Telehealth in Emergency Departments Post-COVID-19 Public Health Emergency FAQ

Yes, during the COVID-19 pandemic, CMS added the ED E/M codes (99281-99285) to the list of approved Medicare telehealth services. This means that these services can be furnished via telehealth—or real time two-way audio and visual interaction. The place of service (POS) code used on the claim should be the same as if the service was rendered face-to face; for the ED that would be POS 23. This is true even if the patient is not physically located in the ED (e.g, patient is in a remote location, including the patient’s home). It is also allowed that the emergency physician may be in a different location, including at home. Modifier -95 should be added to these visits to indicate that they were performed by Telemedicine. 

Section 4113 of the Consolidated Appropriations Act, 2023 prolonged several  important telemedicine service flexibilities until December 31, 2024, and established certain ones as permanent.

Some commercial payers are adopting new POS codes for Telemedicine (02 and 10, see below). Please check with your payer to ensure the proper POS is used.

• POS 02: Telehealth Provided Other than in Patient’s Home: The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
• POS 10: Telehealth Provided in Patient’s Home: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology

In general, you should document in the same manner as a face-to-face visit. Consider including the following documentation for your telehealth ED visits:

1. Please remember to document whether the patient provided verbal or written consent for a virtual appointment;
2. Chief complaint, HPI, past/family/social Hx, review of systems;
3. Visual physical exam;
4. Medical decision-making such as differential (including COVID concern), any prescriptions, testing or self-monitoring instructions;
5. Document location of the provider to determine whether the -95 modifier (service furnished via telehealth) will be required.

Regarding behavioral or mental telehealth, all patients can receive telehealth services regardless of their location, without any originating site prerequisites or geographic location limitations. There are specific restrictions in place under Section 1834(m) of the Social Security Act that limit where telehealth services may be delivered. Specifically, telehealth services may only be performed in rural areas of the country and from certain health care facilities, requiring Medicare beneficiaries to travel to places such as a physician’s office, skilled nursing facility or hospital for the visit.  

Until December 31, 2024, all Medicare-eligible providers authorized to bill for professional services are permitted to offer distant site telehealth. After December 31, 2024, Non-behavioral or mental telehealth services may have specific originating site prerequisites and geographic location limitations. 

During the pandemic, CMS will reimburse for audio-only telephone calls. CMS has temporarily added separate codes (CPT codes 98966-98968 and CPT codes 99441-99443) to the list of approved telehealth services. The codes are valued the same as the office and outpatient evaluation and management (E/M) codes. Note: Telephone services should not be reported for a follow-up call related to a procedure by your same group.

For the majority of non-behavioral or mental telehealth services, the utilization of two-way interactive audio-video technology is required. However, Section 4113 of the Consolidated Appropriations Act of 2023 permits the use of audio-only telehealth for select non-behavioral or mental telehealth until December 31, 2024.

In the case of behavioral or mental telehealth, the option to employ two-way interactive audio-only technology is still available.

An EMTALA mandated medical screening exam may be furnished via telehealth. Telehealth services may be delivered through telephones that have audio and video capabilities. The HHS Office for Civil Rights (OCR) is waiving penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information, please see Emergency Situations: Preparedness, Planning, and Response.

CMS also allows reporting the critical care services (CPT codes 99291 and 99292), and the observation services (CPT codes 99217-99220, 99224-99226, and 99234-99236) to the list of approved Medicare telehealth services for the duration of the COVID-19 national emergency. CMS is also allowing the majority of these codes to remain on the list for an extended period of time—through the end of the calendar year in which the PHE ends.  However, CMS explicitly decided not to extend a subset of the observation codes: CPT 99218-99220 and CPT 99234-99236. These codes will be removed from the list immediately once the PHE ends.

CMS has provisionally approved the Observation services (99234-99236, 99221-99223, 99231-99233, and 99238-99239) as well as Critical Care through December 31, 2024. For all information related to CMS and Telehealth, please refer to MLN901705 from December 2023. 

Medicare patients may have a brief communication service with practitioners via communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. Clinicians may provide remote evaluation of patient video/images and virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients. These services were previously limited to established patients.

Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists may provide e-visits. E-visits are non-face-to-face communications with a practitioner via online patient portals. (HCPCS codes G2061-G2063)

Clinicians may provide remote patient monitoring services to both new and established patients. These services may be provided for both acute and chronic conditions, and may now be provided for patients with only one disease. For example, remote patient monitoring may be used to monitor a patient’s oxygen saturation levels using pulse oximetry. (CPT codes 99091, 99457-99458, 99473-99474, 99493-99494)

CPT coding guidance states that the remote physiologic monitoring service described by CPT code 99454 (device(s) supply with daily recordings or programmed alerts transmission each 30 day(s)), may not be reported for monitoring of less than 16 days. However, for purposes of treating suspected COVID-19 infections, Medicare will allow the service to be reported for shorter periods of time than 16 days as long as the other code requirements are met.

CMS has issued a temporary waiver to allow physicians who are licensed in one state to provide services to a patient in another state. This applies to Medicare and Medicaid, and certain conditions apply. Further, in order for the waiver to be effective, the state where the physician is performing the telehealth service must also waive its licensure requirements.

CMS has not addressed the issue of credentialing with respect to telehealth and has pointed out that this is within the jurisdiction of the states to address.

Resources

Telehealth.HHS.gov 

Coronavirus waivers & flexibilities

CMS guidance to providers related to relaxed reporting requirements for quality reporting programs  

HHS Fact Sheet on ED Telehealth 

HHS has published a guide for the types of telehealth services that can be utilized in the ED. They include the following:

Tele-triage

Tele-triage is like traditional triage but uses technology to supplement or replace elements of the patient interaction. Tele-triage involves screening patients remotely to determine the patient's condition and the care needed.

Tele-emergency care

Tele-emergency medicine connects providers at a central hub emergency department to providers and patients at spoke hospitals (often small, remote, or rural) through video or similar telehealth technology.

Virtual rounds

Telehealth technology can be used by health care providers to check on emergency department patients virtually. This helps limit the number of providers who are physically present and exposed to contagious diseases. It also saves time and conserves personal protective equipment.

E-consults

E-consults help providers get recommendations from other providers with specialty expertise.

Telehealth for follow-up care

Telehealth technology can also be used to provide follow-up care for patients who were triaged but not sent to the emergency department, or for patients after they are discharged from the emergency department.