01-058 Traditional Telehealth 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 Part B traditional telehealth services billed on dates of service from March 6, 2020 through May 13, 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 Cornoavirus waivers & flexibilities external-link.
Under the waivers and flexibilities established during the PHE, CMS expanded the use of 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. Under the new section 1135 waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. For additional information view the CMS Medicare Telemedicine Health Care Provider Fact Sheet external-link.

The SMRC is tasked with performing claim review on a sample of traditional telehealth claims from March 6, 2020 through May 13, 2021. Applicable waivers and flexibilities established during the PHE will be utilized during claim review activities.

Claim Sample Detail

CPT CODES DEFINITIONS
99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:
A problem focused history;
A problem focused examination;
Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:
An expanded problem focused history;
An expanded problem focused examination;
Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:
A detailed history;
A detailed examination;
Medical decision making of low complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:
A comprehensive history;
A comprehensive examination;
Medical decision making of moderate complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:
A comprehensive history;
A comprehensive examination;
Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:
A problem focused history;
A problem focused examination;
Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:
An expanded problem focused history;
An expanded problem focused examination;
Medical decision making of low complexity.
Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:
A detailed history;
A detailed examination;
Medical decision making of moderate complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:
A comprehensive history;
A comprehensive examination;
Medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

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 the code(s) and modifier(s) billed
  2. Office visit/E&M documentation if billed on same date of service under medical review
  3. Documentation to support the level of evaluation and management service billed to include beneficiary history, examination, provider medical decision making, counseling, coordination of care, nature of presenting problem and time spent when the code is based on duration of visit
  4. Detailed breakdown of time billed for evaluation and management visit, if applicable
  5. Documentation to support the virtual service was provided using audio/video, real time communication technology
  6. Documentation to support the originating site billed
  7. Any other supporting documentation
  8. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC) if applicable for code billed
  9. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  10. 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
  11. If medical record documentation is submitted via esMD: beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation

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
  • 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
  • CMS 1744-IFC. Medicare and Medicaid Programs, Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
  • 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 410.74. Physician Assistants’ Services
  • CFR, Title 42, Section 410.75. Nurse Practitioners’ Services
  • 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
  • American Medical Association, Current Procedural Terminology (CPT) Manual, Professional Edition (2020)
  • National Correct Coding Initiative Coding Policy Manual for Medicare Services

Last Updated Dec 21, 2021