12-001 Consolidated Appropriations Act (CAA) Telehealth Services Notification of Medical Review
Noridian Healthcare Solutions, LLC, (Noridian) as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting a two-phase post-payment review of claims for Medicare Part B telehealth services with dates of service January 1, 2022, through June 30, 2024. Phase 1 will include claims billed with dates of service (DOS) January 1, 2022, through June 30, 2023. Phase 2 will include claims with DOS July 1, 2023, through June 30, 2024. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
Background
Historically, telehealth was the use of telecommunication and information technology to provide beneficiaries with access to healthcare services as an alternative option to an in-person visit in designated rural locations. Specific criteria for interactive audio and video telecommunications systems were established to permit real-time communication between the provider and the beneficiary. Beneficiaries that had a prior history with a provider, considered as an established patient, could receive telehealth services at an eligible originating site in counties outside of a Metropolitan Statistical Area or in a rural Health Professional Shortage Area.
A nationwide Public Health Emergency (PHE) was declared on January 31, 2020, in response to the effects of the 2019 Novel Coronavirus (COVID-19), in accordance with the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Public Law 100-707), commonly referred to as The Stafford Act. In response to the PHE declaration, the Department of Health and Human Services (HHS) authorized waivers and modifications on March 13, 2020, retroactive to March 1, 2020, under Section 1135 of the Social Security Act (SSA), which outlines the authority to waive requirements during national emergencies.
To help slow the spread of COVID-19, without compromising beneficiary access to healthcare, temporary waivers and regulatory changes were implemented, expanding access for telehealth services, effective March 1, 2020. Specific flexibilities allowed providers to deliver a wider range of healthcare services to Medicare beneficiaries nationwide. The waivers and flexibilities allowed new patients as well as established patients, to receive access to healthcare services via telehealth from their home using non-public facing audio or audio-video telecommunication technology, such as FaceTime or Skype.
The Consolidated Appropriations Act of 2023 (CAA, 2023) was signed into law on December 29, 2022, which included funding for disaster relief and extended several expiring waivers or flexibilities put in place during COVID-19. Some of the waivers and flexibilities specific to telehealth were extended through December 31, 2024. Those extended flexibilities include access to telehealth in any geographic location within the United States, beneficiaries can receive telehealth visits from their homes, and certain telehealth visits can be conducted via audio-only technology if the beneficiary was unable to use audio and video technology, audio-only telephone E/M services, and behavioral health counseling sessions were also extended.
In addition, section 4113 of the CAA, 2023, Advancing Telehealth Beyond COVID-19, requires a study to be conducted using medical record review related to telehealth services under Medicare Part B. In addition, an analysis of those findings will be done to align with the CAA, 2023 requirements.
Reason for Review
The SMRC is tasked to perform data analysis and conduct a medical record review on claims billed with select telehealth Evaluation and Management (E/M) Current Procedural Terminology (CPT) codes and select audio-only telehealth codes as specified in section 4113 of the CAA, 2023.
The CPT codes in the table below, will be reviewed in both Phase 1 and Phase 2 of the project.
The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
The CPT codes in the table below, will be reviewed in both Phase 1 and Phase 2 of the project.
| CPT Code | Short Description |
|---|---|
| 90832 | Psychotherapy, 30 minutes |
| 90833 | Psychotherapy with evaluation and management visit, 30 minutes |
| 90834 | Psychotherapy, 45 minutes |
| 90836 | Psychotherapy with evaluation and management visit, 45 minutes |
| 90837 | Psychotherapy, 1 hour |
| 90838 | Psychotherapy with evaluation and management visit, 1 hour |
| 99202 | New patient outpatient visit, total time 15-29 minutes |
| 99203 | New patient office or other outpatient visit, 30-44 minutes |
| 99204 | New patient office or other outpatient visit, 45-59 minutes |
| 99205 | New patient office or other outpatient visit, 60-74 minutes |
| 99211 | Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional |
| 99212 | Established patient office or other outpatient visit, 10-19 minutes |
| 99213 | Established patient office or other outpatient visit, 20-29 minutes |
| 99214 | Established patient office or other outpatient visit, 30-39 minutes |
| 99215 | Established patient office or other outpatient visit, 40-54 minutes |
| 99441 | Telephone medical discussion with physician, 5-10 minutes |
| 99442 | Telephone medical discussion with physician, 11-20 minutes |
| 99443 | Telephone medical discussion with physician, 21-30 minutes |
| G0406 | Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth |
| G0407 | Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth |
| G0408 | Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth |
| G0425 | Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth |
| G0426 | Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth |
| G0427 | Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth |
| G2212 | Add-On Code; Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes) |
| 90863 | Add-On Code; Management of prescriptions and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure) |
Access related project details below.
Documentation Requirements
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- Documentation to support the beneficiary initiated the telehealth visit
- Documentation to support consent for telehealth visit
- Documentation to support the originating site and distant site billed
- Documentation to support the virtual service was provided using audio/video, real time communication technology or CPT codes 99201-99205 and 99211-99215
- Documentation to support both the medical necessity and the level of evaluation and management service billed, such as: beneficiary history, examination, provider medical decision making, counseling, coordination of care, nature of presenting problem, or minimum time spent for the duration of visit
- For audio-only CPT codes 99441-99443, documentation to support the services provided on the DOS under review is not related to any E/M service(s) provided within the previous 7 days, including, but not limited to, visit notes, progress notes, if applicable
- For audio-only CPT codes 99441-99443, documentation to support the services provided on the DOS under review is not related to any E/M service(s) or procedure provided within the next 24 hours or soonest available appointment, including, but not limited to, visit notes, progress notes, if applicable
- Documentation to support the code(s) and modifiers(s) billed
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
- Any other supporting/pertinent documentation
- All medical records: Must have beneficiary identification, date of service, and provider of the service be clearly identified on each page of the submitted documentation
- PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met
References
Social Security Act (SSA), Title XI
- § 1135 Authority to Waive Requirements During National Emergencies
Social Security Act (SSA), Title XVIII
- § 1815(a) Payment to Providers of Services
- § 1833(e) Payment of Benefits
- § 1834(m) Payment for Telehealth Services
- § 1842(p)(4) Provisions Relating to the Administration of Part B
- § 1861 Part E Miscellaneous Provision
- § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
- § 1877(g) Blanket Waivers of Section 1877 (G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
- § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
- §§ 1893(f)(7)(A)(B) (i-iv), (h)(4)(B) Medicare Integrity Program
42 Code of Federal Regulations (CFR)
- § 410.78 Telehealth Services
- § 411.15(k)(1) Particular Services Excluded from Coverage
- § 414.65 Payment for Telehealth Services
- §§ 424.5 and 424.5(a)(6) Basic Conditions and Sufficient Information
Public Law
- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020), Telehealth Services During Certain Emergency Periods. Retrieved from H.R.6074 – 116th Congress (2019-2020): Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 | Congress.gov | Library of Congress
- Public Law 117 – 103, Consolidated Appropriations Act, Approved March 15, 2022. Retrieved from Public Law 117 – 103 – Consolidated Appropriations Act, 2022 – Content Details – (govinfo.gov)
- Public Health Service Act, 2021, Section 319(e) Telehealth Enhancements for Emergency Response. Retrieved from https://www.congress.gov/109/plaws/publ417/PLAW-109publ417.htm
- Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments. Retrieved from Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, and Related Authorities (fema.gov)
Federal Register
- Final Rule with Comments (FC), Volume (Vol.) 66, No. 212. November 1, 2001. Medicare Program; Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 2002. CMS-1169-FC. Retrieved from FR-2001-11-01.pdf (govinfo.gov)
- Final Rule with Comments (FC), Vol. 73, No. 224. November 19, 2008. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009. CMS–1403–FC, CMS–1270–F2. Effective January 1, 2009. Retrieved from E8-26213.pdf (govinfo.gov)
- Final Rule with Comments (FC), Vol. 74, No. 226. November 25, 2009. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010. CMS–1413–FC. Effective January 1, 2010. Retrieved from E9-26502.pdf (govinfo.gov)
- Final Rule with Comments (FC), Vol. 77, No. 222, November 16, 2012. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule. CMS–1590–FC. Effective January 1, 2013. Retrieved from 2012-26900.pdf (govinfo.gov)
- Final Rule, Vol. 81, No. 220, November 15, 2016. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017. CMS-1654-F. Effective January 1, 2017. Retrieved from 2016-26668.pdf (govinfo.gov)
- Final Rule and Interim Final Rule with Comments (IFC), Vol. 84, No. 221, November 15, 2019. Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies. CMS–1715–F and IFC. Effective January 1, 2020. Retrieved from 2019-24086 (govinfo.gov)
- Final Rule and Interim Final Rule with Comments (IFC), Vol. 87, No. 222, November 18, 2022. Medicare and Medicaid Programs; CY 2023 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; and COVID-19 Interim Final Rules. CMS–1770–F, CMS–1751–F2, CMS–1744–F2, CMS–5531–IFC. Effective January 1, 2023. Retrieved from 2022-23873.pdf (govinfo.gov)
- Interim Final Rule with Comments (IFC), Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, CMS-1744-IFC. Effective March 1, 2020. Retrieved from CMS-1744-IFC
- Interim Final Rule with Comments (IFC), Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. Effective March 1, 2020. CMS-5531-FC. Retrieved from CMS-5531-IFC
- Interim Final Rule with Comments (IFC), Vol. 85, No. 90, May 8, 2020, Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID– 19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program, CMS–5531–IFC. Effective March 1, 2020. Retrieved from 2020-09608.pdf (govinfo.gov)
- Interim Final Rule with Comments (IFC), Vol, 85, No. 248, December 28, 2020, Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID–19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID–19. CMS-1734-F, CMS-1734-IFC, CMS-1744-F, CMS 5531-F and CMS-3401-IFC. Effective January 1, 2021. Retrieved from 2020-26815.pdf (govinfo.gov)
Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02
- Chapter (Ch.) 15, § 270 Telehealth Services
- Ch. 16 General Exclusions from Coverage
IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 12, § 30.6 Evaluation and Management Service Codes-General (Codes 99201-99499)
- Ch. 12, § 150 Clinical Social Worker (CSW) Services
- Ch. 12, § 160 Independent Psychologist Services
- Ch. 12, § 170 Clinical Psychologist Services
- Ch. 12, § 190 Medicare Payment for Telehealth Services
- Ch. 23, § 20.9 National Correct Coding Initiative (NCCI)
IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3 Verifying Potential Errors and Taking Corrective Action
Other
- American Medical Association, Current Procedural Terminology (CPT) Manual, Professional Edition (2020)
- CMS. Coronavirus Disease (COVID-19) Emergency Declaration Blanket Waivers for Health Care Providers. Updated November 29, 2021. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (cms.gov)
- CMS. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing. Updated January 7, 2021. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing (cms.gov)
- CMS. General Provider Telehealth and Telemedicine Tool Kit. Effective March 20, 2020. General Telemedicine Toolkit (cms.gov)
- CMS. List of Telehealth Services for Calendar Years 2022, and 2023. Retrieved from List of Telehealth Services | CMS
- CMS. Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19. Updated May 10, 2023. Retrieved from Physicians and Other Clinicians: CMS Flexibilities to Fight COVID
- CMS. Place of Service Code Set. Updated September 2021. Retrieved from Place of Service Code Set | CMS
- CMS Newsroom. Medicare Telemedicine Health Care Provider Fact Sheet. May 17, 2020. MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET | CMS
- Health and Human Services. Best Practice Guide. Telehealth for Behavioral Health Care. Updated March 4, 2022. Billing for telebehavioral health | Telehealth.HHS.gov
- Medicare Learning Network (MLN) Matters, MM12427. New/Modifications to the Place of Service (POS) Codes for Telehealth. October 2021. Retrieved from MM12427 – New/Modifications to the Place of Service (POS) Codes for Telehealth (cms.gov)
- MLN Booklet. Medicare Mental Health. MLN1986542. March 2022. Medicare Mental Health (cms.gov)
- MLN MM10152. Elimination of the GT Modifier for Telehealth Services. Effective January 1, 2018. Retrieved from MM10152 (cms.gov)
- MLN MM10883. New Modifier for Expanding the Use of Telehealth for Individuals with Stroke. Effective January 1, 2019. Retrieved from MM10883 (cms.gov)
- MLN MM11043. Revision of Definition of the Physician Supervision of Diagnostic Procedures, Clarification of DSMT Telehealth Services, and Establishing a Modifier for Expanding the Use of Telehealth for Individuals with Stroke. Effective January 1, 2019. Retrieved from MM11043 (cms.gov)
- MLN MM12982. Medicare Physician Fee Schedule Final Rule Summary: CY 2023. Effective January 1, 2023. Retrieved from MM12982 – Medicare Physician Fee Schedule Final Rule Summary: CY 2023 (cms.gov)
- MLN SE20011 Revised. Medicare FFS Response to the PHE on COVID-19. May 12, 2023. Retrieved from SE20011 (cms.gov)
- Office of Inspector General (OIG). Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic. Report number OEI-02-22-00150. November 30, 2022. Retrieved from Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic OEI-02-22-00150 11-30-2022 (hhs.gov)
- OIG. Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency. Report number A-09-21-03021. May 2, 2023. Retrieved from Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency A-09-21-03021 05-02-2023 (hhs.gov)
- U.S. Department of Health & Human Services (HHS). Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. Last Reviewed, January 20, 2021. Retrieved from Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency | HHS.gov
Last Updated Sep 10, 2024