Through the CARES Act, the Centers for Medicare & Medicaid Services (CMS) enacted a permanent change to the Home Health rules.  The changes now allow NPs and PAs to certify and perform Home Health supervision or certification.  Previously, only physicians could bill for these services.  Effective for claims with dates of service on or after March 1, 2020, Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) may bill the following codes:

• G0179: Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care. Arizona Medicare rate is $40.39 (MD/DO); $34.33 (NPP) (This is for the provider recertifying every 60 days). A copy of the signed 485 form should be in the chart.
• G0180: Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care. This is for the provider’s initial certification. Arizona Medicare rate is $52.75 (MD/DO); $44.84 (NPP). A copy of the signed 485 form should be in the chart.
• G0181: Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans. This one requires 30 calendar minutes a month of the provider documenting on a daily basis what they were doing, regarding the patient’s HHA services. Arizona Medicare rate is $106.72 (MD/DO); $90.71 (NPP).

Implementing Home health may create questions, but we can help you find the answers.  If you want more information on this or other strategies designed to improve patient outcomes and quality of life, boost provider quality scores, or increase practice revenue then click here to fill out a brief survey to include any specific questions you may have (requires registration of a valid email address to communicate with).
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Reference:
Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L. No. 116-136) amended sections 1814(a) and 1835(a) of the Social Security Act.

     CMS released another update 30 April 2020, impacting the delivery, coding, billing, and reimbursement of non-face-to-face care during the current PHE.  The document is 221 pages and, as always, it is recommended to refer to the source document.  Keep in mind that this information has not been finalized in the CFR and might have some slight edits by the time you see it in final form.
Voice-only visits (i.e. phone calls, no video) will receive higher reimbursements, backdated to March.  Providers should use telephone codes 99441 – 99443 for voice only E/M services for Medicare; these correspond to 99212 – 99214.  The full discussion begins on page 122.  This change does not mean you can bill a 99213 for a voice-only telehealth visit; you would use 99442 for the comparable time or MDM. 
       This modification was made for instances when the two-way, audio and video standard required for a Medicare telehealth service might not be available, CMS felt there could be “many circumstances where prolonged, audio-only communication between the practitioner and the patient could be clinically appropriate yet not fully replace a face-to-face visit.”
     CMS also posted information concerning selecting appropriate level for Medicare office / outpatient E/M visits furnished via telehealth; the discussion on time for E/M begins on page 135.  Level selection for these services when furnished via telehealth can be based on MDM or time. 
The IFC also addresses the impact of COVID-19 on Part C and Part D quality ratings, beginning on page 137.
Source:  https://www.cms.gov/files/document/covid-final-ifc.pdf

We have been sending e-mails out through our various contact lists and connections over the past couple of weeks and concluded it best to post any updates to one, single location from which everyone can see.  The one constant during this PHE has been change.  Practices have been working hard to keep up with new information impacting covered patient services, modifiers, etc. coming out almost daily.  Clearly, if you are working off information updated last week, you might be out of date already. 

So here is our attempt to get up to date (as of today, anyway).  As always, what we provide is intended to inform and educate but we do not pretend to be experts in all areas of healthcare.  The most up-to-date information and posted changes will come from your individual payers as they post their specific plan update information, so please ensure you are checking with them frequently.  Here is a chronology of CMS updates and the associated references:
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17 April:  Telehealth coverage flexibilities now include RHCs and FQHCs for the duration of the COVID-19 PHE.  Reminder, telehealth services require both audio and video.  The entire release notice is here.  RHCs will be paid at their all-inclusive rate (AIR), and FQHCs will be paid based on the FQHC Prospective Payment System (PPS) rate.  Medicare will also be paying RHCs and FQHCs for the portal codes 99421-99423 the same way they pay physician offices (7 days cumulative time) as well as the G2012 and G2010.
14 April clarification on telehealth added below with the 6 April information.
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10 April:  New and revised immunology codes provided

• 86318 (REVISED):    Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip);
• 86328 (NEW):   severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])        (For severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease {COVID-19}] antibody testing using multiple-step method, use 86769)
• 86769 (NEW):   Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

6 & 7 April: Coding for telehealth
“To modifier or not to modifier?”, that was the question (among others). 
Much confusion arose over how to properly code E&M services, POS, modifier use, etc. during the PHE.  Well, CMS has spoken on this matter one more time with the information updated to the Federal Register this month as well as during the recording they posted on 7 April.

For PART B Medicare patients, you CANNOT bill face-to-face E&M codes for any encounter in which the provider – patient interaction does not utilize audio AND video.  Some PART C Medicare Advantage plans have different guidelines – BE SURE TO FOLLOW WHAT THE PAYER STATES.  If you want their money, follow their rules.  Medicare PART B requires live audio-video interaction with the billing provider to legally bill the code (not with the MA).  Some examples to help illustrate the latest take:
Office-based MD/DO/NP/PA not doing nursing home, hospital work, etc.:

• Office visits 99201-99215 (REQUIRES LIVE AUDIO AND VIDEO)
• POS:  11
• Modifier 95
• Does not matter where patient is; does not matter where provider is

Office-based MD/DO/NP/PA doing nursing home, hospital work, etc. use POS and appropriate E&M code for patient location:

• POS 11 – Office Visits for PTs at home, Modifier 95
• POS 21 – Hospital codes for PTs at hospital, Modifier 95
• POS 31 – SNF codes for PTs in SNF, Modifier 95

Home visitation MD/DO/NP/PA (audio-video visits):

• Home Visit codes 99341-99349
• POS: 12
• Modifier 95

Reminder:  use MDM or time when billing E&M via telehealth.  According to the 6 April posting to the Federal Register, CMS stated they are maintaining the current rules for MDM.  Time, however, ended up being a slightly different outcome: Clarified 14 April, use either CPT time or Federal Register time.  Please note that this only applies to telehealth performed during the COVID-19 PHE.  If seeing a patient in office, and billing for time only if more than half the visit is spent counseling and / or care coordination, the normal CPT times are to be used.  Use of time or MDM alone for in-office visits doesn’t go into effect until 2021… maybe.

2 April:  Still more updates coming out from CMS.  I will be sending these with the hope that you will also share with all the HCPs and offices you work with, colleagues, and friends that can further share the info and (hopefully) have a positive influence on patient care in this challenging time.
Medicare clarified guidance for E/M Telehealth documentation requirements:  need EITHER Time or MDM for E/M level.  Telehealth involves synchronized video and audio interaction between the provider and patient.  Only provider time counts.  As previously reported, the Tele-Health originating site rules were suspended 17 March 2020, effective back to 6 March 2020.  That means the patient’s home can be the originating site during the emergency period.  This should be finalized in the CFR on 6 April, but the draft is out.
Yes, patients can communicate from their home to the provider at a ‘distant site’.  Requirement for both audio AND video remains; however, available applications temporarily include non-HIPAA compliant tools Skype and Facetime.  We recommend still using a HIPAA-compliant app such as Zoom that also allows for easy recording and downloading and clearly documenting the consent in the recording and the note.  Several EMRs have this functionality via their portal or an add-on, as well. 
Additionally, all Medicare beneficiaries can use telehealth services for common visits and preventive screenings – the rural area requirement is also waived. 
Effective 31 March, add 2 new HCPC codes for specimen collection:
·         G2023:  Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
·         G2024:  Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source
These codes indicate "any source" so don't restrict these only to the nasal swabs.   These are only for trained personnel and not for any patient self-tests.