moment, refer to CCHP’s previous article on the evolution of these policies and explore the Evolution of Telehealth in Prescribing of Controlled Substances timeline graphic. The DEA's proposal is currently under White House review, and should be publicly available soon. Stay tuned to CCHP’s newsletters for updates. |
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CMS Clarifies Telehealth Payment Policy for Services Provided at Home
In August, the Centers for Medicare & Medicaid Services (CMS) released a clarification in their Medicare Learning Network newsletter to indicate that starting January 1, 2024, use of place of service (POS) code 10 for telehealth services provided in a patient’s home would pay the Medicare Physician Fee Schedule non-facility rate. This ensures higher payments compared to POS code 02, used for telehealth services at locations other than home, which are paid at the lower facility rate.
As reported in a previous CCHP newsletter, earlier in the year, confusion arose when some claims billed with POS 10 were incorrectly reimbursed at the lower facility rate, and was flagged through an alert by Medicare Administrative Contractor (MAC) Noridian. In June, CMS released a transmittal officially correcting the problem through a change request. To ensure compliance, CMS has instructed contractors to apply these changes to all claims with service dates on or after January 1, 2024. The MLN newsletter also indicates that additional information is available in the Telehealth Services factsheet, Medicare Claims Processing Manual, Ch. 12 and Ch. 26. |
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Essential Telehealth Resources from HHS
The Department of Health and Human Services (HHS) offers a variety of resources to support healthcare providers and patients in navigating the telehealth landscape. Here are three crucial tools and guides you may not be aware of:
- Privacy and Security HHS Tool: This resource provides best practices for maintaining patient privacy and data security during telehealth sessions. It offers guidance on securing telehealth technologies and ensuring compliance with HIPAA regulations to protect sensitive patient information.
- Community Health Workers and Telehealth: This one-page guide outlines how community health workers can effectively integrate telehealth into their services, enhancing access to care for underserved populations. It highlights the importance of community-based support in maximizing the benefits of telehealth, particularly in reaching those with limited healthcare access.
- What Happens After My Telehealth Visit?: This patient-focused resource explains the steps that follow a telehealth visit, from follow-up care to prescription management. It aims to help patients understand what to expect and how to manage their ongoing care after a telehealth appointment.
These resources are designed to enhance the effectiveness and accessibility of telehealth services, ensuring both providers and patients are well-equipped for successful virtual healthcare experiences. |
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Latest Policy Developments in CCHP’s Telehealth Policy Finder and Policy Trends Map
CCHP’s Telehealth Policy Finder look-up tool and Policy Trend Maps were updated throughout the past month based on the latest information from our ongoing state telehealth policy tracking. The latest states to be updated include Colorado, Iowa, Indiana, Massachusetts, Mississippi, Nebraska, New Jersey, Puerto Rico, South Carolina, Tennessee, Virginia, Wisconsin.
Over the past month, multiple states made changes to their telehealth policies in an array of policy areas, including their Medicaid programs, professional regulations, and cross-state licensing. Highlighted changes from this group of states include:
- COLORADO: Passed SB 24-168 which requires the Colorado Department of Health Care Policy and Financing to reimburse for remote monitoring for outpatient clinical services. The Department is required to initiate a stakeholder process to determine the billing structure on or before September 1, 2024. The bill also creates the Telehealth Remote Monitoring Grant Program to provide grants to outpatient health-care facilities located in a designated rural county or a designated health-care professional shortage area to assist the hospitals and clinics with the financial costs associated with providing telehealth remote monitoring for outpatient clinical services. Additionally, the bill defines continuous glucose monitor and requires, beginning November 1, 2025, the state department to provide coverage for a continuous glucose monitor and related supplies. The CO Department of Health Care Policy and Financing also released a bulletin in May 2024 providing requirements for continuous glucose monitoring coverage, including providers adhere to an in-person visit with the member every six months and documentation of education and counselling. Other Medicaid related bills that were enacted included HB 24-1045 which adds substance use disorder treatment to the definition of healthcare services required to be reimbursed via telehealth, and SB 24-034 which expands the school-based health care definition to include school-linked healthcare services that may be delivered through telehealth or mobile services. SB 24-141 was also passed which allows a healthcare provider who possesses a license, certificate, registration, or other approval as a healthcare provider in another state to provide healthcare services through telehealth to patients located in Colorado if the applicant registers with the regulator that regulates the healthcare services and meets certain criteria. Additionally, Colorado enacted the Social Work Compact by enacting HB 24-1002.
- INDIANA: Effective July 1, 2024, Indiana terminated their Telehealth Certificate process for out-of-state practitioners, alerting providers through a press release by the Indiana Professional Licensing Agency. The press release emphasizes that all practitioners still must be properly licensed in the state of Indiana in order to practice in Indiana, even to provide telehealth services.
- IOWA: New administrative code was adopted for physical and occupational therapists, dietitians and hearing aid dispensers which defines telehealth broadly (the use of technology when the practitioner and client are not at the same physical location). Regulations were also adopted pertaining to certified professional midwives (CPM) which included circumstances when a CPM could provide services through telehealth and a requirement to establish a CPM-client relationship prior to providing services through telehealth. Iowa also joined the Occupational Therapy Compact and Dietitian Compact.
- NEW JERSEY: A new rule was adopted by the Board of Applied Behavior Analyst (ABA) Examiners which provides telehealth practice standards for ABAs. The rules require that prior to initiating contact with a client through telehealth, that the licensee determine whether they will be able to provide the same standard of care using telehealth as would be provided in-person. New Jersey Medicaid also issued a newsletter providing coverage for acute hospital care at home services.
- PUERTO RICO: Two adopted rules, (Number 9517 (Cybertherapy) and Number 9518 (Telehealth), went into effect earlier this year providing regulations on the use of Telehealth and “Cybertherapy” (the latter of which is a patient-therapist interaction through technological communication tools). Most of the regulations in both rules focused on Puerto Rico’s certification requirement for telehealth providers, professional obligations of the providers, and duties of boards that oversee specific professions. However, included in both regulatory documents was a section noting that professionals licensed and certified may bill health insurance companies and the Health Insurance Administration (ASES) for the services provided via telehealth. ASES manages the Medicaid program in Puerto Rico. This regulation would indicate that Puerto Rico Medicaid, as well as other payers, will cover telehealth-delivered services. However, providers will have to request from the insurance companies and ASES the corresponding codes for billing the services provided.
- SOUTH CAROLINA: South Carolina Medicaid issued a notice expanding coverage for continuous glucose monitoring, providing for its full coverage under either the pharmacy or durable medical equipment state plan benefit under certain circumstances (such as prior authorization, being prescribed by a primary care provider, obstetrician or endocrinologist, and the patient having diabetes). S 858 was also passed which defines acute hospital care at home as including continuous remote patient monitoring (RPM) and connectivity to the patient, and requires acute hospitals in the state to provide the service. The bill also requires promulgating of regulations that must address RPM standards. Additional legislation that was passed recently includes H 5183 which allows the delegation of nursing tasks, including performing nonclinical tasks, via telemedicine and H 4234 which allows court discretion regarding examinations of alleged incapacitated individuals to occur via telehealth. South Carolina also passed S 610 which enacts the Counseling Compact in the state.
- TENNESSEE: Passed HB 2857, removing a part of the definition of a provider-based telemedicine that required a health care provider to have an established provider-patient relationship that is documented by an in-person encounter within 16 months prior to the interactive visit. The law does still require that evidence be submitted to a health insurance entity of an in person encounter prior to the interactive visit. Additionally, the provider must have the ability to render services through an in-person encounter.
- VIRGINIA: Virginia Medicaid updated their Telehealth Services Supplement to provide reimbursement and billing guidelines for audio-only telehealth, along with a table that lists services authorized for audio-only telehealth. The population eligible for remote patient monitoring was also updated to be consistent with statute and place of service code guidance was updated to require the use of telehealth place of service codes. Additional modifications were made to mental health and substance use disorder services authorized for telemedicine, and a table was added listing Medicaid-covered developmental disabilities waiver services authorized for delivery by telemedicine. See the notice for details. SB 250 was also passed which requires Medicaid to include a provision for payment of medical assistance for remote ultrasound procedures and remote fetal non-stress tests under certain circumstances. Virginia also joined the Social Work Licensure Compact.
- WISCONSIN: ForwardHealth (Wisconsin Medicaid) issued an update which clarified that qualified treatment trainees (QTTs) can be reimbursed for telehealth delivered services when allowed by the coverage policy of the service provided and consistent with their other telehealth and supervision policies.
Given the nuanced and varied approaches states are taking with their telehealth policies, please reference CCHP’s telehealth Policy Finder to link to additional details and access each states’ policies in their entirety. |
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Key Telehealth Resources from CHCF
The California Health Care Foundation (CHCF) has long supported telehealth services aimed at addressing healthcare equity. Most recently they have supported three reports that offer valuable insight into telehealth in California. They include:
- An Evaluation, in partnership with the Center for Community Health and Evaluation (CCHE), of the Telehealth Improvement Community Fund (TICF) which is managed by the Center for Care Innovations (CCI): TICF aims to enhance telehealth services in community clinics and other safety net health centers in California. 27 organizations participated in CHCF’s telehealth initiatives, the Tipping Point for Telehealth Initiative, which included telehealth improvement projects, resource access and minimal reporting requirements. The evaluation report highlights high engagement from the grantees, steady telehealth utilization and high levels of satisfaction and flexibility. The report also featured lessons learned and best practices for improving telehealth access and quality in underserved communities.
- An additional evaluation report, also administered by CCHE examining the Connected Care Accelerator Equity Collaborative (CCA EC): CCA EC was a 13-month learning collaborative that included 22 safety-net organizations in California funded by CHCF and Cedars-Sinai and led by CCI. The collaborative focused on improving the use of video telehealth, enhancing access for patients that preferred languages other than English and supporting digital barriers. The evaluation found that improvements were made in telehealth workflows, technology and staff training in order to achieve greater progress towards equity and access goals.
- A Landscape Assessment of Digital Navigation in the California Safety Net report, funded by CHCF and conducted by the University of California San Francisco: The report asses the landscape of digital navigation services within California's safety-net healthcare system. It identifies challenges and opportunities in supporting patients with limited digital literacy and access, crucial for effective telehealth utilization.
Although these reports focus on safety-net providers in California, the findings and results have broader implications for a wide range of healthcare providers and states. The valuable insights and strategies outlined in these resources can inform efforts to improve telehealth services, enhance health equity, and support digital navigation across diverse healthcare settings nationwide. |
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Addressing Telemedicine Barriers for Mandarin-Speaking Adults with Limited English Proficiency
Kaiser Permanente researchers recently conducted a study, published in the Journal of General Internal Medicine, titled “Telemedicine Experiences and Care Needs of Mandarin-Speaking Patients with Limited English Proficiency”. The study took a random sample of Kaiser Permanente Northern California members who completed at least one primary care telemedicine visit in August 2021, aged 40 years or older and had an electronic health record documented need for a Mandarin interpreter. The researchers approached the research with semi-structured Mandarin language telephone interviews. The results showed that Mandarin-speaking adults with limited English proficiency find telemedicine essential and convenient, but they frequently encounter issues with communication due to language skills and impatience of healthcare providers and interpreters. A significant ongoing challenge is the lack of comprehensive language support that extends beyond the telemedicine visits. The researchers determined that to improve patient autonomy and ensure fair access to care, it is crucial to enhance the training of healthcare providers and interpreters and to offer personalized, consistent language services that reduce the reliance on patients' families. For more on the study, see Kaiser Permanente’s Division of Research summary and the complete abstract. The full article is available for purchase on the publisher, Springer’s website. |
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What’s New at CCHP this Month?
CCHP is continually working to create helpful informational content to keep those interested in telehealth and related policies up to date via our policy finder, informational factsheets, webinars, reports and email blasts. As you may already be aware, CCHP regularly distributes a single topic specific email every Tuesday titled “Telehealth Tuesdays”. If you are not yet on our distribution list to receive these emails, and would like to be added, you can do so by registering on the CCHP website.
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Quick links to recently curated and featured insightful topics in our Telehealth Tuesday email blasts:
SEPTEMBER 3, 2024: Addressing Bias in Artificial Intelligence (AI) covering research that has shown that AI systems can produce biased outcomes, often because the data used to develop these technologies may not fully represent certain populations or communities. To tackle this issue, a coalition of hospitals and university health technology experts have recently united to address these critical gaps and ensure more equitable and inclusive AI-driven healthcare solutions.
AUGUST 27, 2024: Loper Bright Decision Impacts and Telehealth Policy Across the Branches covering the recent Supreme Court Loper Bright Enterprises Inc. v. Raimondo decision to overrule the “Chevron deference”, which has the potential to profoundly impact the policymaking landscape. The June ruling overturned the longstanding Chevron deference doctrine by shifting the interpretation of ambiguous laws away from administrative agencies and into the courts. CCHP also covered the topic in a webinar listed in the following section.
AUGUST 20, 2024: Finalized 2025 Rules for Inpatient Prospective Payment - CAHs & Telehealth covering changes in reimbursement for Critical Access Hospitals (CAHs). Note: a clarification was published in CCHP’s Sept. 3 newsletter to make it clear that the rules are applied to CAHs participating in the Frontier Community Health Integration Project (FHIP) Demonstration and not CAHs generally. More details can be found in the Federal Register entry on page 1134.
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In addition to our featured topics in CCHP’s Telehealth Tuesday emails we have also released the following valuable resources:
- As announced at the beginning of this newsletter, CCHP has released its 2024 Medicare Fee-for-Service Billing Guide, updated to reflect recent telehealth policy changes from the Centers for Medicare and Medicaid Services (CMS). This edition focuses on billing under the temporarily extended Medicare telehealth policies, with notes on permanent policies where they differ. The guide has been reorganized for easier navigation and includes billing examples to help clarify both simple and complex scenarios.
- CCHP conducted a webinar, which is now available for viewing, covering the Loper Bright/Chevron court cases (as referenced in the previous section) and its potential impact on telehealth policy. Expert panelists discussed how this decision could impact telehealth policy.
To stay up to date on all the latest CCHP releases, view our website’s Resources page which catalogs all of CCHP’s resources. |
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