COVID-19 Reimbursement

During the COVID-19 crisis, sensible reimbursement policies are essential to allow physicians and practices to continue providing preventive, acute, and chronic care for their patients, to provide care in a manner that keeps our health care workforce safe, and to protect physician practice viability.

Here's what you need to know about COVID-19 reimbursement:

New and updated coding guidance from CMS: CMS details several new Medicare fee-for-service policies in response to the COVID-10 pandemic, including guidance on the appropriate modifiers and place of service codes for billing telehealth services and waiving cost-sharing for COVID-19 testing-related services. See the guidance here.

Audio-only telehealth services: The Centers for Medicare & Medicaid Services has waived the interactive audio-video requirement for certain telehealth evaluation and management services, so now providers can bill for these services when provided by audio-only telephone, provided all other applicable requirements are met. CMS has updated the list of eligible codes on the Medicare telehealth services list and clearly marked which codes are eligible for audio-only. You can read the rule here and the press release here.

Payment parity for audio-only telephone codes: CMS has recognized the need to better support audio-only telephone services by increasing payments for telephone visits to match payments for office and outpatient visits. CMS has increased payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020. CMS has cross-walked payment rates for CPT codes 99212, 99213, and 99214 to 99441, 99442, and 99443. CMS is also finalizing on an interim basis and for the duration of the COVID-19 public health emergency the following work RVUs: 0.48 for CPT code 99441; 0.97 for CPT code 99442; and 1.50 for CPT code 99443. You can read the rule here and the press release here.

Gov. Jay Inslee's proclamation requires payment parity: The proclamation implements SB 5385, requiring telemedicine services to be paid for at parity with face-to-face services, immediately. This change applies to all state-regulated plans. However, this change is not applicable to certain self-insured/ERISA plans that are not regulated by the state. Gov. Inslee's proclamation is effective through Dec. 31. With provisions of Senate Bill 5385 requiring payment parity from state-regulated health plans taking effect on Jan. 1, telemedicine payment parity is now effectively permanent in Washington state.

Medicaid also paying at parity: Medicaid, including Medicaid managed care organizations and Medicaid fee-for-service, are both paying for telehealth, including services administered over the telephone, at parity.

Let the WSMA policy department help

Please reach out to policy@wsma.org with any questions on any if the information provided on this page or on using telehealth as a COVID-19 response.

COVID-19 Telehealth Coding and Reimbursement

Medicaid (Apple Health)

New and updated CMS coding guidance (June 2020)

The Washington State Health Care Authority has released guidance, including CPT codes, to help address your questions on billing Apple Health (Medicaid) fee-for-service programs and managed care organizations for services including telehealth: Apple Health (Medicaid) clinical policy and billing for COVID-19. (Updated May 1, 2020)

Note: The FAQ specifies that telemedicine needs to be delivered via HIPAA-compliant communications; however, the federal government announced that it has relaxed HIPAA rules for health care providers using telehealth in response to COVID-19. See COVID-19 Temporary Legal Changes.

Additional Medicaid telehealth reimbursement guidance and resources:

HCA information about COVID-19 webpage
HCA Apple Health (Medicaid) telemedicine & telehealth brief (Updated April 28, 2020)
HCA Apple Health, PEBB, and SEBB COVID-19 provider resources webpage
HCA Apple Health Eligibility and COVID-19 webinar and presentation slides (May 5, 2020)
Apple Health (Medicaid) telehealth policy - slide deck - recorded webinar (April 30, 2020)

Medicare

On April 30, 2020, CMS issued an interim final rule that builds on the previous regulatory waivers and flexibilities issued on March 17, 2020 and March 30, 2020. These temporary waivers and flexibilities remove barriers so health care systems and physicians can better respond to the COVID-19 pandemic.

The Provider Page (of the HHS Telehealth Toolkit for Providers and Your Patients) contains comprehensive information on the telehealth waivers and other flexibilities, including HIPAA, cost sharing, and more. It also provides information on billing and reimbursement, legal considerations, planning your telehealth workflow, and how to prepare your patients for telehealth.

Of note: The HHS Office of Inspector General notified physicians and other practitioners that they will not be subject to sanctions for reducing or waiving any cost-sharing obligations that beneficiaries may owe for telehealth services (March 17, 2020).

Additional Medicare telehealth reimbursement guidance and resources:

See all COVID-19 CMS waivers and flexibilities here

Second CMS waiver and rule change that further expands access to telehealth services, including raising audio-only telephone payments to match with office and outpatient rates, and waiving a requirement that certain evaluation and management (E/M) services delivered via telemedicine contain a video component. (April 30, 2020)
Expansion of the first telemedicine waiver and rule change that provided coverage for 80+ additional services furnished via telehealth, including audio-only. (March 30, 2020)
First CMS telemedicine waiver and rule change (March 17, 2020)

CMS COVID-19 Telehealth Policy Updates to Medicare Video (Updated May 1, 2020)
CMS COVID-19 Emergency Declaration Blanket Waivers for Healthcare Providers (updated April 30, 2020)
Medicare Fee-for-Service (FFS) Billing FAQ (Updated April 9, 2020)
CMS Telehealth Risk Adjustment FAQ on COVID-19 (April 27, 2020)
CMS guidance and reimbursement information regarding flexibilities specific to FQHCs and RHCs (Updated April 30, 2020)
CMS list of covered telehealth services

AMA CPT Reporting for COVID-19 Testing Flowchart
AMA special coding advice related to COVID-19 (outlines coding scenarios - in-person and telehealth - designed to help health care professionals apply best coding practices)
AMA CMS payment policies and regulatory flexibilities during COVID-19 webpage

Commercial insurers

The Washington State Office of the Insurance Commissioner issued an emergency order on March 5, 2020, indicating that a carrier cannot deny telehealth reimbursement for use of a non-traditionally HIPAA-compliant platform.

America's Health Insurance Plans has compiled this list of individual insurance carriers' response to the COVID-19 outbreak. While not all carriers operate in Washington state, the list details which are offering reimbursement and waivers for COVID-19-related treatment, including telehealth. (Updated regularly)

L&I

The Washington State Department of Labor and Industries has announced a temporary telehealth policy. This policy will allow physicians and health care providers to treat injured workers from their homes with the goal of supporting the containment of COVID-19. Read the policy in full. (March 10, 2020)

Uninsured

The U.S. Department of Health and Human Services, through the Health Resources and Services Administration, launched a new COVID-19 Uninsured Program Portal, allowing physicians and providers who have conducted COVID-19 testing or provided treatment for uninsured COVID-19 individuals on or after Feb. 4, 2020 to submit claims for reimbursement. Access the portal at COVIDUninsuredClaim.HRSA.gov. The reimbursement was established as part of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act.

Standard COVID-19 Coding and Reimbursement

Medicaid (Apple Health)

New and updated CMS coding guidance (June 2020)

The Washington State Health Care Authority (HCA) has released guidance to help address your questions on billing Medicaid (Apple Health) fee-for-service programs and managed care organizations - Apple Health (Medicaid) clinical policy and billing for COVID-19.(Updated May 1, 2020)

Additional Medicaid (Apple Health) reimbursement guidance and resources:

HCA information about COVID-19 webpage
HCA Apple Health behavioral health policy and billing during the COVID-19 pandemic (FAQ) (updated April 8, 2020)
HCA Apple Health, PEBB, and SEBB COVID-19 provider resources webpage
HCA Apple Health Eligibility and COVID-19 webinar and presentation slides (May 5, 2020)

CMS State Medicaid & CHIP COVID-19 FAQ
CMS COVID-19 state resources webpage

Medicare

Medicare has created this website to answer COVID-19-related questions.

Additional Medicare reimbursement guidance and resources:

HHS Office of Inspector General FAQs (PDF) details flexibilities for physicians to reduce or waive Medicare beneficiary cost-sharing

AMA CPT Reporting for COVID-19 Testing Flowchart
AMA special coding advice related to COVID-19 (outlines coding scenarios - in-person and telehealth - designed to help health care professionals apply best coding practices)
AMA CMS payment policies and regulatory flexibilities during COVID-19 webpage

Commercial insurers

Washington

The OIC waives copays, deductibles, and preauthorizations for COVID-19 testing and requires insurers that are regulated by the OIC must: allow a one-time early refill for prescription drugs; suspend prior authorization requirements for treatment or testing of COVID-19; and, if an insurer does not have enough medical providers in its network to provide testing and treatment for COVID-19, it must allow enrollees to be treated by another provider within a reasonable distance at no additional cost. Read the announcement and the OIC emergency order. (March 5, 2020)

National

Uninsured

Quality reporting programs

The Centers for Medicare & Medicaid Services is implementing policy exceptions and extensions for physicians, hospitals, and facilities participating in quality reporting programs, including MIPS and ACOs. Read the press release. (March 22, 2020)

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