Telehealth Coverage in California
Before You Begin Practicing Via Telehealth
Investigate and consider the issues within the following areas
as you make decisions on whether or not to use telehealth in your practice. In addition, become familiar with some of the commonly used terms in telehealth.
Telehealth: Billing and Coding Considerations
CMS is waiving the requirements of section 1834(m)(4)(E) of the Social Security Act and 42 CFR § 410.78 (b)(2) which specify the types of practitioners that may
bill for their services when furnished as Medicare telehealth services from the distant site. The waiver of these requirements expands the types of health care professionals that can furnish telehealth services to include all those
that are eligible to bill Medicare for their professional services. As a result, a broader range of practitioners, such as physical therapists, occupational therapists, and speech language pathologists can use telehealth
to provide many Medicare services. The current expiration date for the Public Health Emergency (PHE) due to COVID-19 is July 24, 2020. This expiration date could end sooner or be extended once again.
Clinicians who bill on the CMS-1500 form can now provide the following additional services by telehealth:
- CPT codes 97161-97164; CPT codes 97110, 97112, 97116, 97530, 97535, 97542, 97750, 97755, 97760, 97761, 92521, 92524, and 92507
CMS also now permits a treating physical therapist who developed or is responsible for a skilled maintenance
program may delegate the performance of maintenance therapy services to a physical therapist assistant when clinically appropriate.
Outpatient therapy services that are furnished via telehealth, and are separately paid and not included as part of a bundled institutional payment, can be reported on institutional claims with the “-95” modifier applied to the service line. This includes:
- Hospital – 12X or 13X (for hospital outpatient therapy services);
- Skilled Nursing Facility (SNF) – 22X or 23X (SNFs may, in some circumstances, furnish Part B physical therapy (PT)/occupational therapy (OT)/speech-language pathology (SLP) services to their own long-term residents);
- Critical Access Hospital (CAH) – 85X (CAHs may separately provide and bill for PT, OT, and SLP services on 85X bill type);
- Comprehensive Outpatient Rehabilitation Facility (CORF) – 75X (CORFs provide ambulatory outpatient PT, OT, SLP services);
- Outpatient Rehabilitation Facility (ORF) – 74X (ORFs, also known as rehabilitation agencies, provide ambulatory outpatient PT & SLP as well as OT services); and
- Home Health Agency (HHA) – 34X (agencies may separately provide and bill for outpatient PT/OT/SLP services to persons in their homes only if such patients are not under a home health plan of care).
View the official CMS announcement.
The California Emergency Services Act (Gov. Code sections 8566, et seq.), states all Medi-Cal managed care health plans shall, effective
immediately, reimburse providers at the same rate, whether a service is provided in-person or through telehealth, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the
service on the claim. DHCS All Plan Letter
The California Emergency Services Act (Gov. Code sections 8566, et seq.), states all health plans operating under the Department of Managed Health Care
shall, effective immediately, reimburse providers at the same rate, whether a service is provided in-person or through telehealth, if the service is the same regardless of the modality of delivery, as determined by the provider’s description
of the service on the claim. To date, Blue Shield of California and Anthem have confirmed they plan to adhere to this order. DMHC All Plan Letter
UnitedHealthcare (UHC) Announces Telehealth Coverage
UnitedHealthcare will reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology.
Cigna Announces Telehealth Coverage
Cigna has announced interim billing guidelines that will cover limited telehealth services for physical therapist providers.
Anthem announces telehealth coverage in California plans
Anthem has announced that it will cover telehealth for all providers in California plans.
Blue Shield of California Telehealth Update
Shield of California shared the following telehealth update on its website.
*There is no state order regarding telehealth for California Workers’ Compensation plans and Self-Insured plans, at this time. CPTA is actively seeking clarification of coverage for these insurance systems.
Payment for telehealth depends on your contract with your payer. Confirm with each payer whether the originating site can be a private home or office, if services must
be real-time or can be asynchronous, and any other limitations to your use of telehealth.
For third-party billing, there are "telephonic" CPT codes. But
before reporting CPT codes you traditionally use for clinical visits or billing for telephone services (98966-98969), check with your payer. 98970-98972 are e-visit codes. To clarify, neither of these code sets are true “telehealth”
and they have very specific requirements, including a 7-day period. Codes 99421-99423 are Evaluation and Management codes and cannot be billed by physical therapists. Many of the physical medicine and rehabilitation codes (97000 series)
specify "direct 1-on-1 patient contact," which by strict definition would exclude telehealth unless you and your payer have agreed to include these services. A payer also may require an addendum attached to the bill that identifies
the service as being provided via telehealth, along with an explanation of the charges, so be prepared to outline the reasoning for using telehealth.
You also should
check with your payer about using place-of-service code "02" when billing for telehealth services to specify the entity where service(s) were rendered. Regardless of the payer or policy, if you provide and bill for services using telehealth,
make sure that you are practicing legally and ethically, and are adhering to state and federal practice guidelines and payer contract agreements.
telehealth platforms are
eVisit and VisuWell.
If you use them, it's a good idea to check their information against the primary sources of state law.
CPTA has contacted all major private and commercial payers to confirm payment for telehealth PT services. We are also seeking assistance from the governor’s office to promote payment by the private payer community for telehealth.
In light of the national emergency it is our duty as health professionals to provide the care that is required by our patients. The immediate future may place
financial hardships on us a business people but that must remain as a secondary concern to the healthcare needs of our patients. Whenever possible, provide the care that is needed regardless of how you will be paid. When we arise from
this period we will be a stronger community as a result of the caring we have shown to others.
Click here for California telehealth laws regarding covered services.
Click here for a telehealth platform matrix developed by the APTA Health Policy and Administration Technology Special Interest Group.
Telehealth webinars and resources
In light of the recent COVID-19 pandemic, the CDC has recommended
‘social distancing’ as a key tactic to help reduce the spread of the virus. Check out these upcoming webinars for further education.
- Webinar: Social Distancing for Rehab Therapists: Leveraging Part-B In-Home Care and Telehealth in Your COVID-19 Response
Mar 26, 2020 02:00 PM in Eastern Time (US and Canada)
- VIRTUAL MEETING: Telehealth: Moving Digital Practice Forward in Physical Therapy
Thursday, March 26, 2020, 5:30 PM - 8:30 PM PST
- Telehealth in Physical Therapy in Light of COVID-19
Presented on March 16 by APTA
- Telehealth Training For Clinicians from Agile Physical Therapy
Get CEU credits while learning what Telehealth is, how to effectively evaluate a patient remotely, and how to start your own Telehealth practice from home!