| Last month in partnership with the National Consortium of Telehealth Resource Centers (NCTRC), the Center for Connected Health Policy (CCHP) held a webinar on federal telehealth policy for 2025. During the hour-long webinar, over 100 questions were asked, and due to such a high number, CCHP was unable to answer all the questions before the webinar concluded. As a telehealth resource center, CCHP is charged with providing one-to-one technical assistance and regularly fields questions from the public regarding telehealth policy. As a result, CCHP thought it would be helpful for our audience to have us answer some of the more frequently asked questions regarding current federal telehealth policy that we have received through the aforementioned channels in this week’s #TelehealthTuesday newsletter. Audio-Only When the Continuing Resolution passed in December 2024, it contained language that would extend the telehealth Medicare waivers. Specifically, HR 10545 extended the following for an additional three months, through March 31, 2025: Waiving geographic and specific site requirements Maintaining the list of eligible providers to use telehealth to provide services Continuing to allow Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to provide services via telehealth Delaying the requirement for in-person visits for mental health services taking place without the geographic and eligible site requirement (such as a doctor’s office or clinic) being metContinuing to allow services to be provided via audio-only Continuing to allow telehealth to be used to conduct the face-to-face encounter recertification for beneficiaries eligible for hospice care Extending the acute hospital at home programHowever, in November 2024 (prior to the passage of HR 10545), the Centers for Medicare and Medicaid Services (CMS) finalized their 2025 Physician Fee Schedule (PFS)policies, which also touched upon some of the same areas as the waiver extension policies. In particular, the topic of audio-only caused confusion as the Congressional action created the continued ability to use audio-only to deliver services and be reimbursed by Medicare through March 31, 2025, while the CMS PFS essentially sought to expand audio-only permanently (though the change is limited substantially by restrictions in statute, as discussed more below). Additionally, the final 2025 PFS eliminated certain audio-only codes that some providers may have been using in previous years, 99441-99443. In the CMS 2025 Medicare Telehealth Services List, these codes (99441-99443) were marked as “deleted” and unlike previous years, there was no longer a specific column on the eligible telehealth code list indicating which codes could be provided via audio-only. In an effort to gain some clarity on this, an inquiry was submitted to CMS regarding how providers were to bill for audio-only in 2025 given the three-month extension by Congress and lack of clarity in the fee schedule. The inquiry asked whether codes such as 99202-99215 may be used with an appropriate modifier. CMS responded stating that, while they cannot provide specific guidelines, the language that was submitted for clarification is correct. In other words, for audio-only: 99441-99443 are deletedCodes 99202-99215 can be used with the following modifiers to signify that the service was provided via audio-only:Modifier 93 for non-FQHC/RHC distant site providersModifier FQ when the service is provided by an FQHC/RHCThe initial inquiry sent into CMS mentioned only codes 99202-99215 as an example, and CMS went no further with their response in regards to what other codes may or may not be provided via that modality. As mentioned earlier, unlike in previous years, the 2025 eligible Telehealth Services list lacks the notation of which specific services may be provided via audio-only. This lack of notation could indicate that other eligible CPT/HCPCS codes, if the definition does not prevent audio-only from being used, may also be eligible to be provided via audio-only. At the time CMS was preparing and finalizing the 2025 PFS, the only information they had available to them was that the telehealth waivers would expire at the end of 2024 including the option to use audio-only to deliver services. The lack of indication on the eligible telehealth services list regarding which codes could be provided via audio-only would make sense from that perspective, because under permanent telehealth Medicare policy, the use of audio-only is limited (see below), and at the time the PFS was finalized, CMS had no information to indicate that permanent telehealth Medicare policy would not go back into effect again beginning January 1, 2025. However, CMS also proposed permanent expansions of audio-only in the 2025 PFS, which even if limited by statutory restrictions, shows a desire to maintain the availability of the modality when appropriate. Additionally, CCHP has received several questions regarding the status of audio-only should no other telehealth policy changes be made and the telehealth waivers are not extended beyond the new March 31, 2025 deadline. In current federal law, telehealth is noted as being provided via a telecommunication system, but no definition was provided as to what that term means, leaving CMS to define this term. Some years back, CMS added the word “interactive” before “telecommunications system”. In the 2025 PFS, CMS finalized the definition of “interactive telecommunication system” as: May also include two-way, real-time audio-only communication technology for any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system as defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication, but the patient is not capable of, or does not consent to, the use of video technology. This definition indicates a significant expansion of services that could be provided via audio-only under current Medicare telehealth policy, however, as noted from the above, two conditions must be met: For any telehealth service furnished to a beneficiary in their homeThe distant site physician or practitioner is technically capable of using an interactive telecommunications system as defined as a multimedia communications equipment that includes, at a minimum, audio and video equipment… but the patient is not capable of or does not consent to, the use of video technology. While the second requirement may not pose many issues, the first requirement that the service is furnished in the beneficiaries’ home does in fact create some limitations. Under statutory permanent Medicare telehealth policy, only substance use disorder (SUD) services, mental/behavioral health services (in some cases previous conditions must be met) and end stage renal disease services (ESRD) can be provided in the home. Therefore, while the definition change made by CMS does allow for more services to be provided via audio-only, without an additional extension of the Congressional Medicare telehealth waivers or a permanent elimination of the statutory geographic and site limitations around telehealth reimbursement, the expansion remains restricted. For more information on the 2025 PFS, you can read the CCHP fact sheet, or access the entry in the Federal Register. For more information and background on Medicare telehealth billing rules, please view CCHP’s Federal information and Medicare Billing Guide. Prior In-Person Visit for Mental Health Services In their current extension of the telehealth waivers, Congress also delayed implementation of the requirement to have a prior in-person visit before mental/behavioral health services via telehealth are provided to a patient in their home, and without meeting the geographic requirement or qualifying for one of the currently existing narrow exceptions. Under current permanent Medicare telehealth policy, services that can take place in the home, and without having the geographic requirement apply, include ESRD and treatment for SUD and a co-occurring mental health condition (additionally, the geographic limitation does not apply to treatment for stroke). If the mental health service does not fall into one of the exceptions, according to Social Security Act, Sec. 1834(m) (Title 42, Sec. 1395m) and the CY 2022 Physician Fee Schedule, CMS, p. 63, the in-person requirements will be as follows: “There must be an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient’s medical record. CMS will allow a clinician’s colleague in the same subspecialty in the same group to furnish the in-person, non-telehealth service to the beneficiary if the original practitioner is unavailable.” Should no additional extension or changes to this policy be made, beginning on April 1, 2025 under permanent Medicare telehealth policy, there will be a two coverage track available for mental/behavioral health via telehealth in Medicare for the remainder of 2025 – one track will require providers to meet the geographic/site requirements and the other track will require providers to instead meet the in-person requirements. If waivers are not further extended, readers can check whether an address qualifies under CMS’ definition of a rural HPSA to meet the geographic requirement, via the locator toolthat has been provided by the agency. For FQHCs/RHCs providing mental health services via telehealth, according to the CY 2025 Physician Fee Schedule (p. 879), the in-person requirements are waived through January 1, 2026. The reason for this discrepancy is due to the FQHC/RHC in-person requirements initially originating from CMS regulations, rather than federal statute enacted by Congress. CCHP has received several questions regarding how providers would document or indicate that there was a previous in-person visit on a claim, or if CMS would automatically be able to identify this from prior claim history. CCHP has no further information on this at this time. If and when this in-person requirement goes into effect, it is hoped that CMS will provide greater clarification on the proper documentation process. CCHP has also received some questions regarding general telehealth in-person requirements. It is important to clarify that the policy requirement discussed above is specific to Medicare reimbursement. It is possible, however, that states have enacted their own in-person visit requirements (these can be searched by topic and state utilizing CCHP’s Policy Finder tool). There are also in-person prescribing requirements specific to controlled substances found in federal law (see more information regarding these requirements below) that should be taken into account. Should We Bill Medicare the 98000 New Telehealth Codes? No, not for Medicare. In the 2025 PFS, CMS declined to adopt the 98000-98015 Telehealth Evaluation and Management (E/M) Services CPT Codes recently created by the American Medical Association (AMA) CPT Editorial Board, with one exception. CMS did adopt 98016, noting the similarities with G2012, which it will now replace. However, G2012 was not a telehealth code in Medicare, but rather a communication technology-based service (CTBS) code, and thus not subject to the telehealth statutory requirements. The remaining 98000 codes that the AMA proposed were not adopted by CMS for Medicare this year. Within the PFS discussion of the codes, CMS noted other already existing codes (that can be billed for both in-person and/or telehealth) may be more suitable, and Medicare reimburses at parity for those services, however the AMA codes would necessitate the creation of a new rate methodology. If you’d like to read more about this Medicare consideration of the AMA codes you can read CCHP’s 2025 PFS Fact Sheet and page 234 of the 2025 PFS. For Medicaid and private payers, coverage of the new AMA telemedicine codes (98000-98016) will vary. Through our technical assistance services, CCHP has heard that at least one state Medicaid program, Arizona Medicaid, has adopted the 98000 code-set for 2025. We are uncertain if any other Medicaid program has done the same, but this adoption has already raised some questions and concerns, particularly around how to bill for dual eligibles. Dual eligibles are covered by both Medicare and Medicaid with the Medicare program paying first for the eligible services and the state Medicaid program covering the remainder. However, complication exists because the two programs are not using the same codes for the same services. At this point in time, CCHP does not have absolute confirmation on how this scenario should be handled, but without further information, it would likely mean that the practitioner would submit to Medicare first, coded in the manner in which they will accept the claim, and then anything that is refused, would be resubmitted to the Medicaid program with the services then recoded with the applicable 98000 codes. It is important to note, however, that we do not currently have absolute confirmation that this is the process that should be employed. We will continue to attempt to gain confirmation/clarity on this process. Furthermore, it was noted that Arizona Medicaid was paying less for the 98000 codes than what their typical CPT counterparts would be reimbursed, despite the presence of telehealth payment parity laws in Arizona (see private payer law and AHCCS Policy Manual). It should be highlighted that requirements for telehealth payment parity usually state that reimbursement must be the same amount for services that would have been provided in-person. By using the 98000 codes, which were created specifically for telehealth, there is no longer an in-person counterpart equivalent. When providers previously billed for telehealth before the 98000 codes were available, they were using CPT/HCPCS codes used for in-person services, therefore, necessitating payment parity. However, the 98000 codes currently have no in-person counterpart. This loophole allows the Medicaid program to develop their own fee schedule amount for reimbursement of that code. This is similar to what we have seen with Communications Technology Based Services (CTBS) codes in Medicare. It is unknown whether other Medicaid programs and private payers may follow this lead and adopt the new AMA codes, either in addition to, or in place of, other codes currently billed for telehealth services and reimbursed at parity with in-person services. Using Telehealth to Prescribe Controlled Substances In November 2024, the Drug Enforcement Administration (DEA) extended to the end of 2025 the waivers for prescribing a controlled substance via telehealth. Through the end of this calendar year, providers will be able to prescribe a controlled substance via telehealth without fitting into one of the currently existing narrow exceptions for telehealth or having conducted a prior in-person exam of the patient. However, last month the DEA published three separate items in the Federal Register: Final Rule – Expansion of Buprenorphine Treatment via Telemedicine EncounterFinal Rule – Continuity of Care via Telemedicine for Veterans Affairs PatientsNotice of Proposed Rulemaking (NPRM) – Special Registrations for Telemedicine and Limited State Telemedicine Registrations The first two listed above are final rules and are now permanent policy. The final item, NPRM on Special Registrations, is only proposed at this time and is open for public comment (the comment submission deadline is March 18, 2025). The CCHP January 21, 2025 newsletter edition does provide more information on this topic, but given the amount of specificity the DEA went into for the proposal, every single detail could not be captured in one newsletter. If this topic is of interest or importance to you, CCHP recommends that you read the entire NPRM. Meanwhile, the DEA in-person requirement waiver remains in effect until the end of 2025. However, it is possible that state professional requirements around prescribing may also apply – please utilize CCHP’s Policy Finder tool to search by state and topic for additional information. It is important to highlight that the latest DEA waiver may also encompass an exception to the need for separate registration in each state (see section here referencing the 2020 DEA Registrant Letter regarding State Reciprocity), although it is not entirely explicit in the FR notice and information elsewhere on the DEA website appears to not have been updated consistent with the waiver/letter, as the DEA FAQs indicate that separate registration is still required. Some providers have also asked whether there is a time limit on when the required in-person visit must have taken place to qualify to prescribe controlled substances after the extension expires (without having to qualify under the other narrow exceptions in law, finalized regulations mentioned above, or proposed telemedicine registry). To CCHP’s knowledge, the DEA has not specified a timeframe, meaning any prior visit with a DEA-registered provider may satisfy the requirement. Billing & Licensure While CCHP has historically always received a large number of questions regarding licensure and cross-state practice via telehealth, lately we have begun to see those policies being conflated with billing policies. For instance, there has been some confusion related to Medicare’s waiver of “geographic limitations” applying to cross-state practice, which is not the case – that policy waives requirements around Medicare reimbursement being limited to patients’ location in rural areas at the time of the telehealth visit and certain healthcare settings. The federal Medicare waivers do not address licensure, which is governed by state law, not federal law (though Medicare does generally require providers to abide by state practice laws as well). Additionally, if a provider is licensed in the same state the patient is located within during a telehealth visit, that typically means they will meet state licensure requirements overseen by the board that licenses the profession in that state. Billing rules, however, are regulated separate from licensing and provider practice requirements, and unless there is a specific prohibition in state law that prevents insurers from denying claims from providers located out-of-state (even if licensed in-state), it is possible that payers can create their own locational restrictions specific to billing that result in claim denials in these instances. What’s Changed for 2025 CCHP has received numerous questions trying to determine if the ability to provide telehealth in general has changed in 2025. The aforementioned policies primarily discussed in this newsletter are specific to Medicare and federal telehealth reimbursement and prescribing rules and do not limit the ability to provide telehealth generally. Given the Congressional extension regarding Medicare, and the DEA extension regarding prescribing, federal telehealth billing and prescribing rules have largely not changed at this time and can continue as they have been occurring since the onset of the COVID-19 pandemic through this first quarter of 2025. However, for Medicare that may change beginning April 1, 2025. As of the writing of this newsletter, there has not been any information regarding the likelihood of an additional Medicare telehealth waiver, and the latest deadline is quickly approaching (March 31, 2025). CCHP will provide updates on future Congressional actions and federal rules applicable to telehealth as they become available. Generally speaking, the ability to provide services via telehealth and receive reimbursement will vary based upon a number of different policies and factors. The basic ability to provide services via telehealth is mostly dictated by the professional licensing requirements within the state the provider practices, as well as those within the state the patient is located in, if the provider sees patients out-of-state (professional requirements can be searched using CCHP’s Policy Finder tool). The ability to receive reimbursement for services provided via telehealth, rather, will vary by payer depending on the different types of insurance a provider accepts. The above extension means Medicare billing for telehealth will primarily remain the same, at least until March 31, 2025, but it is possible another extension may be passed by Congress prior to that date. While other payer policies are less up in the air at this time, it is always possible that state Medicaid programs and private payers could adopt changes in the future. Medicaid policies can be searched by state and topic using CCHP’s Policy Finder tool, as well as state private payer laws, however private payer policies vary widely and CCHP recommends contacting them directly for specific telehealth coverage rules and any recent updates. Today, we addressed just a handful of the most commonly asked questions we receive. If you have a telehealth policy question related to your specific situation, or are simply seeking further clarity on these areas, please feel free to send us a note! You can submit your questions via our online contact form, or by emailing us at info@cchpca.org. |
Source: Center for Connected Health Policy, personal communication, February 4, 2025
