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
Billing physical therapy services that have been provided through telehealth is
an emerging challenge. Due to the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act, the Centers for Medicare and Medicaid Services (CMS) is expanding access to Medicare telehealth services
so that beneficiaries can receive a wider range of services from their providers without having to travel to a healthcare facility. For the first time, PTs will be allowed to bill Medicare for E-visits under codes associated with online
assessment and management services (HCPCS codes G2061: Qualified non-physician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes; G2062: Qualified
non-physician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes; G2063: Qualified non-physician healthcare professional online assessment,
for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes). Providers must use place-of-service code “02” and “CR” modifier. CMS guidance instructs providers to use the CR (catastrophe/disaster
related) modifier for both institutional and noninstitutional Medicare Part B billing. (These are claims submitted using the ASC X12 837 professional claim format or CMS-1500.) Please note: For institutional billing, the DR condition
code and CR modifier are required. For noninstitutional billing, only the CR modifier is required. The payment rates are significantly lower than the traditional payment for an in-person visit under the CPT 97000 code series. To determine
the reimbursement rates for G2061-G2063, visit the CMS Physician Fee Schedule lookup tool.
Medicare coinsurance and deductible apply to the services.
To qualify as an e-visit, three basic qualifications must be met:
- The billing practice must have an established relationship with the patient, meaning the provider must have an existing provider-patient relationship;
- The patient must initiate the inquiry for an e-visit and verbally consent to check-in services;
- The communications must be limited to a seven-day period through an "online patient portal."
Although the patient must initiate the service, CMS allows "practitioners to educate beneficiaries on the availability of the telehealth service prior to patient initiation." For example, if a patient cancels treatment because they can’t
come to the clinic or are concerned about leaving home, then the PT may advise the patient that she or her can “virtually” contact the therapists as needed.
Medicare patients that want to continue PT interventions and are willing to pay cash, there is an alternative to billing with the three HCPCS G-Codes (G2061-G2063). Physical therapists are not statutorily authorized Medicare providers
of telehealth and physical therapy services are not on the list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth you can charge the Medicare patient your fee to provide telehealth services
and no CPT codes would be billed to the Medicare program. An ABN would not be required to be issued to the Medicare beneficiary since an ABN is only required when normally the services would be covered by the Medicare program but under
the circumstance, you expect the Medicare program not to pay for that service(s). You could issue a voluntary ABN to the Medicare beneficiary if so desired. For further information on the ABN, click here and read Section 50.3.2. If there is a secondary insurer, providers may want to submit a claim to Medicare to get a denial and then submit to the secondary payer.
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!