01-055 Audio Only Telehealth Services During the PHE Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare audio only telehealth services billed on dates of service from March 6, 2020 through June 1, 2021. 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

In response to the declaration of the COVID-19 outbreak as a Public Health Emergency (PHE), the Secretary authorized waivers and modifications under Section 1135 of the Social Security Act (the Act). Additional flexibilities were granted during the PHE via rulemaking. These waivers and flexibilities help prevent potential gaps in access to care for beneficiaries impacted by the emergency. These flexibilities and waivers can be found at https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers external-link.

Title XVIII of the Social Security Act (SSA) § 1834(m) indicates the Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician or a practitioner to an eligible telehealth individual providing the telehealth service is not at the same location as the beneficiary. Under the waivers and flexibilities established during the PHE, CMS expanded the use of audio only telehealth codes to a range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, who will be able to offer telehealth to their patients. In addition, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country, including in patient’s places of residence. CMS further changed the payment status of CPT codes 98966-98968 and 99441-99443 from categorically noncovered services, to allowable services.

The SMRC is tasked with performing claim review on a sample of audio only telehealth claims from March 6, 2020 to June 1, 2021. Applicable waivers and flexibilities established during the PHE will be utilized during claim review activities.

Claim Sample Detail

TOB CPT
Audio Only Telehealth 98966: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
Audio Only Telehealth 98967: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.
Audio Only Telehealth 98968: Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.
Audio Only Telehealth 99441: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
Audio Only Telehealth 99442: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
Audio Only Telehealth 99443: Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

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. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Documentation to support virtual service(s) provided
  2. Documentation to support the code(s) and modifier(s) billed
  3. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  4. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  5. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC) if applicable for code billed
  6. PT/OT/SLP – plan of care, if applicable
  7. Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care if applicable
  8. Individualized treatment plan for psychiatric services with updates if applicable
  9. For 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
  10. For 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
  11. For codes 98966-98968. documentation to support the services provided on the DOS under review were not related to any assessment and management service(s) provided within the previous 7 days, including but not limited to visit notes, progress notes if applicable
  12. For codes 98966-98968. documentation to support the services provided on the DOS under review were not related to any assessment and management service(s) or procedure within the next 24 hours or soonest available appointment, including but not limited to visit notes, progress notes if applicable

References/Resources

  • Social Security Act (SSA), Title XI, Section 1135. Authority to waive requirements during national emergencies
  • SSA, Title XVIII, Section 1815(a). Providers must furnish information
  • SSA, Title XVIII, Section 1833(e). Payment of Benefits
  • SSA, Title XVIII, Section 1834(m). Payment for Telehealth Services
  • SSA, Title XVIII, Section 1842(p)(4). Provisions Relating to the Administration of Part B
  • SSA, Title XVIII, Section 1861. Part E – Miscellaneous Provision.
  • SSA, Title XVIII, Section 1862 Exclusion from Coverage and Medicare as a Secondary Payer
  • SSA, Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • SSA, Title XVIII, Section 1893 (f)(7)(A)(B)(i-iv). Medicare Integrity Program
  • Code of Federal Regulations (CFR), Title 42, Section 400.200. General Definitions
  • CFR, Title 42, Section 405.2464(e). Payment Rate
  • CFR, Title 42, Section 410.20. Physician Services
  • CFR, Title 42, Section 410.69. Services of a Certified Registered Nurse Anesthetist or an Anesthesiologist’s Assistant: Basic Rule and Definitions
  • CFR, Title 42, Section 410.71. Clinical Psychologist Services and Services and Supplies Incident to Clinical Psychologist Services
  • CRF, Title 42, Section 410.73. Clinical Social Worker Services
  • CFR, Title 42, Section 410.74. Physician Assistants’ Services
  • CFR, Title 42, Section 410.75. Nurse Practitioners’ Services
  • CFR, Title 42, Section 410.76. Clinical Nurse Specialists’ Services
  • CFR, Title 42, Section 410.77. Certified Nurse-Midwives’ Services: Qualifications and Conditions
  • CFR, Title 42, Section 410.78. Telehealth Services
  • CFR, Title 42, Section 410.134. Provider Qualifications
  • CFR, Title 42, Section 411. Exclusions from Medicare and Limitations on Medicare Payment
  • CFR, Title 42, Section 411.15. Particular Services Excluded from Coverage
  • CFR, Title 42, Section 413.65. Requirements for a determination that a Facility or an Organization has Provider-Based Status
  • CFR, Title 42, Section 424.5. Basic Conditions
  • CFR, Title 42, Section 482.24. Condition of Participation: Medical Record Services
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 270. Telehealth Services
  • MBPM Publication 100-02, Chapter 16. General Exclusions from Coverage
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 12, Section 20.3. Bundled Services/Supplies
  • MCPM, Publication 100-04, Chapter 12, Section 30.6. Evaluation and Management Service Codes-General (Codes 99201-99499)
  • MCPM, Publication 100-04, Chapter 12, Section 190. Medicare Payment for Telehealth Services
  • MCPM, Publication 100-04, Chapter 18. Preventive and Screening Services
  • MCPM, Publication 100-04, Chapter 23. Fee Schedule. Administration and Coding Requirements
  • MCPM, Publication 100-04, Chapter 30, Section 30.2. Healthcare Provider or Supplier Knowledge and Liability
  • MCPM, Publication 100-04, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No response of Insufficient Response to Additional Documentation Requests
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements
  • MPIM, Publication 100-08, Chapter 3, Section 3.6.2.1. Coverage Determinations
  • MPIM, Publication 100-08, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
  • MPIM, Publication 100-08, Chapter 3, Section 3.6.2.3. Limitation of Liability Determinations
  • MPIM, Publication 100-08, Chapter 3, Section 3.6.2.4. Coding Determinations
  • MPIM, Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types
  • MPIM, Publication 100-08, Chapter 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs
  • CMS 1744-IFC. Medicare and Medicaid Programs, Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
  • Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). Telehealth Services During Certain Emergency Periods
  • Public Health Service Act, 2021, Section 319(e) Telehealth Enhancements for Emergency Response
  • 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
  • American Medical Association, Current Procedural Terminology (CPT) Manual, Professional Edition (2020)
  • National Correct Coding Initiative Coding Policy Manual for Medicare Services

Last Updated Oct 29, 2021