UPDATE: Billing for Hospital Outpatient Services During the COVID-19 PHE

On July 28, 2020, CMS released a new FAQ for Hospital Billing for Remote Services (Section LL) and expanded the FAQ for Outpatient Therapy Services (Section MM) in the COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing document[1].

The example list of provided hospital outpatient services has not changed since the original release in April 2020.  At that time, CMS stated,

“When these services are furnished by hospital clinical staff within their scope of practice, the hospital should bill for these services as if they were furnished in the hospital and consistent with any specific requirements for billing Medicare during the COVID-19 PHE.

When these services are provided by clinical staff of the physician or other practitioner and furnished incident to their professional services and are not provided by clinical staff of the hospital, the hospital would not bill for the services.”

In the CMS-5531-IFC published in April 2020, the Centers for Medicare and Medicaid Services (CMS) extended additional flexibilities to hospitals to bill for outpatient therapeutic services in temporary locations including the patient’s home and clarified the flexibility for remote outpatient services via telehealth. Panacea followed that IFC guidance with an article describing the difference between the remote outpatient and in-person outpatient therapeutic services.

Highlights from the CMS FAQ

A high-level overview and summary with some of the more common hospital outpatient scenarios on coding and billing is below.

Registered patient visit of an outpatient provider-based department (PBD) of the hospital

When a face-to-face outpatient evaluation and management (E/M) service is performed with the patient either in the PBD or in the patient’s home, CMS will allow hospitals to report HCPCS code G0463. During the PHE as part of the CMS Hospital Without Walls Initiative, CMS will consider the patient to be “in the hospital” when the face-to-face E/M visit occurs in the patient’s home (or other temporary location). If the entire claim falls under the waiver, the hospital would only use the DR condition code. If some claim lines fall under this waiver and others do not, then the hospital would only append the CR modifier to the particular line(s) that falls under the waiver. The PO or PN modifier will be appended to the HCPCS code in the first position and, if applicable, the CR modifier will be appended in the second position. The provider will need to document in the encounter note where the visit occurred if in the home (or other temporary location).

Registered hospital outpatient receiving in-home therapeutic services

If the hospital clinician (e.g., nurse, practitioner) of the provider-based department (PBD) goes to the patient’s home to provide a therapeutic service (e.g., infusion, wound care, etc.) CMS says the hospital may bill as if the care was furnished “in the hospital”. This means the hospital will include on the claim any applicable CPT/HCPCS code(s) for the therapeutic service performed, drug HCPCS code, etc. Hospitals should append to the applicable CPT/HCPCS code the PO modifier for excepted items and services or the PN modifier for non-excepted services. The DR condition code should also be reported on the claim. The clinician will need to document in the medical record that the services were provided in the patient’s home. Remember during the PHE, the outpatient hospital therapeutic supervision is extended to the patient’s home and is considered to be met when the services are performed per the physician order.

Telehealth (via two-way telecommunication or audio-only) for a registered patient of a provider-based department (PBD) of the hospital

The PBD practitioner performs a telehealth or audio-only visit with the registered patient, then the hospital may report HCPCS code Q3014 (originating site facility fee). The modifier PO or PN is not applicable for this scenario. The practitioner will be at a distant site (not same location as the patient) in order to report this HCPCS. The practitioner may also perform the telehealth visit from his/her own home. The provider will need to document in the encounter note that a telehealth or audio-only visit was performed.

Registered hospital outpatient receiving in-home rehabilitative services by PT, OT or SLP

When the hospital employed (including contracted therapists) Physical Therapist, Occupational Therapist or Speech Language Pathologist goes to the patient’s home to provide medically necessary therapy CMS says the hospital may bill as if the care was furnished “in the hospital”. This means the hospital will report the applicable rehabilitative CPT code and units on the claim. If the entire claim falls under the waiver, the provider would only use the DR condition code. If some claim lines fall under this waiver and others do not, then the provider would only append the CR modifier to the particular line(s) that falls under the waiver. The applicable therapy modifier (GP, GO, GN) will be appended to the CPT code in the first position, the PO or PN modifier will be appended in the second position and, if applicable, the CR modifier in the third position. The therapist will need to document in the medical record where the services were provided.

Rehabilitative therapist telehealth (via two-way telecommunication) visit with a registered outpatient of the hospital

If the hospital employed (including contracted therapists) Physical Therapist, Occupational Therapist or Speech Language Pathologist performs a telehealth visit with the patient who is in their home, then the hospital may bill for the approved telehealth therapy service on the claim. CMS is requiring modifier 95 also be appended to the therapy service provided via telehealth. The hospital will include the applicable therapy modifier (GP, GO, GN) in the first position, modifier 95 in second position, and, if applicable, modifier CR in the third position. Only append the DR condition code if this is the only service being billed on the claim. Per CMS, the hospital may not also report Q3014 for this scenario. The therapist will need to document in the rehab note that a telehealth visit was performed with the patient.

NOTE:  As a reminder the Non-face-to-face Nonphysician Services codes 98966-98968 may still be used when clinicians who cannot independently bill for E/M phone visits (such as therapists, social workers and clinical psychologists). These codes would not be used for a nurse only assessment. These codes are selected and reported based on the time spent by the clinician. The time spent must be documented in the patient medical record. The CR modifier will be appended to the CPT code if not the only service on the claim. Otherwise DR condition code would be reported if the E/M phone visit is the only service billed.

Update to 2020 Annual Therapy Code Designations

In a recently published CMS Transmittal (10241, CR 11792, release date July 31, 2020), CMS is instructing therapists to apply the therapy modifiers (GP, GO, GN) as applicable to select codes that are being allowed for reporting during the COVID-19 PHE. The select codes have a special designation as “always therapy” when the service is performed by a therapist furnished under a therapy plan of care. The codes in the table below will require the therapy modifier in the first position and, if applicable, the CR modifier in the second position:

Allowed Codes During the COVID-19 PHE / Designated as Always Therapy
HCPCS	Short Descriptor		HCPCS	Short Descriptor
98966	Hc pro phone call 5-10 min		G2012	Brief check in by md/qhp
98967	Hc pro phone call 11-20 min		G2061	Qual nonmd est pt 5-10m
98968	Hc pro phone call 21-30 min		G2062	Qual nonmd est pt 11-20m
G2010	Remot image submit by pt		G2063	Qual nonmd est pt 21>min

 

Footnotes:

[1]  The following link may be accessed to read the FAQ updates: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Additional resources:

MLN Matters Number SE20011, release date July 24, 2020 https://www.cms.gov/files/document/se20011.pdf

Covered Telehealth Services for the PHE for the COVID-19 https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

CMS Transmittal 10241, release date July 31, 2020, Reason Code Updates for the 2020 Annual Therapy Current Procedural Terminology (CPT) Codes https://www.cms.gov/files/document/r10241otn.pdf