ASTRO Guidance on 2024 CMS Telehealth and Supervision Policies

The Centers for Medicare and Medicaid Services (CMS) issued several guidance documents to provide physicians with the flexibilities necessary to continue treating patients during the COVID-19 Public Health Emergency (PHE). Many of those policies have been continued on a temporary basis after the May 11, 2023, conclusion of the COVID-19 PHE.

Note: Unless otherwise noted, the guidance below is effective only as of the release of the 2024 MPFS final rule (November 2, 2023) and retroactively applicable to March 1, 2020. For the most current guidance from CMS, see Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19.

I. Initial Patient Consult and Follow-up Care

The expansion of telehealth established three distinct categories of services for use during the COVID-19 PHE. ASTRO believes that most practices will want to consider the application of Medicare Telehealth Visits to existing initial consults and follow-up care. However, practices may also utilize Virtual Check-ins and E-Visits when appropriate.

1. Medicare Telehealth Visits for new or established patients require the provider to use an interactive audio and video telecommunications system for real-time interactive communication between the physician and the patient, including the use of telephones that have audio and video capabilities, desktop or mobile computing devices with audio and video capabilities allowing for two-way communication. Health care providers may no longer use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video or Skype, to provide telehealth. This flexibility ended on August 9, 2023 (see HIPAA Compliance section below).

2. Medicare Telehealth Visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. These telehealth interactions apply to specific codes, including the Office/Outpatient Visit codes (99202-99215) for new and established patients. View a complete list of codes.

   In the 2023 MPFS final rule, CMS finalized the policy that at the end of the calendar year in which the PHE ends, which was 2023, practitioners will no longer bill claims with Modifier -95 along with the place of service (POS) code that would have applied had the service been furnished in person. Telehealth claims will instead be billed with the following POS indicators:

   • POS “02” – Telehealth Provided Other than in Patient’s Home (Descriptor: 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.); and
   • POS “10” – Telehealth Provided in Patient’s Home (Descriptor: 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.).
   • Beginning in 2024, claims billed with POS 10 will be paid at the nonfacility PFS rate; claims billed with POS 02 will continue to be paid at the PFS facility rate, under the assumption that those services will be furnished in originating sites that were typical prior to the PHE.

3. Virtual check-in visits (CPT codes G2010 and G2012) for new or established patients allow patients to have a brief check-in with their practitioner via a broad range of communication methods, including the telephone (no video requirement), audio/video, text messaging, email or use of a patient portal. These services may only be reported if they do not result in a visit, including a telehealth visit.
   
   Note: In instances when the brief communication technology-based service originates from a related E/M service (including one furnished as a telehealth service) provided within the previous seven days by the same physician, this service would be considered bundled into that previous E/M service and would not be separately billable.

4. E-Visits for new or established patients involve a communication between an established patient and provider through use of an online patient portal. The patient must initiate the initial inquiry through the patient portal. Communications may take place over a seven-day period. There are three time-based E/M codes specific to this service (99421-99423).

The chart below summarizes the distinct types of telehealth that may be provided:

More information about the use of these codes can be found on the CMS Flexibilities to Fight COVID, which was last updated on November 6, 2023.

II. Telephone Evaluation and Management (E/M) Services (99441-99443)

Physicians can also use CPT codes 99441-99443 for Telephone Evaluation and Management Services for new or established patients. On an interim basis, these codes will be reimbursed by CMS for E/M visits provided via audio-only telephone at the same rate as if the services had been provided in person. This was extended through December 31, 2024, under the Consolidated Appropriations Act of 2023.

CMS crosswalked CPT codes 99212, 99213 and 99214 to CPT codes 99441, 99442 and 99443 respectively.

• 99441 – Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven 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.

• 99442 – Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.

• 99443 – Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

In the 2021 MPFS final rule, CMS recognized the value of audio-only services given the widespread support for the continuing need for audio-only conversations with patients. To address this need the Agency established HCPCS code G2252 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; 11-20 minutes of medical discussion. G2252 will have a direct crosswalk to CPT code 99442, the value which most accurately reflects the resources associated with a longer service delivered via synchronous communication technology, which can include audio-only communication.

III. Selection of E/M Levels

On an interim basis, office/outpatient E/M level selection when furnished via telehealth could be based on medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter. Any requirements regarding documentation of history and/or physical exam in the medical record were removed. CMS established that the times listed in the code descriptors were the most appropriate for the purpose of E/M level selection.

This policy only applied to office/outpatient visits furnished via Medicare telehealth, and only during the COVID-19 PHE.

IV. Radiation Oncology Treatment Management COVID-19 Flexibility Extended through December 31, 2024

During the COVID-19 PHE, telehealth flexibilities were broadened to include in-person, face-to-face interactions associated with radiation oncology on-treatment visits (OTVs) under CPT Code 77427, Radiation Treatment Management, 5 treatments, recognizing that practices needed flexibility to ensure that both care teams and patients were protected from exposure to the virus.

CPT Code 77427 was added to the Medicare Telehealth Services List for the duration of the PHE. It was set to be removed from the telehealth list at the end of the PHE, per the 2021 MPFS final rule, but due to extensions of the PHE, as well as CMS and Congressional action, it was extended to the end of 2023. Then, to align with the extension of other telehealth flexibilities, the telehealth flexibility for the OTV portion of 77427 was extended through December 31, 2024, in the 2024 MPFS final rule.

VI. Supervision Policies after COVID-19 Public Health Emergency

On an interim basis, CMS relaxed certain Medicare supervision policies to support radiation oncologists’ ability to continue treating patients during the PHE. Many of these flexibilities have been extended through the end of 2024. See below for additional information.

Freestanding Supervision Policy
Medicare policy requires adherence to “direct supervision” for radiation oncology services paid under the Physician Fee Schedule. “Direct supervision” requires that the physician be immediately available to provide assistance throughout the duration of the procedure. However, given the circumstances of the PHE, CMS stated that it recognized in some cases, the physical proximity of the physician might present an additional exposure risk and allowed for direct supervision via real-time, two-way audio/video technology. ASTRO ;interpreted the flexibility to apply to all radiation oncology services delivered in the freestanding setting for the duration of the PHE.

These flexibilities were extended through the end of 2023 via various Agency and Congressional action. However, CMS was concerned about an abrupt transition to its pre-PHE policy that defines direct supervision as requiring the physical presence of the supervising practitioner beginning after December 31, 2023, given that practitioners have established new patterns of practice during the PHE. Therefore, it extended virtual direct supervision flexibility through December 31, 2024.

Hospital Supervision Policy
CMS also adopted temporary flexibilities to diagnostic services provided in hospital outpatient settings, which have been extended through the end of 2024.

Effective January 1, 2020, CMS requires hospitals to adhere to general supervision for many therapeutic services. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. However, this change did not apply to radiation therapy image guidance services, which are designated by CMS as diagnostic services and are assigned supervision levels according to their CPT codes. For example, CMS requires direct supervision for CT Image Guidance (CPT 77014).

However, given the circumstances of the PHE, CMS recognized that hospitals should have the most flexibility possible to provide the services Medicare beneficiaries need. The Agency allowed for the direct supervision of hospital outpatient diagnostic services to be met through the virtual presence of the physician through audio/video real-time communications technology, when use of such technology was indicated to reduce exposure risks for the beneficiary or health care provider during the PHE.

ASTRO interpreted the revised policy to apply to both CT Image Guidance (CPT code 77014) and Stereoscopic X-Ray Guidance (CPT code 77421) for the duration of the PHE. In the 2024 HOPPS final rule, CMS extended this flexibility and will allow virtual direct supervision through the end of 2024 (not audio-only).

Finally, in the 2021 MPFS final rule, CMS finalized policy revisions related to the scope of practice for physician fee schedule services that would allow NPs, CNSs, PAs and CNMs to provide the appropriate level of supervision assigned to diagnostic tests, to the extent authorized under State law and scope of practice. In accordance with statute, these NPPs would be working either under physician supervision or in collaboration with a physician. According to CMS, this flexibility is designed to increase the capacity and availability of practitioners who can supervise diagnostic tests, which would alleviate some of the demand on physicians as the only source to perform this specific function. This provision is permanent and did not expire at the end of the PHE. ASTRO remains concerned regarding the impact this policy will have on patient safety.

VII. Hospital Services Accompanying a Professional Service Furnished via Telehealth

During the PHE, in certain circumstances, CMS allowed the hospital to bill and be paid an originating site facility fee for telehealth services provided when the clinician was in the hospital and the patient was at home. Now that the PHE has ended, in this situation, the billing practitioner should use a hospital place of service (POS) code along with modifier -95.

VIII. Guidance on Private Payer/Medicaid Coverage for Telehealth Services

Private payers and state Medicaid plans operate under their own payment policies and are not obligated to follow Medicare's policies (except for Medicare Advantage plans that are required to follow Medicare denial/appeal rules). Check with them directly for the most up-to-date guidance.

IX. HIPAA Compliance

During the PHE, health care providers, who must follow the HIPAA Privacy, Security, and Breach Notification Rules (HIPAA rules), used readily available remote communication technologies to provide telehealth services. These technologies may not have fully complied with HIPAA rules. The HHS Office for Civil Rights (OCR) announced on March 17, 2020, that it would not penalize health care providers for not following HIPAA rules when using remote technologies for telehealth during the PHE. This leniency applied to all telehealth, not just for COVID-19-related health issues.

On April 11, 2023, OCR announced that this leniency would end on May 11, 2023, with the conclusion of the COVID-19 PHE. OCR provided a 90-day transition period, from May 12, 2023, to August 9, 2023, for health care providers to adapt their operations to provide telehealth securely and in compliance with HIPAA rules. During this transition, OCR did not penalize health care providers acting in good faith while providing telehealth services that did not fully comply with HIPAA rules.

Beginning on August 10, 2023, the provision of telehealth services must comply with HIPAA rules. For additional information, visit the HIPAA Enforcement website.

DISCLAIMER

ASTRO Guidance on use of Telehealth during COVID-19 Public Health Emergency is based on information available from HHS and private payers. It is being provided for voluntary, educational use by health care providers during an urgent and evolving COVID-19 pandemic. The Guidance is based on information available at the time it was prepared. There may be new developments that are not reflected here and that may, over time, be a basis for ASTRO to revisit and update this Guidance. Before relying on any of the codes, information or opinions contained in this Guidance, users should verify correct code usage with the appropriate health care provider, legal counsel and/or contractor. The final decision for the coding of any procedure must be made by the physician, considering the regulations of insurance carriers and any local, state or federal laws that apply to the physician’s practice. The Guidance is provided on an “as-is” basis; users of the Guidance assume all responsibility and risk for any and all use. Neither ASTRO nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including but not limited to any claim for costs and legal fees, arising from the use of this Guidance or opinions provided by ASTRO in response to user inquiry.