Therapy Newsletter’s COVID-19 Response Unit

A Financial Relief Plan & Telehealth / E-visit Guidance to Reduce your Burden and Help Combat COVID-19

Use our financial relief plan to reduce your economic burden, and telehealth / e-visit guidance plan to maintain business continuity during the COVID-19 pandemic.

An open letter from Therapy Newsletter CEO Nitin Chhoda PT, DPT

“What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t so.”

 – Mark Twain

Updated 12.31 pm EST on Sunday, 4-5

Please bookmark this article since it is updated daily

Disclaimer: This resource is updated in real-time, multiple times a day and is informational only. None of the content is legal or billing advice, and every reader is solely responsible for their own actions, and for independently verifying any / all content below including the Telehealth Manifesto article. Email support@intouchemr.com to contribute to this resource.

To all private practice owners, physical therapists and members of our community,

COVID-19 has changed life as we know it. The things we felt sure about don’t feel so sure anymore.

This is a moment of reckoning unlike any other in modern times. The extent of destruction will depend on how we monitor the virus, and how we exercise our civic responsibility over the next few weeks.

The White House has called this ‘war’. Some thought leaders have called for a nationwide shutdown and referred to COVID-19 as a ‘once in a century pathogen’.

As private practice owners and clinicians, we are the soldiers at the front lines of this war. Patients, elderly family members and children depend on us for solace and comfort. Ironically, we look after everyone but ourselves, as we risk exposure going to work and getting into close contact with patients.

To help the community, Therapy Newsletter has formed the Therapy Newsletter COVID-19 Response Unit (CRU) to alleviate some of the financial burden and provide emergency guidance on e-visits and telehealth.

The goal is to provide disaster recovery loan information, immediate economic benefit (cost savings) and specific guidance on e-visits and telehealth, including which codes to bill.

Private practice owners are in trouble. Patient cancellations, delays with reimbursements and inability to meet payroll are taking place all over the country. Practice owners are scrambling to do e-visits and cut costs as quickly as they can since income has dried up.

The unit is taking 2 actions, effective immediately. The first action is economic, designed to reduce your financial burden. The second action is specific, real-time guidance on e-visits and telehealth.

ACTION ONE – HELP TO REDUCE YOUR FINANCIAL BURDEN 

Every private practice is eligible for an Economic Injury Disaster Loan and the Paycheck Protection program (among other programs) from the Small Business Administration (SBA) due to COVID-19. Normally, EIDL loans are available to small businesses in response to drought, snowstorms and earthquakes.

We don’t live in normal times.

The federal government has declared COVID-19 as a disaster in every state, which means your practice is eligible for disaster loan assistance from the SBA. There are several programs including the EIDL loan advance, the PPP program, an SBA express bridge loan and SBA debt relief. It is beyond the scope of this article to explain the differences between EIDL and PPP, and the editorial board recommends that you review all the available options from the SBA here.

The SBA provides low-interest disaster loans to businesses of all sizes, homeowners, and renters. Some loans can be entirely forgiven. Such loans can be used to repair or replace items damages caused by disasters, including debt payments, employee paychecks, bills, outstanding invoices and more. Even though private practices are not physically damaged by the current pandemic, many are closed or inaccessible. Such practices are eligible for an SBA disaster loan to cover the costs of business income lost due to the COVID-19 crisis.

This article explains everything you need to know about an SBA disaster loan. If you have any questions about the SBA disaster loan program, schedule a call with a member of our management team using this link

This loan is available to businesses, homeowners and renters.

You’ll need information about your business (tax ID), and your most recent tax return. You will make disclosures about your personal assets and debt (personal and business).

Therapy Newsletter’s COVID-19 Response Unit recommends you apply online for a federal disaster loan from the SBA right away if you need it, since the applications are flooding in by the tens of thousands every day and processing delays will increase quickly.

To verify if your state and county belong to a COVID-19 disaster area (most states and counties are included), click here to review current declared disaster areas.

“Practice owners should consider applying for an SBA Disaster Loan right away.”

DO THIS NOW – REVIEW ALL AVAILABLE OPTIONS FROM THE SBA NOW AND APPLY FOR ONE OR MORE PROGRAMS

If you are an Therapy Newsletter customer, schedule a call with a member of our management team using this link. Together, we will explore options to ease your financial burden.

If you are not a customer yet, contact customer support and ask about scholarships, service fee waivers, 90 day payment deferments and more. We’ll find the best plan for you to maintain patient communication and business continuity. The following services are eligible:

In Touch EMR and In Touch Biller Pro – Integrated Scheduling, Documentation and Billing Software with SMS / voice appointment reminders with a simple, easy and customizable layout – HIPAA and MIPS Compliant.

In Touch Billing – Drastically cut your billing costs & slash denials to maximize revenue without having to switch your EMR.

Eligibility Verification – Done-for-you patient benefit calls – make us an extension of your front desk. We’ll stay on the phone with the payer as long as it takes to get your benefits verified.

Therapy Newsletter – Done-for-you monthly email newsletter to patients and faxed, printed newsletter (evidence-based) for physicians where we do all the writing and delivery, and you take all the credit.

Clinical Contact – SMS marketing, voice broadcasting for your practice to drive your practice into the 21st century.

WHAT TO DO ABOUT RENT WHEN YOU HAVE NO INCOME

Rent payments are an immediate cause for concern for most practices. Here are a couple of options:

Talk to your landlord and say “I need rent deferment by 30 / 60 days since I’m going to be late on my rent”.

Also, talk to all your vendors and services (EMR, billing software, billing service) and ask for discounts / waivers / payment deferments for the next 30 / 60 days.

Banks are already waiving fees, deferring payments on credit cards, mortgages and auto loans during the coronavirus pandemic.

“If you are working with us already or even if you are not, reach out and we’ll help you with an action plan. Talk to your landlord and / or other service providers and ask for discounts / deferments of monthly expenses”

ACTION TWO – OUTLINE OF SPECIFIC GUIDELINES ON E-VISITS & TELEHEALTH (BREAKING NEWS)

The Coronavirus Preparedness and Response Supplemental Appropriations Act, signed into law by the President on March 6, 2020, includes a provision allowing the Secretary of the Department of Health and Human Services to waive certain Medicare telehealth payment requirements during a Public Health Emergency (PHE). This allows beneficiaries across the country to receive telehealth services at home.

Under normal circumstances, physical therapy services are not authorized as telehealth services under Medicare, but a recent update from CMS indicates that several physical therapy CPT codes are now covered under telehealth temporarily due to the COVID-19 emergency. The condition is that the service provided during that visit must fall within the benefit category of that clinician. At the current time, physical therapists cannot get reimbursed by CMS for telehealth codes (since they are not distant site practitioners).

Please note there is a difference between telehealth (a very broad term) and e-visits (a specific component of telehealth applicable under a specific situation).

According to the office of the National Coordinator for Health Information technology, telehealth is “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications”

An e-visit, on the other hand, has a more precise definition with a specific use-case. It is not a sweeping, all-encompassing term like tele-health. It is an online exchange of clinical information between a patient and a provider where the provider evaluates one or more specific conditions that lead to a diagnosis and treatment. Under normal circumstances, the e-visit must be done via a secure, HIPAA-compliant online patient portal.

According to the APTA, CMS describes e-visits as “non face-to-face patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office”. E-visits are conducted online or via some other digital platform and include any associated clinical decision-making. These services can be billed to CMS with either POS 11 (from the clinic) or POS 12 (from home).

Based on recent guidelines from CMS, physical therapists can provide e-visit services using the place of service 11 (same as in-office visit) or place of service 12. Here are recent guidelines from the Private Practice Section of the American Physical Therapy Association about digital communication with patients.

Telehealth E-visit
DEFINITION Broad application, may or may not include clinical decision making Specific use-case (subset of telehealth) requiring clinical decision making
APPLICABLE PROVIDERS Intended for physicians & other healthcare providers, not physical therapy (as per CMS on 4-2-20) Recently applicable to physical therapy (as per CMS)
SCENARIO Broad scope – A visit normally done in the clinic, but now done remotely using audiovisual connections real-time, face-to-face with the patient. Narrow scope – A patient initiates an online assessment or management via HIPAA compliant, secure online portal. Neither real-time, nor face-to-face. Not intended for PT / OT treatment.
TYPE OF PATIENT New and established patient Normally, only for established patients. CMS recently expanded the scope to include new patients (as per the CMS interim final rule).
PAYER GUIDELINES Commercial payers may pay for physical therapy services as ‘telehealth’ (check with individual payers for payer-specific guidelines) CMS will only pay for physical therapy services as an ‘e-visit’
BILLING CODES Typical PT / OT codes (9-series codes like 97001, 97110, 97112, 97530 but not 97140) are appropriate. Commercial payers may accept these (check with each payer since some payers follow CMS guidelines and may accept HCPS codes) Use HCPS codes (G codes) for CMS. Can only charge one unit every 7 consecutive days regardless of how many e-visits were done in that 7-day period.
PLACE OF SERVICE Generally bill with place of service 02 (check with individual payers for payer-specific guidelines) Bill CMS with place of service 11 (from the clinic) or 12 (from home)
MECHANISM OF DELIVERY Delivered using multiple technologies including video conferencing and live chat. Delivered primarily using HIPAA-compliant patient portal (with broader provisions recently for non-public facing applications including Skype, Facebook messenger video chat, Facetime, Google hangouts and video conferencing tools like Zoom). Cannot use public facing applications like Facebook Live, Twitch, TikTok.

Before we explore telehealth and e-visit codes, please note they don’t pay very much, because they were intended for nominal reimbursement for telehealth in a ‘normal world’, where care might occasionally be rendered without an in-person visit. Neither the APTA or CMS anticipated, or had a provision for ‘full blown telehealth’ in a quarantined world under lockdown from a pandemic. Since we’ve been forced into the wild west of telehealth and e-visits so quickly, we must rely on the APTA and CMS to provide guidance, which changes rapidly.

As a practical matter, these codes pay very little. Unfortunately, they will not help cover all your expenses and match your in-person visit reimbursements, considering the duration and 7-day period restrictions indicated in the CPT code description (see below).

We’ve had a lot of questions about billing out ‘regular codes’ through e-visits via video calls and it’s important to set the record straight. Guidance on this is constantly evolving, so make sure to bookmark this page and come back to it.

Criteria

For a therapist to bill an e-visit, the patient must already be an existing patient under an established physical therapy plan of care and must initiate and consent to the e-visit.

We recommend you update your website, send out an email broadcast, text messages and make outbound calls to announce to patients that e-visits are currently available. The goal is to educate patients and get them to initiate an e-visit. More details on how a patient can initiate an e-visit is available in our article on the “The Telehealth Manifesto for PT, OT & Speech Practices During COVID-19 – What to Know Before you Begin”.

Once a patient requests an e-visit, briefly document the patient request and the services rendered. Examples include any review of records, conversations with other caregivers and your clinical decision-making associated with the visit. Since the services may be intermittent over a seven-day period, briefly document all components of patient assessment and management performed during the time period. The time spent on e-visits is cumulative. This means that PT/OT can conduct multiple e-visits, but only bill the patient for one unit of one of these codes during a consecutive 7-day period. Note that this 7-day period begins when the therapist responds to the patient’s request for e-visit and ends after 7 consecutive days (it appears this includes weekends, and this is something we are currently trying to verify). In every subsequent 7-day period, a maximum of one unit of one e-visit code can be charged.

For example, if a PT had 4 e-visits with Mrs. Robinson during a 7-day period that cumulatively took 75 minutes, the PT can only bill one unit – G2063 – and will be paid a total of just under $34.

Use the code that best represents the cumulative amount of time spent in the e-visits (see examples below).

E-Visit Guidelines with Medicare

For Medicare, e-visits by physical therapists can be billed using these HCPCS codes:

G2061
Qualified non-physician health care professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes

G2062
Same as above; 11-20 minutes

G2063
Same as above; 21 or more minutes

Payments to Expect from Medicare:

For G2061, the allowed amount is $12.01. 

For G2062, the allowed amount is $21.16.

For G2063, the allowed amount is $33.17.

The actual reimbursement from CMS will vary slightly depending on the location.

G2010
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, 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.

G2012
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, 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.

Current guidance from CMS allows PT, OT and speech therapists to bill out HCPCS codes G2010 and G2012 on the CMS-1500 form.

Also note that CMS has designated the above mentioned HCPCS Level II codes, in addition to G2010 and G2012 as “sometimes therapy” services. This means that the PT, OT or speech therapist must include the appropriate GO, GP, or GN therapy modifier on claims for these services. The same also applies to some new CPT codes that CMS will pay for. CMS has designated telephone assessment and management service (CPT codes 98966, 98967 and 98968) as “sometimes therapy” services for PT, OT and Speech, which count towards the annual therapy dollar threshold. This means that the PT, OT or speech therapist must include the appropriate GP, GO, or GN therapy modifier respectively on claims for these services.

Understandably, these payments fall way short of rates that are common with outpatient services, but this is a step in the right direction for PT, OT and Speech.

Append modifier CR (catastrophe/disaster related) for Part B billing. Your reimbursement may vary slightly based on the state and the region within the state. For institutional billing, both the DR condition code and CR modifier are required. For non institutional billing, the CR modifier is required.

Medicare will pay 80% of the allowed amount for the above mentioned HCPCS codes. We recommend you check with your State Medicare office to determine the exact allowed amount before billing out these codes.

Communication Platform

Under normal circumstances, CMS required clinicians to use a HIPAA-compliant online patient portal for e-visits. However, based on recent guidance for the COVID-19 pandemic, CMS has indicated that in the absence of broadband access, online accounts, or smartphones, other means can be used.

The emphasis for CMS is that the service can be furnished, since they want patients to get much-needed care. Currently, providers have some flexibility when choosing a platform for e-visits. Clinicians have reported using skype, facetime calls, zoom video conferencing, In Touch EMR and other services to provide e-visits.

Place of Service

The POS is the location of the billing practitioner. With CMS e-visits, POS 11 would be reported on the claim form when the place of service is the clinic (same as in-office visit). POS 12 would be reported on the claim form when the place of service is the home. 

With many commercial payers, POS 02 would be used if providing a Telehealth visit, but e-visits are separate and distinct from Telehealth as outlined by Medicare. Some commercial payers may classify such care as either telehealth or e-visits and may require POS 02. Therefore, it is best to check with the payer.

Here are some scenarios for the use of such codes:

Scenario 1

A patient is currently under the care of a physical therapist and is scheduled to visit the clinic twice a week. However, the patient cancels visits due to a desire to shelter in place and practice social distancing. The PT advises the patient about the risks of an interruption in care and the importance of care continuity at home. The PT also advises the patient that they have the option to initiate an e-visit if they need care, skilled supervision, recommendations on advancing their program, or are concerned about regression or new symptoms. Three days later, the patient initiates an e-visit. The PT bills Medicare with the appropriate G code (or commercial payer with the appropriate CPT code) based on the amount of time spent providing assessment and management over a seven-day period.

Scenario 2

A patient was recently evaluated for care by a physical therapist. The patient calls to cancel the first follow-up visit due to a need to shelter in place. The PT documents the cancellation and advises the patient about the option for an e-visit as an alternative to a trip to the clinic. The next day the patient calls the clinic to request an e-visit, and the PT supports the patient by initiating components of the plan of care that can be safely executed with remote direction, care that is skillful and medically necessary. The PT bills Medicare with the appropriate G code (or commercial payer with the appropriate CPT code) based on the amount of time spent providing assessment and management over a seven-day period.

BREAKING NEWS FROM APTA – New CMS rule includes Therapy Codes in Telehealth, stops short of allowing PTs to conduct Telehealth Services

In addition to existing e-visits for physical therapists, CMS has announced that several physical therapy CPT codes are covered by telehealth, but physical therapists are not telehealth providers (yet). Some ambiguity exists in the language in the new interim rule outlined in the section in italics below. Click here for the CMS webpage to keep track of all waivers and liabilities related to coronavirus. Click on the 3rd link – Medicare IFC: Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). This PDF is the interim final rule from CMS which is yet to be released to the public. Download the PDF, then search for the words “physical therapy” in the document and read all content surrounding the 12 instances of the phrase “physical therapy” in the document. The interim rule includes additional guidance for a Home Health Agency plan of care and inpatient rehabilitation clinics.

According to a new announcement by the APTA, it’s true that the rule changes recently announced by CMS in response to the COVID-19 pandemic add codes commonly associated with therapy to those that may be delivered through telehealth. But there’s one problem: CMS has made no related changes to allow PTs, occupational therapists, and speech-language pathologists to actually provide services through telehealth, even though the codes have now been okayed for that use.

The apparent contradiction may be partly because the new rules were written prior to the passage of the CARES Act last week — the $2 trillion COVID-19 relief package that granted CMS the authority to use waivers to expand the range of providers permitted to conduct services through telehealth. To date (3-31-20), CMS has not extended telehealth authority to PTs, OTs, and SLPs. But with coding rules now in place, such an expansion would be easier to implement quickly. Read about APTA’s efforts to work with CMS and push for permanent inclusion of PTs in telehealth through advocacy for the CONNECT Act.

A new list of CPT codes commonly used by PTs, OTs and SLPs has been added to the list of covered Medicare telehealth services during the COVID-19 pandemic. The entire list is available on the CMS website. The original intention behind telehealth services by CMS is that certain providers like state-licensed physicians, physician assistants, nurse practitioners, and clinical nurse specialists can provide therapy services and bill the CPT codes listed above. The APTA is advocating for inclusion of physical therapists in this list.

Here are some important comments from the interim rule (page 34 and 35):

“We have received a number of requests, most recently for CY 2018 PFS rulemaking, that we add therapy services to the Medicare telehealth list. Since the majority of the codes are furnished over 90 percent of the time by therapy professionals, who are not included on the statutory list of eligible distant site practitioners, we stated that we believed that adding therapy services to the telehealth list could result in confusion about who is authorized to furnish and bill for these services when furnished via telehealth.

In light of the PHE for the COVID-19 pandemic, we believe that the risks associated with confusion are outweighed by the potential benefits for circumstances when these services might be furnished via telehealth by eligible distant site practitioners. We believe this is sufficient clinical evidence to support the addition of therapy services to the Medicare telehealth list on a category 2 basis. However, we note that the statutory definition of distant site practitioners under section 1834(m) of the Act does not include physical therapists, occupational therapists, or speech-language pathologists, meaning that it does not provide for payment for these services as Medicare telehealth services when furnished by physical therapists, occupational therapists, or speech-language pathologists.”

The Therapy Newsletter COVID-19 Response unit (CRU) follows the APTA recommendation, which advises members to assume that PTs are not recognized as telehealth providers by CMS, and the association calls on member to press the agency to expand telehealth waivers, using an APTA-developed template letter. At the current time, PT, OT and speech therapists cannot get reimbursed by CMS for telehealth codes (since they are not distant site practitioners), in the absence of a physician (who qualifies as a distant site practitioner).

The list of CPT codes covered under telehealth by CMS are as follows;

CPT Description
97110 Therapeutic exercises
97112 Neuromuscular reeducation
97116 Gait training therapy
97161 PT Eval low complex 20 min
97162 PT Eval mod complex 30 min
97163 PT Eval high complex 45 min
97164 PT re-evalest plan care
97535 Self-care management training
97750 Physical Performance Test
97755 Assistive Technology Assess
97760 Orthotic mgmt. &traing 1st en
97761 Prosthetic traing 1st enc

Place of Service: The place of service for Medicare telehealth services is 02. For e-visits the place of service 11 or 12 can be used. CMS may require the modifier GT for telehealth services.

Provider Enrollment: CMS has established toll-free hotlines for physicians, non-physician practitioners including physical therapists, establishing isolation facilities to enroll and receive temporary Medicare billing privileges.

Providers should only contact the hotline for the MAC that services their geographic area.

The hotlines are operational Monday – Friday at the specified times below:

1. CGS Administrators, LLC (CGS)

Call: 1-855-769-9920

Hours of Operation: 7:00 am – 4:00 pm CT

2. First Coast Service Options Inc. (FCSO)

Call: 1-855-247-8428

Hours of Operation: 8:30 AM – 4:00 PM EST

3. National Government Services (NGS)

Call: 1-888-802-3898

Hours of Operation: 8:00 am – 4:00 pm CT

4. National Supplier Clearinghouse (NSC)

Call: 1-866-238-9652

Hours of Operation: 9:00 AM – 5:00 PM ET

5. Novitas Solutions, Inc.

Call: 1-855-247-8428

Hours of Operation: 8:30 AM – 4:00 PM EST

6. Noridian Healthcare Solutions

Call: 1-866-575-4067

Hours of Operation: 8:00 am – 6:00 pm CT

7. Palmetto GBA

Call: 1-833-820-6138

Hours of Operation: 8:30 am – 5:00 pm ET

8. Wisconsin Physician Services (WPS)

Call: 1-844-209-2567

Hours of Operation: 7:00 am – 4:00 pm CT

CMS is providing the following flexibilities for provider enrollment:

  •  Postpone all revalidation actions.
  •  Allow licensed physicians and other practitioners including physical therapists to bill Medicare for services provided outside of their state of enrollment.
  •  Expedite any pending or new applications from providers.
  •  Allow practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from your currently enrolled location.
  • Allow opted-out practitioners to terminate their opt-out status early and enroll in Medicare to provide care to more patients.

CMS Announcement: Expansion of the Accelerated and Advance Payments Program for Providers and Suppliers during COVID-19

In order to increase cash flow to providers of services and suppliers impacted by the 2019 Novel Coronavirus (COVID-19) pandemic, the Centers for Medicare & Medicaid Services (CMS) has expanded our current Accelerated and Advance Payment Program to a broader group of Medicare Part A providers and Part B suppliers. The expansion of this program is only for the duration of the public health emergency. Details on the eligibility, and the request process are available on the CMS website and a request form needs to be submitted. The information below reflects the passage of the CARES Act (P.L. 116-136).

What is an Accelerated/Advance Payment?

An accelerated/advance payment is a payment intended to provide necessary funds when there is a disruption in claims submission and/or claims processing. These expedited payments can also be offered in circumstances such as national emergencies, or natural disasters in order to accelerate cash flow to the impacted health care providers and suppliers. CMS is authorized to provide accelerated or advance payments during the period of the public health emergency to any Medicare provider/supplier who submits a request to the appropriate Medicare Administrative Contractor (MAC) and meets the required qualifications.

Medicaid Coverage on Telehealth

Medicaid programs have issued varying guidance on PT and rehabilitation telehealth services across different states. Although each state’s laws, regulations, and Medicaid program policies differ significantly, Medicaid has started to expand the physical therapy services covered by telehealth, based on the status of the COVID-19 epidemic in the state.

Many states are expanding their access for Medicaid patients via telehealth and it’s best to monitor your state Medicaid website. It is imperative to check if PT/OT services are included and if PTs are permitted providers. In some cases, Medicaid mentions codes (98966, 98967, 98968) that are generally used by non-physicians. However, there is no clear guidance for PT/OT. Therefore, it is best to check with each state for updated guidelines. Additionally, some state Medicaid programs have begun incorporating specific documentation and/or confidentiality, privacy and security guidelines within their documented manuals for telehealth.

Visit your state Medicaid agency website to search for your state’s current telehealth covered services under Medicare payment policy. For more information, visit:

https://medicaiddirectors.org/about/medicaid-directors/

Below, we have outlined state-specific Medicaid coverage information. This is breaking news and it is subject to change, and we advise you to verify this information with your state Medicaid agency before billing out these codes. Although physical therapy CPT codes are increasingly covered, we have not yet established if physical therapists are considered ‘telehealth providers’ by Medicaid.

Colorado Medicaid

Colorado department of healthcare policy and financing has expanded Medicaid policy to include the use of physical therapy codes for telehealth (and expanding the definition of telemedicine services to include telephone only and live chat modalities). The codes that would normally be billed in an in-office visit can potentially be billed out through telehealth.

Florida Medicaid 

Florida Medicaid will reimburse for evaluation, diagnostic, and treatment recommendations for services included on the respective therapy services fee schedule.The services can be delivered in a manner that is consistent with the standard of care and all service components designated in the American Medical Association’s Current Procedural Terminology and the Florida Medicaid coverage policy. Physical therapists must append the GT modifier to the procedure code in the fee-for-service delivery system. We recommend that you check with Florida Medicaid to determine the list of covered CPT code for physical therapy services.  

Louisiana Medicaid 

Louisiana Medicaid has included all Louisiana Medicaid managed care organizations to cover telehealth services for physical therapists. The CPT codes covered by Louisiana Medicaid are 97161, 97162, 97163, 97164, 97110, and G0151. Physical therapists need to bill telehealth claims with place of service 02 and modifier 95.    

Michigan Medicaid

Michigan Medicaid covers CPT code 97110, 97112, 97116, 97530 and 97535 under telehealth and the place of service should be 02 with modifier 95. This expanded telehealth coverage as a result of the COVID-19 emergency is effective until June 30 according to Michigan Medicaid.

NY Medicaid

NY Medicaid covers CPT code 99441-99443 for physical therapy under telehealth. The payment is 150% of the 2020 Medicare fee schedule effective for dates of service on and after March 13.

Medicare has required Medicare Advantage plans to expand telemedicine benefits. Most of the MA plans are required to follow in the footsteps of CMS.

The telehealth and PT reimbursement rates and guidelines for commercial payers vary, and are constantly changing. They are discussed below.

General Telehealth / E-Visit Guidelines with Commercial Payers

Based on our recent discussions with commercial payers (current as-of 4-2-20), most representatives don’t know the difference between ‘telehealth’ and an ‘e-visit’. The terms are being used interchangeably by uninformed payer representatives, but there are vital distinctions. Therefore, it is important to be extremely specific while talking to a payer representative to get accurate information on e-visit coverage. 

The APTA has issued specific guidance on telehealth and whether it is appropriate, or allowed with commercial payers. With Medicare patients however, physical therapists cannot provide ‘telehealth’ and must instead do ‘e-visits’ as per current guidance (current as of 4-2-20).

For commercial payers, e-visits by physical therapists can be billed using the following CPT codes:

98970
Qualified non-physician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

98971
Same as above; 11-20 minutes

98972
Same as above; 21 minutes or more

APTA Guidance on Questions to Ask Commercial Payers about Telehealth

Talk to your commercial payer to confirm if they will reimburse for the above-mentioned codes, since some codes are plan-specific. Guidelines are changing rapidly as the COVID-19 outbreak continues to evolve. The APTA has released guidance on which questions to ask commercial payers.

1. Will services provided by physical therapists (and PTAs working under the direction and supervision of the PT) be covered when provided via telehealth?

2. If so, what codes should be billed and what modifiers are required?

3. What device(s) or application(s) can be utilized?

4. What, if any, consents are required?

5. Are there any special documentation requirements?

We believe it makes sense to ask a couple more questions

6. Current guidance indicates that most commercial payers will only pay for current patients (like CMS), however this may change at any time. Therefore, it’s worth asking – Will they pay only for current patients or new patients (including evaluations)?

7. Will they only pay for in-network providers? For out-of-network providers, will they pay the out-of-network benefit amount?

In addition to the above CPT codes, additional telehealth / e-visit codes may be covered by some commercial payers. Each payer has specific guidelines about telehealth / e-visit codes. 

Any limitations on e-visit services for commercial payers depend on the individual member plan. For most commercial payers (check with each payer), the POS for telehealth services should be 02 with GT / 95 / GQ modifiers. However, we recommend that you verify this information with each commercial payer, since they may or may not follow CMS guidelines. This will help you determine whether to bill out as telehealth, or e-visits.

Specific Telehealth Announcements from Major Commercial Payers

Our team is gathering information daily from commercial payers about telehealth services for physical therapists and the information below will be updated in real-time. 

Disclaimer – While we do our best to provide you with real-time information, it’s impossible to keep up with every change across all payers. We are not responsible for any changes / updates made by CMS and other payers since guidelines are changing daily, so it is the responsibility of your benefit verification team to verify the benefits for each patient, for their specific plan and ask about the requirement for pre-authorizations before providing telehealth or e-visits. Commercial payers have different policies and may or may not follow CMS guidelines and things keep changing.

1. United Healthcare – FIRST MAJOR PAYER TO SUPPORT TELEHEALTH FOR PT/OT

United Healthcare will reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology. This is applicable for all Medicare Advantage, commercial and managed Medicaid plans, for new and established patients. State laws and regulations apply. Benefits will be processed in accordance with the member’s plan. This change is effective immediately for dates of service March 18 through June 18, 2020. United Healthcare will reimburse eligible codes when submitted with a place of service code 02 and modifier 95.

UHC has introduced some limitations. Billable codes include initial evaluations, re-evaluations, 97110, 97112, 97116, 97530 and 97535. The good news is that the rates are still the same as an in-office visit. There had been no clear guidelines with regards to PTAs and COTAs, but if the guidelines are similar to an in-office visit, PTAs and COTAs they should still be able to see UHC commercial and Medicaid patients as if it is an in-office visit, except for Medicare Advantage patients. For more details, visit UHC’s page on COVID-19 Physical, Occupational and Speech Therapy Telehealth.

Click here to view the list of CPT codes covered by UHC for PT, OT and Speech Therapy.

2. Aetna expands Telehealth coverage by PTs

The following are nationwide Aetna rules, including Aetna’s Medicare Advantage and commercial plans. An audio-visual connection is required, and there is no specific guidance about a preferred communication platform. Skype, facetime or zoom can be used.

The insurer, officially known as CVS Health/Aetna, will cover the telehealth-based delivery of the services and procedures by PTs for CPT codes 97161, 97162, 97163, 97164, 97110, 97112, 97116, 97535, 97755, 97760, and 97761. Providers are required to append the GT modifier to the codes.

Aetna will allow PTs to bill e-visits only (not telehealth) using either G2061-G2063 or 98970-98972. Therefore, it is important to verify benefits directly with Aetna prior to providing telehealth services. Aetna may require clinical records during the claim submission process. It appears Aetna will cover 100% for both in-network and out-of-network providers for the next 90 days. It also appears there is no copay, deductible or coinsurance requirement.

Aetna will pay for Medicare-type e-visits and G codes (G2061-G2063). Providers are not restricted to the use of G codes. The good news is that providers have the additional option to use similar CPT codes (98970-98972). The use of the GT or 95 modifier is not required for e-visit CPT codes.

In either case, the reimbursement rates are going to be low relative to an in-person visit and an ‘audiovisual connection’ must be used. However, there are situations where only a telephone connection may be available. In such situations, Aetna will pay for 98966, 98967 and 98968 (telephone assessment and management services).

By definition, these services must be provided by a qualified non-physician 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; 11-20; or 21-30 minutes of medical discussion.

3. Cigna also expands Telehealth coverage by PTs

Cigna announced a series of temporary changes that open the doors for telehealth by PTs, occupational therapists, and speech-language pathologists. CIGNA also covers PT/OT telehealth visits for all Medicare Advantage and commercial plans for new and established patients and an audiovisual connection is required. Reimbursement rates are the same as an in-office visit. PTAs and COTAs can see commercial patients but not Medicare Advantage patients. However, CIGNA has a limited number of billable codes that can be used. Cigna allows for reimbursement of 97161 (evaluation, low complexity, 20 minutes, telephone or virtual), 97162 (evaluation, moderate complexity, 30 minutes, virtual), and 97110 (therapeutic exercises, two-unit limit). Codes must be appended with a GQ modifier and billed with a standard place-of-service code 11. Cigna recommends that providers follow CMS guidance on the use of a specific software program but states that it will not require the use of a specific software for now. For more details, visit Cigna Coronavirus (COVID-19) Interim Billing Guidance for Providers for Commercial Customers.

4. BCBS

BCBS guidelines differ by state and we recommend signing up for email updates from your local BCBS carrier and monitoring their state guidelines here. At In Touch Billing, we have called several BCBS payers in different states and revealed our findings in the sections to follow. We have been notified by clients that BCBS of North Carolina and BCBS of Texas have announced that they are covering PT/OT telehealth visits with the same guidelines and reimbursement rates as in-office visits.

More state-specific BCBS payers are moving in the right direction and expanding coverage as of 4-3-20. For Florida Blue, CareCentrix (their provider) is playing a big role by covering telehealth visits through home health agencies and this includes OT, PT and SLT services. Click here for Florida BCBS guidelines.

BCBS of Rhode Island just made an announcement about telehealth and e-visit coverage. Several temporary changes to telemedicine/telehealth policies have been made to allow for telephone only services. The goal is to ensure that BCBS members are able to access appropriate care from providers.

The new changes are effective for dates of service on or after March 18, 2020. It appears these changes are in effect until Friday, April 17, 2020. Extensions are possible after April 17, and it’s best to check back with BCBS. Based on these updates, physical therapists are allowed to provide telemedicine/telehealth or telephone only services. Keep in mind that physical therapists cannot bill for services like manual therapy which need in-person interaction with the patient. Services must be suitable for delivery via telemedicine and/or telephone, be clinically appropriate and medically necessary and otherwise covered under the member’s benefit plan or subscriber agreement.

It appears that prior authorization is not required for such services at the present time. BCBS RI will reimburse telemedicine/telehealth or telephone only encounters at 100% of the in-office allowable amount for any clinically appropriate, medically necessary covered health service. BCBS RI will temporarily waive cost-share (e.g.co-pays and/or deductibles and co-insurance) for services provided by physical therapists.

Services may be provided via the following non-HIPAA compliant secure electronic communication applications that allow for video chats:

  • FaceTime
  • Facebook Messenger video chat
  • Google Hangouts video
  • Skype

For state and county-specific information, check with local BCBS provider services.

5. Triwest

Triwest covers physical therapy telehealth services, depending on the patient’s plan. Similar to Aetna, Triwest is more flexible in terms of mode of communication, including skype, facetime or zoom. Consents or special documents are not required, however Triwest may require authorization for all the patients availing a telehealth service, but it is best to verify with Triwest directly.

6. Tricare

Tricare has indicated that PT/OT can be performed via telemedicine for an established patient with the same rates as an in-office visit but not for new patients. The patient has to be established, which means that the initial evaluation was done in the clinic, and follow up treatments and visits were done via telehealth. Tricare has indicated that the same referral/authorization requirements that are in place with an in-office visit are in place with telehealth visits, which requires the same level of coordination with the referring physician. For synchronous telemedicine services, bill using either CPT codes or HCPCS codes with a GT modifier for the distant site and Q3014 for the originating site to distinguish telemedicine services. Use place of service “02” in conjunction with the GT modifier. The same modifiers normally used in an in-office visit can be used for telehealth. For asynchronous telemedicine services, bill using CPT or HCPCS codes with a GQ modifier and place of service “02.” Note: You may indicate “Signature not required – distance telemedicine site” in the required patient signature field on the claim form.

The Department of Defense has issued a final rule that establishes PTAs as authorized providers under TRICARE, the health insurance system used throughout the military. The rule, set to take effect on April 16, largely follows the PTA approach used by CMS, and includes requirements related to supervision, the reach of state and local law, and the scope of allowable PTA activities. Therefore, it is our opinion that PTA and COTA should not do a Tricare telehealth visit at all.

7. BCBS NY, WY and Ohio Aetna 

May allow physical therapists to bill CPT codes 99441-99443 via telehealth. This coverage is state specific and you need to check with your payer.

8. BCBS of Michigan

May pay for CPT codes 97110, 97112, 97116, 97530 and 97535 via telehealth effective for both commercial and Medicare Advantage population until June 30.

9. Payer Providence Health Plan of Oregon, Oklahoma

May allow physical therapists to bill 92507, 92526, 92609, 97110, 97112, 97129, 97130, 97161, 97162, 97163, 97530, 97535 via telehealth. 2-way video services performed by PTs for services within the scope of license may be covered. The POS should be 02. Do NOT append GT or 95 modifier. Append modifier GQ. It appears that payment is allowed only when provider originating site is used.

10. Payer Independence Blue Cross of Southeast PA

May cover CPT codes 97110, 97112, 97116, 97129, 97130, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535 for physical therapists. The POS should be 02 and modifier GT or 95 is required in the claim.

11. Regence Blue Cross of WA and Premera Blue Cross of WA

May pay for 97000 series codes at contracted rates. We recommend that you check with the payer for specific CPT code coverage information.

12. Anthem Blue Cross – CA

Normally, physical therapy services require face-to-face interaction and therefore are not appropriate for telephone-only consultations. All Anthem contracted providers can provide telehealth services if clinically appropriate. For telehealth services, providers should bill the same CPT codes that they would normally bill for in-person visits, with modifier GT and POS code 02.

13. Anthem Blue Cross – WI

Coverage of telehealth therapy evaluation only; does not include treatment. Claims should be billed with POS code 02, Modifier 95 or GT, and the appropriate CPT code. Anthem will cover the initial evaluation, which should be provided through a certified telehealth platform including video and audio.

14. BCBS- Louisiana

 Any credentialed network physical therapist can provide limited telehealth encounters to replace office visits. Therapy providers must adhere to telehealth guidelines. Therapy providers filing claims for telehealth should use standard office billing practices and CPT codes along with POS code 11 and Modifier GT or 95. Telehealth therapy services are limited to the following CPT codes: 97161, 97162, 97164, 97110, 97112, 97116, 97530, 97535, 97165, 97166, 97168. Claims will be paid using standard member cost shares.

15. BCBS- Massachusetts

BCBS of Massachusetts reimburses contracted health care providers for covered, medically necessary telehealth (telemedicine) services. When you provide services via telehealth, you are not restricted to specific telephonic CPT codes. You may be able to bill all covered services that you render either by telehealth/video or telephone as if you are performing a face-to-face service using the codes that are currently on your fee schedule. You must use one of the following telehealth modifiers: GT, 95, G0, and GQ and use POS 02.

16. Independence Blue Cross

This payer has expanded telemedicine to physical therapists which should be done via video conferencing. We recommend that you check with the payer for the list of covered CPT codes.

17. Kaiser Permanente

Payer Kaiser Permanente allows telephone and video visits by physical therapists. We recommend that you check with the payer for the list of covered CPT codes.

18. Vantage Health Plan

Physical therapy visits performed through telemedicine must be in lieu of a face-to-face visit for an established patient with an existing plan of care. Physical therapists should bill these telemedicine visits with CPT 97110 (therapeutic exercise) with the appropriate modifier GP or GO. Vantage Health Plan allows up to three PT and three OT units per week per patient. These claims must be billed with a POS code of 02 instead of POS 11. Vantage will pay these telemedicine claims at the current allowable with NO patient cost share.

19. Humana

Humana has not provided clear guidance. It appears Humana will allow e-visits for Medicare Advantage plan members. They are currently following CMS guidelines. It is our opinion that Humana will make a formal announcement once CMS recognizes PTs as telehealth providers. They haven’t issued any specific guidelines on commercial plans, so we advise you to call Humana and ask for guidance about specific plans.

Telehealth Considerations for Workers Compensation Claims

As COVID-19 forces the lockdown of many physical therapy clinics across the country, worker’s compensation payers are covering more telehealth services to keep injured worker care on track. Telehealth services provide injured workers with an opportunity to continue their care even as brick and mortar clinics temporarily close their doors.

The guidelines still differ state by state and often carrier by carrier basis so please check individual websites about the COVID-19 update. Regardless of whether the state is providing guidance or not, it is essential to contact the case manager in order to get telehealth approved for reimbursement. Similar to the recommended list of questions for commercial payers set forth by the APTA, we recommend a set of questions when talking to case managers.

  • Is PT / OT covered via telehealth?
  • How many “visits” are allowed?
  • Can visits be done by phone / patient portal / is audio/visual required?
  • What codes can be used and are there specific modifiers or POS that must be used?
  • Do authorization, copay, deductibles apply like in-office visits?
  • Can PTAs and COTAs perform care via telehealth and get reimbursed?

MedRisk’s tele-rehab program, which has been running for almost three years, combines in-person visits with video conference visits.

Here is some state specific information from the team at Therapy Newsletter:

NY Workers Compensation

NY Workers Compensation allows physical therapists to bill CPT 99441 with place of service 02 and modifier 95 for telehealth services. The services should be medically appropriate.

 KY Workers Compensation

KY Workers Compensation states that telehealth services may be offered when clinically appropriate in the judgment of a physical therapist, for treatment of workplace injuries and occupational disease. Modifier 95 should be appended to the CPT code.

Further, KY WC regulations state that patients with emergent or urgent conditions are not considered for telehealth services in the acute phase of their recovery. The reason is that these patients are at increased risk for a lifetime of disability if physical therapy services cannot be performed in-person with a licensed physical therapist.

Every day, an increasing number of workers compensation payers are starting to cover telehealth services for physical therapists. We recommend you contact the claims adjuster to determine payer-specific coverage information before you treat patients and bill out claims.

Telehealth Considerations for State-Regulated Payers

Several states are issuing guidelines to expand telehealth. Several states such as Massachusetts, California, Illinois Arizona have taken the lead. States have announced that all telehealth visits must be reimbursed at the same reimbursement rates as in-office visits. Click here to check state-specific guidelines regarding telehealth.

Just Announced – MIPS Date Submission Deadline Extended

Clinicians and facilities participating in CMS quality reporting programs, including the Merit-based Incentive Payment System (MIPS) will have more flexibility with data submission.

For the MIPS program, 2019 data submission deadlines have been moved to April 30. The previous deadline was March 31.

Just Announced – Telehealth Options for NJ-based Physical Therapists

New Jersey Governor Phil Murphy announced departmental actions that permit any requested in-plan exceptions for patients to access out-of-network telehealth providers (including physical therapists) if in-network telehealth providers are not available. Murphy has instructed payers to allow telephonic telehealth services and flexibility in the specific technology used to deliver the services. We recommend that NJ physical therapists use this option and help as many patients as possible during this pandemic.

Telehealth Examples for Physical Therapists – Lots to Do!

  • Provide quicker screening, assessment, and referrals to improve care coordination. 
  • Provide interventions by observing patient movement and function to facilitate proper exercise technique including range of motion. Verbal and visual instructions / cues to help the patient perform various activities. Modification of the patient environment to minimize injury and facilitate functional outcomes.
  • Participate in a joint effort with other health care providers for specific movement-related activities, to optimize the patient’s participation and encourage functional recovery.
  • Quick check-ins with established patients, when a comprehensive in-person visit may or may not be appropriate or possible.

Recommended Telehealth Platforms – Options to Consider

According to recent guidance from BCBS, providers may use non-public facing remote audio and/or video communication services to communicate with their patients. These services include, but are not limited to:

  • Facetime
  • Facebook Messenger
  • Google Hangouts
  • Skype
  • Doxy.me
  • Updox
  • Zoom for Healthcare
  • Google G Suite Hangouts Meet
  • Skype for Business
  • VSee

Providers may not use public-facing services, such as Facebook live, Twitter or TikTok.

Comments on CMS’s ‘Original Restrictions’ on Telehealth for Physical Therapists

The APTA has reached out to CMS to ask that telehealth restrictions be removed at this time. The goal is to allow Medicare coverage of telehealth services provided by physical therapists and physical therapist assistants during the COVID-19 public health emergency. APTA has stated: “It is critical that all Medicare beneficiaries have the ability to receive care at home to avoid placing themselves at greater risk of the virus. Especially considering the delivery of physical therapy services via telehealth has been proven to be safe, effective, and widely implemented beyond the Medicare system”. 

We are closely monitoring the current situation and are in touch with CMS. Please bookmark this article, since it will be updated as soon as we get a response from CMS.

HIPAA Considerations with Telehealth

Effective March 17, 2020 through the end of the COVID-19 public health emergency, the Office for Civil Rights (OCR) will not impose penalties on providers for their failure to comply with the Health Insurance Portability and Accountability Act (HIPAA) while providing telehealth services in good faith to their patients, providing they use non-public facing remote communication technology to provide the services. Providers using non-HIPAA compliant services are encouraged to notify patients about potential privacy risks.

FAQs about Telehealth and E-Visits from CMS

1. What is the difference between synchronous and asynchronous telemedicine services?

Synchronous telemedicine services refer to the exchange of electronic information in at least two directions at the same time, such as real-time video. Asynchronous telemedicine services refer to storing/transmitting information in one direction at a time, such as submitting medical history or images from one party to another.

2. What is meant by “for up to seven days; cumulative time for the seven days”?

The PT would bill the appropriate code based on the cumulative amount of time spent over a seven-day period. The seven-day assessment and management period begins when the provider responds to the patient’s request for an e-visit. The period ends after seven consecutive calendar days.

3. Can a PT bill more than one code per seven-day period?

No. A PT can only bill one code per seven-day period.

4. Does this also mean a PT can only submit this code every seven days?

Yes. The appropriate code would be submitted once for the seven-day period for the same patient within the same episode of care. After seven days, the appropriate code can be billed again using the same guidelines as before.

5. Does an e-visit affect the count toward the 10-visit requirement for a progress report?

E-visit services do not count toward the 10-visit progress report requirement.

Final Note – Time to show Strength & Leadership by Giving Patients Much-Needed Hope

In a time of strife, the strong demonstrate strength and emerge stronger. The weak need help, and need leaders. Use this time to reach out to patients and tell them you can help them through e-visits, and that you will re-open as soon as the situation allows. Show leadership and solidarity. Give patients hope, and lead the way.

Use email newsletters with Therapy Newsletter, text messaging and voice broadcasts with Clinical Contact and make announcements on your website to get the word out quickly. There’s no need to call patients one by one, although you certainly can.

Also use this time to build systems, create written processes and do the things you don’t normally have the time for. Switch to an EMR software like In Touch EMR, or switch to a new, improved billing service like In Touch Billing to improve your collections and reduce denials.

“Use email / SMS / voice broadcasting / website announcements to project strength & solidarity with patients”

Here’s a script you can use and change as needed:

Dear Patient, although we live in uncertain terms, you can count on us to continue taking care of your health and wellbeing. The good news is – we can provide you with physical therapy services via telehealth effective immediately. Contact our office at xxxx or email us at xxxxx to schedule a telehealth visit, which may be covered by your insurance. You can also change an upcoming appointment to a telehealth visit if you so choose. Telehealth is very convenient – you can use your phone (Android or Iphone) or computer connected to the internet to complete the visit. Our office will advise you of next steps to take once the visit is scheduled. Slots are filling up fast, so contact us now. As soon as we’re-open, we’ll take great care of you in the office, like we always have. You are not alone, and you can always count on us to be here for you. Call us if you need anything, we will answer the phone and we can’t wait to talk to you!

Therapy Newsletter’s CRU is designed to act as your shield against this unavoidable pandemic. 

As a community, it’s time for bold, aggressive measures now. There has never been a more pressing time.

If you have any questions or need any help, get in touch with us:


Email:
janice@referralignition.com or
patrice@referralignition.com

Call:
973-797-9286 or
1-800-421-8442 extension 2

Send us a text message: 413-489-2067

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Sincerely,

Nitin Chhoda PT, DPT
CEO, Therapy Newsletter

Additional Resources:

Coronavirus updates from the APTA
APTA document – Federal Payer Telehealth or E-Visits Coverage
APTA document – Commercial Payer Telehealth or E-Visit Coverage
APTA document – State-Mandated Executive Orders Related to Telehealth
APTA document – State Emergency Orders Permitting PTs to Provide Telehealth Services
APTA document – Occupational Medicine Providers Telehealth or E-Visits Coverage
Employee considerations during COVID-19 for PT practices
Difference Between Exempt and Nonexempt Employees
Reducing Exempt Employee Payroll in Response to Coronavirus Uncertainty
CMS guidance on telemedicine
Triwest VA Choice guidance on telemedicine
TriCare guidance on telemedicine
COVID-19 resources from CVS for Aetna members
Aetna provider page guidance on telemedicine
COVID-19 announcement from Aetna for all providers