ModifiedWellCarePolicy CMS-1744-IFC
Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
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Interim final rule providing temporary regulatory and payment flexibilities for Medicare and certain Medicaid provisions during the COVID-19 Public Health Emergency, affecting Medicare beneficiaries, physicians, practitioners, providers, laboratories, and related programs.
Policy Summary
PayerWellCare
PolicyMedicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
Policy CodePolicy CMS-1744-IFC
Change TypeInterim final rule — multiple temporary PHE flexibilities
Effective DateMar 1, 2020
Last ReviewMar 24, 2020
Next Review DateN/A
Key ActionMedicare will pay for telehealth services furnished to beneficiaries located anywhere in the country, including in a patient's home, under section 1135 waiver authority beginning March 6, 2020.
SourceLink
POLICY UPDATE CHANGES
Temporary expansion of Medicare telehealth coverage to allow payment for telehealth services furnished to beneficiaries located anywhere in the country, including in their homes, beginning March 6, 2020, under section 1135 waiver authority.
Modification of originating site facility fee and site-of-service payment assumptions so that telehealth services furnished during the PHE may be paid at rates reflecting non-facility (office) resources when appropriate.
Provision of specimen collection fees for independent laboratories collecting specimens from homebound or inpatient (non-hospital) beneficiaries for COVID-19 testing.
Interim expansion of ambulance destination coverage under Medicare Part B and programmatic adjustments to several CMS models and quality programs (MDPP, CJR, Part C/D Star Ratings) to account for PHE disruptions.
During the PHE, CMS will instruct practitioners to report the place of service (POS) code that would have been reported had the service been furnished in person and to append modifier 95 on telehealth claim lines so payment reflects the rate (facility or non-facility) that would have applied if furnished in person.
March 1, 2020applicability date
Mar 6, 2020telehealth waiver start
2 codesspecimen fees
$23.46/$25.46specimen fee amount
Mar 1, 2020G0071 expansion
Multipleprograms affected
PHE Coverage Criteria and Interim Rules
inv-01: PHE coverage flexibilities and payment changes
Temporary coverage expansions and payment rule changes during the COVID-19 Public Health Emergency — covered when interim PHE conditions are met:
Medicare telehealth payment and coverage flexibilities apply only for dates of service during the declared Public Health Emergency (PHE) as defined in §400.200.
CMS will pay for telehealth services furnished to beneficiaries located anywhere in the country, including in the beneficiary's home, under section 1135 waiver authority (effective March 6, 2020).
When telehealth is furnished under the section 1135 waiver to locations not identified as statutory originating sites, no originating site facility fee is paid; providers should report the place-of-service (POS) that would have been reported had the service been furnished in person and append modifier 95 to telehealth claim lines so payment reflects the rate that would have applied if furnished in person (facility vs non-facility determination preserved for POS 02 if chosen).
Interim additions and frequency/payment changes
- On an interim, PHE-only basis CMS added numerous Category 2 services (E/M across settings, observation, hospital, nursing facility, critical care, domiciliary, home visits, therapy, etc.) to the Medicare telehealth services list for dates of service beginning March 1, 2020 through the end of the PHE.
- Frequency limitations on subsequent inpatient visits, subsequent nursing facility visits, and critical care telehealth consultations are removed for the duration of the PHE.
- CPT code 77427 (radiation treatment management, 5 treatments) is included on the telehealth list so the weekly face-to-face component may be furnished via telehealth during the PHE.
Telehealth practitioner and therapy notes
- Therapy service CPT codes (PT/OT/SLP and related codes) were added to the telehealth list on a Category 2 basis for the duration of the PHE; statutory distant-site practitioner limitations remain (PT/OT/SLP not in the statutory distant site list) so payment when furnished by those therapists remains subject to statutory practitioner rules.
- Non-face-to-face portions of certain services remain not classified as telehealth under section 1834(m); additions do not change statutory coverage/payment scope beyond the interim flexibilities described.
Supervision and CTBS flexibilities
- Direct supervision may be satisfied via real-time interactive audio/video telecommunications during the PHE when indicated to reduce exposure risk; this change affects how supervision presence is met but does not change benefit scope or payment rules.
- Communication Technology-Based Services (CTBS) such as G2010, G2012, G2061–G2063 and online E/M codes (99421–99423) may be furnished to new and established patients during the PHE; beneficiary consent may be obtained at time of service and may be documented by auxiliary staff under general supervision.
Home health, hospice and RHC/FQHC operational criteria
- For HHAs the plan of care must include any use of remote patient monitoring or services furnished via telecommunications and describe how technology achieves plan goals; such technology cannot substitute for ordered in-person home visits and cannot be counted as a home visit for eligibility/payment purposes; HHAs may report telecommunications costs as allowable A&G costs on an interim basis.
- Hospices may furnish routine home care services via telecommunications during the PHE when feasible and appropriate; use of technology must be included on the plan of care and there is no additional per-diem payment (telecom costs reported as other patient care services on Worksheet A).
- RHCs/FQHCs: HCPCS G0071 (virtual communication services, 5+ minutes) payment rate is expanded to include CPT 99421–99423 effective March 1, 2020 during the PHE; face-to-face requirements waived and G0071 may be furnished to new patients during the PHE with consent obtained at time of service or by staff under general supervision.
Specimen collection and laboratory travel
- Independent laboratories may bill new Level II HCPCS codes G2023 (specimen collection, any source) and G2024 (specimen collection for SNF/HHA-related) for a nominal specimen collection fee during the PHE ($23.46 general; $25.46 SNF/HHA), when collection requires trained laboratory personnel; self-collected specimens are not eligible for the fee.
- For specimen collection/travel allowances, 'homebound' means it is medically contraindicated for the beneficiary to leave home (self-quarantine alone is insufficient without clinical contraindication); determinations must be individualized.
RPM and Telephone E/M
- Remote physiologic monitoring (RPM) services may be furnished to new and established patients during the PHE; verbal consent may be obtained once annually and documented at time of service.
Inpatient/resident and hospital under-arrangements flexibilities
- During the PHE hospitals may treat inpatients outside the hospital under arrangements and those routine services provided under arrangements to inpatients admitted during the PHE (beginning March 1, 2020 applicability) may be considered furnished by the hospital provided the hospital exercises sufficient control and responsibility over use of hospital resources.
- Teaching physician presence requirement may be met via interactive telecommunications for many services during the PHE (excluding certain surgical/high-risk/endoscopic/anesthesia services); residents may furnish certain separately billable non-GME inpatient services under stated conditions (identifiable services, state licensure, not part of approved GME) and teaching physician supervision via interactive telecommunications may support payment under PFS.
NCD/LCD and other enforcement discretion
- Face-to-face or in-person encounter requirements in NCDs/LCDs for evaluations, assessments, certifications, and similar requirements will not be enforced during the PHE except where statutory face-to-face mandates apply (e.g., PMD), and clinical indication enforcement (e.g., certain respiratory, infusion pump, home anticoagulation policies) is relaxed for the PHE.
- For nonsurgical extended duration therapeutic services Medicare permits general supervision for the entire service during the PHE where previously direct supervision at initiation was required.
Quality program and reporting adjustments
- HEDIS and CAHPS data collection/submission requirements for the 2019 measurement year used in 2021 Star Ratings are suspended; CMS will use prior-year HEDIS (2018 performance) and CAHPS (March–May 2019) data for 2021 where needed and will not reduce measures to 1 star for failure to report 2020 HEDIS/CAHPS; CMS may substitute 2020 measure scores/stars for 2021 where systemic data quality issues exist or if CMS capabilities are extraordinarily compromised (limited to the PHE).
- Shared Savings Program extreme and uncontrollable circumstances policy and MIPS reweighting deadlines are adjusted to provide relief to ACOs and clinicians affected by the PHE (e.g., extended MIPS deadline to April 30, 2020; removal of restriction tied to extended reporting periods for ACO relief).
All temporary flexibilities, additions, and enforcement discretion described above are limited to the duration of the declared Public Health Emergency and will be rescinded when the PHE ends unless otherwise codified or extended.
inv-02: Interim PHE telehealth coverage rules
Interim coverage determinations during the COVID-19 PHE — covered when ALL of the following interim billing and reporting instructions are followed:
Telehealth services furnished under the section 1135 waiver may be furnished to beneficiaries located anywhere, including the home, for dates of service during the PHE.
When telehealth is furnished under the 1135 waiver to locations not listed as permissible originating sites, no originating site facility fee will be paid.
Report the place-of-service (POS) code that would have been reported had the service been furnished in person; append CPT telehealth modifier 95 to telehealth claim lines so payment reflects the rate that would have applied if furnished in person; practitioners may continue to bill POS 02 to receive facility payment rate if they choose.
Interim Category 2 additions to the telehealth services list (effective March 1, 2020 through end of PHE) include numerous E/M, observation, hospital, nursing facility, critical care, domiciliary, and home visit CPT codes to address access and exposure concerns.
Previously established frequency limits for subsequent inpatient visits, subsequent nursing facility visits, and critical care consults furnished via telehealth are removed for the duration of the PHE; billing should be supported by clinical documentation.
CMS will exercise enforcement discretion in select areas (for example ESRD required face-to-face vascular access exam and CTBS established-patient requirement) as described in the IFC; review may not be conducted to confirm face-to-face status for certain ESRD visits during the PHE.
Definition of interactive telecommunications is clarified for the PHE to explicitly allow multimedia audio/video two-way real-time technology; HHS OCR exercise of enforcement discretion for HIPAA penalties applies to good-faith use of everyday technologies during the PHE.
inv-03: Telehealth coverage criteria during COVID-19 PHE
Interim telehealth coverage stance for the duration of the PHE — allowed when clinically appropriate and documented:
Therapy services (listed CPT PT/OT/SLP codes) are added to the Medicare telehealth list on a Category 2 interim basis during the PHE; practitioners must observe statutory practitioner billing rules (statutory distant site practitioner list excludes PT/OT/SLP for independent telehealth billing).
CPT 77427 (radiation treatment management, 5 treatments) is included to permit the weekly face-to-face visit component to be furnished via telehealth during the PHE when the clinician judges telehealth appropriate.
Frequency restrictions for subsequent inpatient visit codes (e.g., 99231–99233) and subsequent nursing facility visit codes are removed for the duration of the PHE; billing must be clinically justified and documented.
Critical care consultation telehealth limitations (previously limited to once per day) are removed for the duration of the PHE to permit clinically appropriate use of telehealth consultations more frequently when indicated.
ESRD monthly capitation 'hands-on' vascular access examinations and certain ESRD face-to-face visit requirements may be furnished via telehealth during the PHE; CMS will not review whether those visits were face-to-face for services furnished during the PHE.
inv-04: PHE telehealth/CTBS/supervision criteria
Interim coverage and enforcement discretion applied for the duration of the PHE — conditions and supervision/CTBS rules:
Frequency limitations on subsequent inpatient and subsequent nursing facility telehealth visits and once-per-day restriction on critical care telehealth consultations are removed for the duration of the PHE.
CMS will not conduct review to confirm face-to-face provision of certain ESRD-related required visits furnished during the PHE when furnished via telehealth; enforcement discretion applies.
CTBS (including G2010, G2012, G2061–G2063, and 99421–99423) may be furnished to new and established patients during the PHE; beneficiary consent may be obtained at time of service and documented by auxiliary staff under general supervision.
Direct supervision may be satisfied via real-time interactive audio/video telecommunications during the PHE when indicated to reduce exposure risks; this modifies the manner of satisfying supervision requirements but does not change payment coverage scope.
inv-05: Telecommunications and home health/hospice usage (interim)
Interim operational stance for home health and hospice during the PHE — permitted when plan of care and documentation requirements are met:
Home health agencies (HHAs) may use remote patient monitoring and other telecommunications to augment in-person care during the PHE, provided the use is included on the home health plan of care, tied to patient-specific goals and outcomes, and does not substitute for ordered in-person visits or count as home visits for eligibility or payment.
The inclusion of technology on the home health plan of care must describe how technology will help achieve plan goals; HHAs may report telecommunications costs as allowable administrative and general (A&G) costs on an interim basis using specified subscripts.
Hospices may provide routine home care services via telecommunications during the PHE when feasible and appropriate; technology use must be included on the plan of care and no additional per-diem payment is made for technology (costs reportable on Worksheet A line 46 or subscript and identified as 'PHE for COVID-19').
Face-to-face hospice recertification encounters that are solely administrative may be conducted via two-way, real-time audio-video telecommunications during the PHE; these encounters are administrative and not separately billable.
inv-06: Telehealth/Telecommunications PHE criteria
Interim PHE policies permitting telehealth/telecommunications in specific Medicare settings — requirements for documentation and billing:
IRF physician face-to-face supervision visits (minimum 3 days/week) may be conducted via telehealth during the PHE and the post-admission physician evaluation requirement is suspended for the duration of the PHE; deviations from usual therapy standards due to PHE-related staffing impacts should be documented in the medical record.
RHCs/FQHCs: HCPCS G0071 (virtual communication services) payment expanded to include CPT 99421–99423 effective March 1, 2020 for the duration of the PHE; G0071 payment rate is the average of national non-facility rates for G2012, G2010, 99421, 99422, and 99423; face-to-face requirements are waived and these services may be furnished to new patients during the PHE with consent obtained at time of service or by staff under general supervision.
For visiting nurse services, for the duration of the PHE, any area typically served by an RHC or included in an FQHC service area plan is deemed to have an HHA shortage (no request required); RHCs/FQHCs must check HETS to ensure patient is not under active home health plan of care and avoid overlapping 30-day home health periods.
inv-07: PHE coverage criteria
Interim coverage criteria and flexibilities during the PHE — specimen collection, G0071, and related provisions:
G0071 services may be furnished to new patients not seen within the previous 12 months during the PHE; consent may be obtained at time of service or by staff under general supervision before billing.
Independent laboratories must bill HCPCS G2023 (specimen collection, any source) or G2024 (specimen collection for SNF/HHA-related) for a nominal specimen collection fee during the PHE (generally $23.46; $25.46 for SNF/HHA), when collection requires trained laboratory personnel; travel allowance billed via P9603/P9604; electronic mileage logs acceptable if producible to MACs.
RHC/FQHC areas are deemed to have HHA shortages during the PHE enabling expanded visiting nurse services as described; providers must avoid overlap with active home health plans of care.
inv-08: PHE coverage criteria
Coverage and payment criteria applicable during the PHE — specimen collection, teaching physician/resident and related rules:
Specimen collection for SARS-CoV-2 testing billed with G2023 or G2024 is payable a nominal fee during the PHE when collection is performed by trained personnel; fees approximately $23.46 (general) and $25.46 (SNF/HHA).
Homebound for purposes of specimen collection/travel allowance means medically contraindicated to leave home; self-quarantine alone is insufficient without physician determination based on individual assessment.
Teaching physician presence requirement may be met via interactive telecommunications (real-time audio/video) for many services during the PHE except for certain surgical/high-risk/endoscopic/anesthesia services that still require physical presence; residents' non-GME inpatient services may be separately billable under PFS if conditions are met (identifiable services, full state licensure, not part of approved GME).
inv-09: PHE temporary coverage and operational criteria
During the PHE the following temporary coverage and operational criteria apply to RPM, telephone E/M, MDPP, CJR, and psychiatric documentation:
RPM services may be furnished to new and established patients during the PHE; verbal consent may be obtained once annually and documented at time of service.
Telephone E/M CPT codes 98966–98968 and 99441–99443 are payable separately on an interim basis for the duration of the PHE with specified work RVUs and direct PE inputs (work RVUs: 0.25/0.50/0.75) and 3 minutes post-service RN/LPN/MTA input; enforcement discretion permits furnishing to new patients.
MDPP suppliers with virtual capability may provide expanded virtual make-up sessions subject to specified caps (e.g., up to 15 weekly during core, 6 monthly during core maintenance, 12 monthly during ongoing maintenance) and may deliver virtual MDPP sessions during the emergency period; suppliers should not start new cohorts in affected geographic areas during the PHE.
CJR performance year adjustments include financial safeguards capping actual episode payments at the target price for admissions within 30 days before or during the emergency period to protect participant hospitals.
Psychiatric hospitals: deleted term 'licensed independent practitioner(s)' to permit NPPs/APPs (PAs, NPs, CNSs) to document progress notes consistent with State law and hospital policy; estimated operational savings from documentation time reallocation are noted.
inv-10: PHE coverage flexibilities
Temporary enforcement discretion and coverage flexibility during the PHE — applies when the PHE is in effect:
Face-to-face or in-person encounter requirements in NCDs/LCDs for evaluations, assessments, certifications, or similar services will not be enforced during the PHE, except where statutory requirements (e.g., PMD) apply.
Clinical indications for certain respiratory, home anticoagulation management, and infusion pump NCDs/LCDs will not be enforced during the PHE to allow care in alternative settings when clinically appropriate.
Office/outpatient E/M level selection for telehealth during the PHE may be based on medical decision making or total time on the day of the encounter; history/physical documentation requirements are relaxed for these telehealth services during the PHE.
Shared Savings Program extreme and uncontrollable circumstances policy and MIPS automatic policy applications are expanded/adjusted to provide relief for quality reporting when disasters occur during extended reporting periods; MIPS clinicians may apply for reweighting with extended deadlines.
Hospitals may claim IME/DGME when residents perform patient-care activities at home or in patient homes if hospital pays salary/fringe and supervision requirements are met during the emergency.
inv-11: Star Ratings substitution and reporting criteria during COVID-19 PHE
Star Ratings substitution, reporting, and methodological adjustments during the PHE — used to calculate 2021/2022 ratings when PHE conditions affect data availability:
For 2021 Star Ratings, HEDIS measures will use data from the 2018 performance period and CAHPS measures will use survey data collected March–May 2019; carry forward 2020 measure-level improvement change scores for HEDIS/CAHPS measures in 2021 improvement calculations.
CMS will not reduce HEDIS or CAHPS measures to 1 star for failure to report 2020 HEDIS/CAHPS data for the 2021 Star Ratings.
Contingency substitution
- If there is a systemic data quality issue for all plans for any non-HEDIS/non-CAHPS measures due to the PHE, CMS may substitute 2020 measure scores/stars for the 2021 calculations for those measures.
- If CMS capabilities are extraordinarily compromised, CMS may use the 2020 Star Ratings as the 2021 Star Ratings (authority limited to the COVID-19 PHE).
For 2022 Star Ratings, methodology changes include expanded hold-harmless for the Part C and D improvement measure for 2022 only and delayed guardrail application allowing larger cut point changes beginning with 2023 due to PHE impacts.
inv-12: PHE-era coverage and rating adjustments
Key coverage and rating policy criteria affected during the PHE — operational rules that apply while PHE is in effect:
CMS may substitute 2020 measure scores/stars for 2021 calculations when systemic data quality issues affect all plans due to the PHE; this substitution authority is limited to the PHE.
For the 2022 Star Ratings, HEDIS and CAHPS data submissions are expected as usual but specific hold-harmless and methodological adjustments apply for 2022 only to reduce negative impacts from the PHE.
During the PHE, Medicare will expand covered ambulance destinations (interim §410.40(f)(5)) to include any destination equipped to treat the patient's condition consistent with state/local EMS protocols; medical necessity documentation still required.
Medicaid home health ordering authority is temporarily expanded to permit licensed practitioners (e.g., NPs, PAs) to order home health services within scope of practice during the PHE as provided in §440.70 amendments.
inv-13: Inpatient services furnished under arrangements during PHE
Temporary coverage/payment stance for inpatient services furnished under arrangements during the PHE — conditions for hospital responsibility:
Effective for discharges of patients admitted during the PHE beginning March 1, 2020, routine inpatient services provided under arrangements outside the hospital may be considered furnished by the hospital for Medicare payment purposes if the hospital continues to exercise sufficient control and responsibility over the use of hospital resources.
Hospitals must retain sufficient control and responsibility over resources when furnishing services under arrangements and should not provide services outside the hospital under arrangements if they cannot meet that control/responsibility requirement.
inv-14: MDPP PHE flexibilities
MDPP temporary flexibilities during the PHE — allowed for beneficiaries enrolled during the emergency period:
MDPP suppliers with active cohorts may deliver MDPP sessions virtually during the PHE; new cohort starts are suspended in affected areas for the duration of the PHE.
Virtual make-up sessions limits are modified during the emergency: up to 15 weekly during core, up to 6 monthly during core maintenance interval, and up to 12 monthly during ongoing maintenance; flexibilities end when PHE ends.
Certain MDPP beneficiaries receiving services during the emergency period may be permitted to obtain the MDPP set of services more than once for the limited purpose of pausing/resuming services and maintaining eligibility due to PHE interruptions.
Suppliers must adhere to CDC DPRP standards and the CDC-approved curriculum where virtual delivery is used and must observe the retained requirement that the first core-session body weight be measured in-person (waiver limited as specified).
inv-15: ACO quality reporting and relief
ACO and quality reporting relief during the PHE — conditions for applying extreme and uncontrollable circumstances policies:
Extend MIPS 2019 data submission deadline (example: extended to April 30, 2020) and align Shared Savings Program timing with MIPS; eligible clinicians may apply for reweighting based on extreme and uncontrollable circumstances with extended deadlines.
Revise the Shared Savings Program extreme and uncontrollable circumstances policy to allow relief when disasters occur during an extended quality reporting period so ACOs unable to report quality for 2019 by the extended deadline may receive relief.
Estimated financial impacts noted (e.g., approximate range and affected ACO counts) and CMS will apply policy consistent with PHE limitations and extensions.
inv-16: Psychiatric hospital progress note documentation
Psychiatric hospital documentation policy change during the PHE — operational criteria:
Remove the term 'licensed independent practitioner(s)' in psychiatric hospital medical record requirements to permit NPPs/APPs (PAs, NPs, CNSs, psychologists as appropriate) to document progress notes in accordance with State law, scope-of-practice, and hospital policy.
Hospitals should document implementation consistent with State law and hospital policy; estimated operational savings from shifting portions of progress-note documentation time to NPPs/APPs are provided in the IFC analysis.
Codes, Rates, and Billing Keys
Telehealth coding guidanceCPT
| Telehealth services are reported using existing CPT codes that describe face-to-face services when furnished via real-time audio/video communication. |
Interim Category 2 telehealth additionsCPTCovered
| 99281-99285 | Emergency department E/M visit codes |
| 99217-99220, 99224-99226, 99234-99236 | Observation care and observation discharge day management codes |
| 99221-99223, 99238-99239 | Initial hospital care and hospital discharge day management codes |
| 99304-99306, 99315-99316 | Initial nursing facility visits and nursing facility discharge day management codes |
| 99291-99292 | Critical care services codes |
| 99327-99328, 99334-99337 | Domiciliary/rest home E/M codes |
| 99341-99343 | Home visit E/M codes |
Home visit E/M CPT codesCPT
| 99341 | Home visit for evaluation and management of a new patient, problem focused history/exam; straightforward MDM; typically 20 minutes |
| 99342 | Home visit for a new patient; expanded problem focused; low complexity MDM; typically 30 minutes |
| 99343 | Home visit for a new patient; detailed history/exam; moderate complexity MDM; typically 45 minutes |
| 99344 | Home visit for a new patient; comprehensive history/exam; moderate complexity MDM; typically 60 minutes |
| 99345 | Home visit for a new patient; comprehensive history/exam; high complexity MDM; typically 75 minutes |
| 99347 | Home visit for an established patient; problem focused; straightforward MDM; typically 15 minutes |
| 99348 | Home visit for an established patient; expanded problem focused; low complexity MDM; typically 25 minutes |
| 99349 | Home visit for an established patient; detailed; moderate complexity MDM; typically 40 minutes |
| 99350 | Home visit for an established patient; comprehensive; moderate to high complexity MDM; typically 60 minutes |
Therapy and speech-language CPT codes added/clarifiedCPT
| 97161 | Physical therapy evaluation: low complexity (typically 20 minutes) |
| 97162 | Physical therapy evaluation: moderate complexity (typically 30 minutes) |
| 97163 | Physical therapy evaluation: high complexity (typically 45 minutes) |
| 97164 | Physical therapy re-evaluation (typically 20 minutes) |
| 97165 | Occupational therapy evaluation: low complexity (typically 30 minutes) |
| 97166 | Occupational therapy evaluation: moderate complexity (typically 45 minutes) |
| 97167 | Occupational therapy evaluation: high complexity (typically 60 minutes) |
| 97168 | Occupational therapy re-evaluation (typically 30 minutes) |
| 97110 | Therapeutic exercises, per 15 minutes |
| 97112 | Neuromuscular reeducation, per 15 minutes |
1–10 of 21
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Neonatal/pediatric critical care and cognitive care CPT codesCPT
| 99468 | Initial inpatient neonatal critical care, per day (<=28 days) |
| 99469 | Subsequent inpatient neonatal critical care, per day (<=28 days) |
| 99471 | Initial inpatient pediatric critical care, per day (29 days–24 months) |
| 99472 | Subsequent inpatient pediatric critical care, per day (29 days–24 months) |
| 99475 | Initial inpatient pediatric critical care, per day (2–5 years) |
| 99476 | Subsequent inpatient pediatric critical care, per day (2–5 years) |
| 99477 | Initial hospital care per day for neonate requiring intensive observation |
| 99478 | Subsequent intensive care for recovering very low birth weight infant |
| 99479 | Subsequent intensive care for recovering low birth weight infant |
| 99480 | Subsequent intensive care for recovering infant (2501–5000 g) |
1–10 of 11
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Hospital/subsequent care and radiation management codesCPT
ESRD telehealth-allowed codesCPTCovered
| 90951-90970,90963-90970 | ESRD-related monthly and per-day home dialysis services (codes in the 9095x–9097x series) impacted for telehealth delivery during the PHE |
CTBS and online E/M codesHCPCS | CPT | mixedCovered
| G2010 | Remote evaluation of recorded video/images (CTBS) |
| G2012 | Virtual check-in (CTBS) |
| G2061-G2063 | Qualified nonphysician HCPCS online assessment and management services |
| 99421-99423 | Online digital evaluation and management services (physician) |
HH PPS payment examplemixed
| Example explaining HH PPS grouping (MMTA Respiratory clinical group) and LUPA threshold implications when using technology plus in-person visit changes. |
RHC/FQHC virtual communication codeHCPCSCovered
| G0071 | Virtual Communication Services for RHCs/FQHCs (5+ minutes) |
Telehealth and COVID-19 specimen collectionmixedCovered
| G0071 | Payment for communication technology-based services for RHC/FQHC (expanded to include listed CPT codes) |
| G2012 | Communication technology-based services (PFS code used in averaging G0071 rate) |
| G2010 | Remote evaluation of recorded video/images (PFS code used in averaging G0071 rate) |
| 99421 | Online digital E/M service (5-10 minutes) |
| 99422 | Online digital E/M service (11-20 minutes) |
| 99423 | Online digital E/M service (21+ minutes) |
| G2023 | Specimen collection for SARS-CoV-2 (general) |
| G2024 | Specimen collection for SARS-CoV-2 (SNF/HHA-related) |
COVID-19 specimen collection HCPCSHCPCSCovered
| G2023 | Specimen collection for SARS-CoV-2 (COVID-19), any specimen source |
| G2024 | Specimen collection for SARS-CoV-2 (COVID-19), from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source |
RPM and Telephone E/M codes covered during PHECPTCovered
| 99091 | Collection and interpretation of physiologic data digitally stored and/or transmitted |
| 99453 | RPM initial set-up and patient education |
| 99454 | RPM device supply with daily recordings, each 30 days |
| 99457 | RPM treatment management, first 20 minutes |
| 99458 | RPM treatment management, each additional 20 minutes |
| 99473 | Self-measured blood pressure device education/calibration |
| 99474 | Self-measured blood pressure data collection and report |
| 98966 | Telephone assessment 5-10 minutes (nonphysician) |
| 98967 | Telephone assessment 11-20 minutes (nonphysician) |
| 98968 | Telephone assessment 21-30 minutes (nonphysician) |
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Telephone E/M codes with interim paymentCPTCovered
| 98966 | Telephone assessment and management service; 5-10 minutes of medical discussion |
| 98967 | Telephone assessment and management service; 11-20 minutes of medical discussion |
| 98968 | Telephone assessment and management service; 21-30 minutes of medical discussion |
| 99441 | Telephone E/M by a physician: 5-10 minutes |
| 99442 | Telephone E/M by a physician: 11-20 minutes |
| 99443 | Telephone E/M by a physician: 21-30 minutes |
Regulatory citations added/modifiedmixed
| §422.166(j) | Use 2018 HEDIS data and March–May 2019 CAHPS data for 2021 Star Ratings; carry forward improvement change scores from 2020; do not reduce to 1 star for failure to report 2020 HEDIS/CAHPS. |
| §423.186(j) | Parallel provisions for Part D: use prior-year HEDIS/CAHPS data for 2021 and related codifications. |
| §422.166(j)(1)(v) / §423.186(j)(1)(iv) | Authority to use 2020 Star Ratings as 2021 Star Ratings if CMS capabilities are compromised by COVID-19. |
| §422.164(i) / §423.184(i) | Authority to substitute 2020 measure scores/stars for 2021 when systemic data quality issues affect all plans due to the PHE. |
Ambulance destination adjustmentmixed
| Expanded covered destinations for ambulance transports during the PHE as described in §410.40(f)(5) (see regulatory text). |
Part B advance paymentsmixed
| 42 CFR 421.214 | Regulation revised to expand advance payment definition, permit contractors to make advance payments, add emergency paragraph (j), and allow up to 100% of anticipated payment under exceptional circumstances. |
Removed information collection OMB control numbersmixed
| OMB 0938-1028 | HEDIS data collection OMB control number |
| OMB 0938-0732 | CAHPS data collection OMB control number |
Place of Service (POS) for telehealth — claims guidance and payment impact
POS codeCMS requires telehealth claims include POS 02; providers may report the POS that would have been reported had the service been furnished in person to determine facility vs non-facility payment.
Facility vs non-facility paymentServices billed with POS 02 will continue to be paid at the facility rate if practitioners choose POS 02; CMS may instead assign the payment rate that would have applied if furnished in person under the PFS during the PHE.
Modifier guidanceAppend modifier 95 to claim lines describing services furnished via telehealth during the PHE per CMS billing instructions.
Duration of interim additions — dates of service and PHE timeframe
Effective date rangeInterim additions apply to dates of service beginning March 1, 2020 through the end of the declared Public Health Emergency (including renewals).
AuthorityAdditions implemented on an interim, PHE-only basis under section 1135 waiver authority and related regulatory amendments.
ScopeMany Category 2 CPT services (E/M across settings, observation, hospital, nursing facility, critical care, domiciliary, home visits) added for duration of the PHE.
Frequency limits removed during PHE
Frequency limits statusPreviously established frequency limits for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations furnished via telehealth are removed for the duration of the PHE.
ExamplesRestrictions such as once every 3 days for subsequent hospital care, once every 30 days for NF subsequent visits, and once-per-day for critical care consults are suspended during the PHE.
System editsThese restrictions were originally implemented via rulemaking and systems edits; removal is interim for the PHE period.
Consent timing — PHE allowance for at‑service consent and staff documentation
Consent timing flexibilityFor Communication Technology‑Based Services (CTBS) and related services during the PHE, beneficiary consent may be obtained at the time the service is furnished and documented by auxiliary staff under general supervision.
Annual requirementConsent remains required annually but may be obtained at time of service during the PHE.
Who may document consentAuxiliary staff may obtain and document consent under general supervision when prior consent would interfere with timely provision of services.
LUPA threshold (example)
LUPA threshold exampleExample LUPA threshold: MMTA Respiratory clinical group with medium functional impairment and low comorbidities yields a LUPA threshold of 4 visits in a 30‑day period.
Payment effectIf total visits meet or exceed the LUPA threshold (e.g., 4 visits), HHA receives full 30‑day payment amount under HH PPS rather than per‑visit LUPA payment.
Use of technologyUse of virtual visits does not substitute for in‑person visits ordered on the plan of care; plan of care must be updated to reflect virtual visits when used.
Minimum time for G0071
Minimum time requirementHCPCS G0071 is payable for virtual communication services when at least 5 minutes of communication technology‑based service or remote evaluation is furnished by an RHC/FQHC practitioner.
Payment rate componentsG0071 payment rate is set to the average of national non‑facility PFS rates for G2012, G2010, and (during the PHE) CPT 99421‑99423.
Coinsurance/deductibleCoinsurance and deductibles apply to RHC claims for G0071 (coinsurance applies to FQHC claims) as noted in CMS guidance.
RHC/FQHC prior visit requirement for G0071 — waived during PHE
Prior‑visit requirement waivedDuring the PHE, the usual requirement that the beneficiary was seen by the RHC/FQHC within the previous 12 months is waived so new patients may receive services billed under G0071.
Consent and documentationConsent may be obtained at time of service and documented by staff under general supervision prior to billing during the PHE.
Billing expansionG0071 expanded to include CPT codes 99421‑99423 for payment rate averaging effective March 1, 2020 through the PHE.
Specimen collection fee (general)
Nominal specimen collection fee (general)A specimen collection fee of $23.46 is payable for COVID‑19 testing collected by trained laboratory personnel for homebound or non‑hospital inpatient beneficiaries during the PHE.
Payment codesIndependent laboratories must bill using Level II HCPCS G2023 for general specimen collection during the PHE.
DocumentationSpecimen collection applies when collection requires trained personnel; self‑collected specimens are generally ineligible for the fee.
Specimen collection fee (SNF / HHA)
Nominal specimen collection fee (SNF/HHA)A higher specimen collection fee of $25.46 applies when specimens are collected from individuals in a SNF or on behalf of an HHA during the PHE.
Payment codeIndependent laboratories must bill HCPCS G2024 for SNF/HHA‑related specimen collection during the PHE.
Travel allowanceLaboratories may bill travel allowance using existing HCPCS P9603 (per‑mile) or P9604 (flat rate); electronic mileage logs acceptable if producible to MACs.
MDPP virtual make‑up session caps
Weekly/core capsMDPP virtual make‑up sessions: suppliers may offer up to 15 virtual make‑up sessions weekly during the core session period.
Maintenance capsUp to 6 virtual make‑up sessions monthly during core maintenance intervals and up to 12 monthly during ongoing maintenance.
Per‑week limitMaximum one virtual make‑up session per week and a maximum of one session on the same day as a regularly scheduled session.
Telephone E/M RVUs (work)
Work RVUs assignedTelephone E/M work RVUs finalized for PHE: 98966=0.25; 98967=0.50; 98968=0.75; 99441=0.25; 99442=0.50; 99443=0.75.
PE inputsDirect PE inputs include 3 minutes of post‑service RN/LPN/MTA clinical labor time for each telephone E/M code.
CoverageCodes 98966‑98968 and 99441‑99443 payable on an interim basis for the duration of the PHE and may be furnished to new or established patients under enforcement discretion.
Time‑based level selection for telehealth office/outpatient E/M
Time‑based level selectionFor office/outpatient E/M visits furnished via Medicare telehealth during the PHE, level may be selected based on total time on the day of the encounter (all time associated with the E/M).
MDM optionAlternatively, level may still be selected based on medical decision making (MDM); history/physical documentation requirements are relaxed for telehealth during the PHE.
ApplicabilityThis interim time‑based policy applies only to telehealth office/outpatient E/M visits during the PHE.
Measure‑level cut points for HEDIS/CAHPS measures in 2021
HEDIS/CAHPS substitutionFor 2021 Star Ratings, HEDIS measures will use 2018 performance year data and CAHPS measures will use March–May 2019 survey data (the prior‑year values used for 2020); no measure‑level cut point changes for HEDIS/CAHPS measures in 2021.
Improvement carryforwardCarry forward the 2020 measure‑level improvement change score for all HEDIS/CAHPS measures into the 2021 Improvement measure calculations.
No 1‑star penaltyFor 2021 Star Ratings, CMS will not reduce HEDIS or CAHPS measures to 1 star for failure to report 2020 HEDIS or CAHPS data.
Guardrail cut point change limit
Guardrail delayImplementation of guardrails limiting measure cut point changes to ±5 percentage points is delayed; cut points may change by more than 5 percentage points beginning with the 2023 Star Ratings due to the PHE.
ScopeModification affects §§422.166(a)(2)(i) and 423.186(a)(2)(i) to delay guardrail application starting with 2023 ratings; other guardrail aspects unchanged.
RationaleDelay intended to avoid perverse incentives and reflect national performance shifts arising from the PHE.
Advance payment cap (exceptional circumstances)
Maximum advance paymentUnder exceptional circumstances (interim paragraph (j)), contractors may make advance payments up to 100% of the anticipated claim payment.
Authority changeRevised 42 CFR 421.214 permits contractors (not just carriers) to make conditional partial advance payments and adds emergency exception paragraph (j).
IneligibilitySuppliers in bankruptcy are ineligible to receive advance payments under the expanded authority.
Physician documentation time share — psychiatric hospital context
Physician documentation time shareEstimated that 33% of the typical 30 minutes per psychiatric hospital stay spent by physicians documenting progress notes could be shifted to NPPs, producing estimated savings in the analysis.
AssumptionsEstimate based on 4,746,327 psychiatric hospital stays, 2 progress notes per stay, 0.5 hours physician time per note, and $98 hourly wage difference between physicians and NPPs.
Operational impactAllows NPPs/APPs to document progress notes in psychiatric hospitals consistent with State law and hospital policy.
Supervision/technology threshold — virtual presence and audio‑only allowance
Virtual presence counts for supervisionDuring the PHE, direct supervision can be met through real‑time interactive audio/video communications (virtual presence) for physicians' supervision requirements.
Audio‑only allowanceWhen audio/video is not available, audio‑only telephone delivery is temporarily permitted for opioid use disorder counseling and therapy during the PHE if other requirements are met.
Limited scopeChange limited to the manner of meeting supervision requirements and does not alter payment/benefit scope; applies for the duration of the PHE.
What Providers Must Do
Prior Authorization
Telehealth payment expanded; originating-site facility fee waived
Medicare will pay for telehealth services furnished to beneficiaries located anywhere in the country, including in a patient’s home, under section 1135 waiver authority effective March 6, 2020; when telehealth is furnished to locations not statutorily identified as originating sites under the waiver, no originating site facility fee is paid.
Billing Rule
POS and modifier 95 required for telehealth claims
Report the place of service (POS) that would have been reported if the service were furnished in person and append CPT telehealth modifier 95 to telehealth claim lines; providers may continue to bill POS 02 if they choose and receive the facility payment rate.
Prior Authorization
Therapy CPTs added to telehealth list (Category 2)
Specific therapy CPT codes were added to the Medicare telehealth services list on a Category 2 interim basis for the duration of the PHE; note statutory distant site practitioner list does not include PT/OT/SLP for payment when those therapists furnish the services.
- Therapy CPTs added to list on Category 2 basis for PHE
- Statutory distant site practitioner exclusion for PT/OT/SLP remains (payment limits when furnished by those therapists)
Documentation Required
77427 weekly face‑to‑face visit may be furnished via telehealth
CPT 77427 (radiation treatment management, 5 treatments) is added to the telehealth list so the required weekly face‑to‑face visit component may be furnished via telehealth when clinically appropriate.
- Use telehealth for the weekly face-to-face component of CPT 77427 during PHE
Billing Rule
Frequency limits for certain telehealth visits removed
Previously established frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultation furnished via telehealth are removed for the duration of the PHE.
- Once-every-3-days (subsequent inpatient) and once-every-30-days (NF subsequent) limits suspended
- Once-per-day restriction for critical care consultation via telehealth removed
Prior Authorization
Telehealth frequency limits lifted; supervision via audio/video allowed
Remove frequency restrictions on subsequent inpatient and nursing facility telehealth visits and remove the once‑per‑day limit on critical care telehealth consultations for the PHE; additionally, permit direct supervision to be satisfied via real‑time interactive audio/video telecommunications when indicated to reduce exposure risks.
- Frequency restrictions for listed codes are not enforced during PHE
- Direct supervision may be provided via real‑time audio/video communications during PHE
Documentation Required
HIPAA enforcement discretion for good‑faith telehealth use
HHS Office for Civil Rights will exercise enforcement discretion and will not impose HIPAA penalties for good‑faith provision of telehealth using everyday technologies during the PHE.
Documentation Required
Direct supervision may be satisfied via real‑time audio/video
For the duration of the PHE, the definition of direct supervision is revised so that the physician’s necessary presence may be satisfied via real‑time interactive audio/video telecommunications when use of such technology is indicated to reduce exposure risks.
- Virtual presence via real‑time audio/video counts as physician 'presence' for direct supervision during PHE
- Physicians may contract with auxiliary personnel and provide appropriate virtual supervision
Documentation Required
Include telecommunications/remote monitoring on HHA plan of care
Home health plans of care must include remote patient monitoring or telecommunications use and describe how technology helps achieve plan goals; such technology cannot substitute for ordered in‑person home visits or count as a home visit for eligibility/payment.
- Document telecommunications/remote monitoring on the plan of care with rationale
- Technology use cannot replace required in‑person home visits for eligibility/payment
Documentation Required
Telecommunications allowed for administrative hospice recert and IRF supervision
Hospice recertification encounters that are solely administrative may be conducted via two‑way audio‑video telecommunications during the PHE; IRF required physician face‑to‑face supervision visits (minimum 3 days/week) may also be conducted via telehealth during the PHE.
- Administrative-only hospice recertification via two‑way audio‑video is permitted (not separately billable)
- IRF face‑to‑face supervision visits may be done by telehealth for the PHE
Billing Rule
G0071 expanded and payment rate revised to include 99421–99423
RHCs and FQHCs may bill expanded HCPCS G0071 (payment rate revised to include 99421–99423) for virtual communication services effective March 1, 2020; face‑to‑face requirements for these services are waived during the PHE.
Documentation Required
G0071 available to new patients; consent flexibilities
During the PHE RHCs/FQHCs may furnish G0071 services to new patients not seen within the prior 12 months and obtain patient consent at time of service or by staff under general supervision before billing.
- Waiver of the prior 12‑month visit requirement for G0071 during PHE
- Consent may be obtained at time of service or by staff under general supervision
Billing Rule
Labs must bill specimen collection with G2023/G2024; travel allowance via P9603/P9604
Independent laboratories must bill COVID‑19 specimen collection using Level II HCPCS G2023 (general) or G2024 (SNF/HHA‑related) to receive the nominal specimen collection fee during the PHE; labs may bill travel allowance using existing P9603/P9604 and may maintain electronic mileage logs if producible to MACs.
Billing Rule
Mandatory HCPCS G2023/G2024 for COVID‑19 specimen collection
Independent laboratories are required to use the new Level II HCPCS codes G2023 or G2024 when billing Medicare for the nominal COVID‑19 specimen collection fee during the PHE.
- G2023 = specimen collection for SARS‑CoV‑2 (any source)
- G2024 = specimen collection for SARS‑CoV‑2 for SNF or on behalf of an HHA (any source)
Billing Rule
Use P9603/P9604 for lab travel; electronic mileage logs allowed
Use existing HCPCS travel allowance codes P9603 (per‑mile) and P9604 (flat rate) for laboratory travel allowances; laboratories may keep electronic mileage logs rather than paper but must be able to produce them for MAC review.
Prior Authorization
Residents' separable inpatient services may be billed under PFS
During the PHE, residents may furnish separable non‑GME inpatient services while supervised via interactive telecommunications and, if conditions are met (identifiable services, full state licensure, services not part of approved GME), those services may be billed under the Physician Fee Schedule.
- Moonlighting/inpatient resident services not part of approved GME may be separately billed under PFS if conditions met
Documentation Required
Allow NPPs/APPs to document psychiatric hospital progress notes
Permit nonphysician practitioners/advanced practice providers (PAs, NPs, psychologists, CNSs) to document psychiatric hospital progress notes when acting within State law, scope of practice, and hospital policy.
- Remove 'licensed independent practitioner' phrasing; allow NPP/APP documentation per state law and hospital policy
Billing Rule
MDPP suppliers may provide expanded virtual make‑up sessions
MDPP suppliers with virtual capabilities may furnish expanded virtual make‑up sessions within specified caps and may deliver virtual MDPP sessions during the PHE consistent with CDC DPRP standards and CDC‑approved curriculum.
- Virtual make‑up session caps defined (e.g., max one virtual make‑up per week; other period caps apply)
- First core session in‑person weight measurement still required
Billing Rule
Telephone E/M codes payable during PHE with specified RVUs
CPT telephone E/M codes 98966–98968 and 99441–99443 are payable on an interim basis for the duration of the PHE, may be furnished to new or established patients, and have specified work RVUs and direct PE inputs.
Step Therapy
RPM may be furnished to new patients; annual verbal consent allowed
RPM services may be furnished to new patients during the PHE; verbal consent may be obtained once annually and documented at time of service for new and established patients.
- RPM permitted for new and established patients during PHE
- Annual verbal consent documented at time of service acceptable
Billing Rule
Interim telephone E/M payment and therapy modifier guidance
Interim separate payment is established for telephone E/M CPT codes 98966–98968 and 99441–99443 for the duration of the PHE; when furnished by private practice therapists, CPT 98966–98968 require GO/GP/GN therapy modifiers.
- Interim separate payment authorized for the listed telephone E/M codes
- Therapist billing requires GO/GP/GN modifiers for CPT 98966–98968 when applicable
Documentation Required
NSEDTS supervision minimum changed to general supervision
Minimum supervision level for initiation of outpatient hospital NSEDTS is changed to general supervision for the duration of the PHE so physician physical presence is not required during performance.
- NSEDTS initiation default supervision = general supervision during PHE
Prior Authorization
NCD/LCD face‑to‑face encounter requirements not enforced during PHE
Face‑to‑face or in‑person encounter requirements in NCDs and LCDs for evaluations, assessments, certifications, and similar requirements will not be enforced during the PHE (statutory PMD face‑to‑face requirements remain applicable).
- Enforcement discretion applies to NCD/LCD face‑to‑face requirements during PHE
Documentation Required
Suspend HEDIS/CAHPS collection and submission for 2019 measurement year
Plans should curtail HEDIS and CAHPS data collection for the 2019 measurement year and may retain any collected data for internal quality improvement; CMS is eliminating the 2020 submission requirement for those data due to the PHE.
- Curtail collection immediately for 2019 measurement year
- Collected data may be used internally but are not required to be submitted to CMS
Documentation Required
HOS administration may be delayed to late summer
Prepare for Health Outcomes Survey (HOS) administration later in the summer; CMS will provide additional guidance to Medicare Advantage plans if HOS timing changes.
Documentation Required
Licensed practitioners may order Medicaid home health during PHE
During the PHE, licensed practitioners such as nurse practitioners and physician assistants may order Medicaid home health services within their scope of practice under amended § 440.70.
- Orders must remain within State scope‑of‑practice rules
Billing Rule
Ambulance destinations temporarily expanded during PHE
On an interim basis during the PHE, ground ambulance transports may be covered to a broader set of destinations (including testing sites, ASCs, FQHCs/RHCs, urgent care, physician offices, dialysis locations, and the patient's home) consistent with state/local EMS protocols when medically necessary.
- Transport destinations expanded per EMS protocols; medical necessity still required
Prior Authorization
MIPS reweighting application allowed; submission exception applied
MIPS‑eligible clinicians, groups, and virtual groups may apply for reweighting due to extreme and uncontrollable circumstances with an extended deadline; CMS created an exception so submitting some data does not automatically void a timely application for the 2019 performance period/2021 payment year.
- Extended application deadline to April 30, 2020 for affected clinicians
- Partial data submission will not automatically void an approved reweighting application for 2019
Documentation Required
Allow NPP/APP documentation and virtual MDPP delivery
Allow NPPs/APPs (PAs, NPs, CNSs) to document psychiatric hospital progress notes per State law and hospital policy, and permit virtual MDPP delivery and expanded virtual make‑up sessions for enrolled beneficiaries during the PHE.
- NPP/APP documentation allowed for psychiatric hospital progress notes
- MDPP virtual delivery and expanded make‑up sessions authorized for enrolled beneficiaries
Prior Authorization
Extend reporting deadlines and provide Shared Savings Program relief
Extend certain reporting deadlines (for example, MIPS 2019 submission extended to April 30, 2020) and revise the Shared Savings Program extreme and uncontrollable circumstances policy to permit relief when reporting periods are extended.
- MIPS 2019 data submission deadline extended by 30 days to April 30, 2020
- Shared Savings Program relief permitted for ACOs unable to report due to extended reporting period
Documentation Required
Operational flexibilities available to providers under PHE definition
Providers may rely on the PHE definition at § 400.200 to apply temporary flexibilities (e.g., deemed HHA shortage areas for RHC/FQHC visiting nurse services, include remote monitoring/telecommunications on home health plans of care without substituting for visits, permit virtual physician presence for direct supervision, permit audio‑only counseling/therapy for OUD when video unavailable, and expand ambulance destinations) for the duration of the PHE.
- RHC/FQHC areas considered to have HHA shortage without request during PHE
- Direct supervision may be satisfied via real‑time audio/video during PHE
- Audio‑only delivery permitted for OUD counseling/therapy when video unavailable
Key Terms and Regulatory Definitions
Public Health Emergency — definition
DefinitionPublic Health Emergency (PHE) defined in §400.200 as the nationwide emergency determined to exist on January 27, 2020 by the Secretary pursuant to section 319 of the Public Health Service Act, including any subsequent renewals.
ApplicabilityThis definition triggers the interim regulatory flexibilities and amendments throughout the IFC for the duration of the declared PHE.
ScopePHE applies nationwide and is the basis for many temporary CMS flexibilities described in this IFC.
Medicare telehealth services — definition and scope
DefinitionMedicare telehealth services are a discrete set of services that must ordinarily be furnished in‑person but may be furnished using interactive, real‑time audio/video telecommunication technology and are reported using codes that describe face‑to‑face services.
ReportingWhen furnished via telehealth under section 1834(m), many services are still reported using the codes that describe the in‑person service (face‑to‑face codes).
Not CTBSOther remote services (e.g., RPM, virtual check‑ins) are payable separately but are not classified as Medicare telehealth services under section 1834(m).
PFS facility rate — definition reference
PFS facility rateThe PFS facility rate is generally paid when services are furnished in a setting where Medicare makes a separate payment to an entity in addition to the practitioner (reflects originating site facility costs).
Originating site facility feeA nationally applicable flat fee paid to the originating site for telehealth services in most cases under section 1834(m); under the 1135 waiver, this fee may not be paid for non‑statutory originating sites.
POS rolePlace of Service code (e.g., POS 02) is used to determine facility vs non‑facility payment under the PFS.
PFS non‑facility rate — definition reference
PFS non‑facility (office) rateThe PFS non‑facility (office) rate is the single amount paid to a practitioner for services furnished in their office; CMS may assign this rate to telehealth services furnished during the PHE when resource use aligns with in‑person office visits.
Application during PHECMS may assume services furnished via telehealth reflect office‑setting resource use and pay non‑facility rates accordingly for the duration of the PHE when appropriate.
Provider choicePractitioners may continue to bill POS 02 to receive the facility rate if they choose.
Originating site facility fee — definition and PHE effect
Originating site facility fee policyWhen telehealth is furnished under the 1135 waiver to beneficiaries located in places not statutorily identified as permissible originating sites, no originating site facility fee is paid.
Waiver impactExpansion of telehealth under the waiver allows furnishing to beneficiaries anywhere (including home) but removes statutory originating site fee for non‑listed locations.
Payment assignmentCMS may assign payment rates as if services were furnished in person to better reflect resource use during the PHE.
Category 2 — telehealth list addition basis
Category 2 basisInterim additions to the Medicare telehealth list during the PHE were made on a Category 2 basis (services not similar to current list but with clinical benefit in the PHE context).
RationaleCategory 2 additions were used because the PHE context (exposure risk/access) justified temporary inclusion despite prior evidentiary considerations.
Effective scopeCategory 2 additions cover numerous CPT E/M and related codes for dates of service beginning March 1, 2020 through the end of the PHE.
Distant site practitioner — statutory limitation and therapy implications
Distant site practitioner statutory limitationStatutory distant site practitioner list under section 1834(m) does not include PT/OT/SLP; adding therapy CPT codes to telehealth list does not change that statutory limitation for payment when furnished by those therapists.
Practical effectTherapy services were added on a Category 2 interim basis to allow eligible distant site practitioners to furnish them via telehealth during the PHE, but payment when furnished by PT/OT/SLP themselves remains subject to statutory limitations.
Codes addedTherapy CPT codes were listed for interim telehealth coverage during the PHE (see CPT list in IFC).
Interactive telecommunications system — PHE temporary definition
Interactive telecommunications system (temporary PHE definition)For the duration of the PHE, 'interactive telecommunications system' means multimedia communications equipment that includes, at minimum, audio and video equipment permitting two‑way, real‑time interactive communication between the patient and distant‑site practitioner.
OCR enforcement discretionHHS OCR will exercise enforcement discretion for HIPAA penalties for good‑faith use of everyday technologies during the PHE.
Scope limitationException is interim and limited to the duration of the PHE.
Direct supervision (PHE) — virtual presence definition
Direct supervision (virtual) — definitionDuring the PHE, 'direct supervision' may be satisfied through real‑time interactive audio/video telecommunications, allowing a physician's virtual presence to meet supervision requirements.
LimitationsThis change affects only the manner supervision can be met and does not change payment or coverage policies; physical presence still required for some high‑risk procedures.
Application examplesIncludes supervision of auxiliary personnel and allows contractual arrangements with entities (e.g., HHAs, infusion suppliers) to leverage clinical staff for services incident to physicians' services.
Direct supervision (PHE) — additional details
Direct supervision detailsVirtual presence via real‑time audio/video is acceptable for direct supervision during the PHE; the policy is interim and invites comment on possible guardrails.
Not a coverage changeThis revision does not expand benefits or change payment scope; it changes only how supervision presence is met.
Includes teaching physician contextApplies to teaching physician supervision where interactive telecommunications can satisfy presence for key portions of services.
Remote patient monitoring — home health definition and context
RPM (home health) definitionRemote physiologic monitoring (RPM) is the collection of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the HHA (42 CFR 409.46(e)); allowable as administrative costs when used to augment care planning.
New allowancesDuring the PHE, RPM services may be furnished to new as well as established patients and verbal consent may be obtained once annually and documented at time of service.
Use casesRPM can be used for acute and chronic condition monitoring (e.g., pulse oximetry for respiratory illness) to reduce exposure risk.
Homebound (confined to the home) — definition and conditions
Homebound definition (general)Homebound (confined to the home) means an individual whose condition restricts ability to leave home except with assistance or if leaving is medically contraindicated; self‑quarantine alone does not establish homebound without physician certification.
ExamplesApplies when physician determines it is medically contraindicated to leave due to confirmed/suspected COVID‑19 or vulnerability to infection.
Implication for servicesHomebound status informs eligibility for home health services and specimen collection/travel allowances during the PHE.
Multimedia communications equipment — two‑way real‑time audio/video requirement
Multimedia communications equipment requirementCertain telehealth uses require multimedia communications equipment including, at minimum, audio and video permitting two‑way, real‑time interactive communication between patient and distant‑site practitioner.
Hospice recertificationTelecommunications for hospice recertification must permit two‑way, real‑time audio‑video; such administrative encounters are not separately billed.
Temporary exceptionException to prior prohibition on telephones/facsimile/email is interim for the PHE to allow mobile devices with audio/video capabilities.
Hospice administrative recertification visit — PHE telecommunications allowance
Hospice recertification administrative visitsFace‑to‑face hospice recertification encounters that are solely administrative may be conducted via telecommunications (two‑way audio‑video) during the PHE; these encounters are administrative and not separately billable.
Technology requirementTelecommunications must include at minimum two‑way, real‑time audio and video between patient and distant‑site hospice clinician.
OCR discretionHHS OCR will not audit prior patient‑practitioner relationship for claims during the PHE and will exercise HIPAA enforcement discretion for good‑faith telehealth use.
Virtual communication services (G0071) — definition and inclusions
G0071 definition (virtual communication services)HCPCS G0071 covers virtual communication services for RHCs/FQHCs (5+ minutes) and includes CTBS, remote evaluation of recorded video/images, and online digital E/M services (99421‑99423) during the PHE.
Payment updateEffective March 1, 2020 through the PHE, G0071 payment rate equals the average of national non‑facility PFS rates for G2012, G2010, 99421, 99422, and 99423.
New patient accessRHC/FQHC face‑to‑face requirements and prior 12‑month visit restriction waived for G0071 services during the PHE; consent may be obtained at service by staff under general supervision.
Homebound — specimen collection and travel allowance context
Homebound for specimen collection/travel allowanceFor specimen collection and travel allowance during the PHE, a patient is 'homebound' if it is medically contraindicated for the patient to leave home (normal inability to leave and leaving would require considerable and taxing effort); self‑quarantine alone insufficient unless certified by physician.
ApplicabilityThis homebound definition is used to determine eligibility for specimen collection fees (G2023/G2024) and travel allowances (P9603/P9604) during the PHE.
DocumentationDeterminations of homebound status must be based on individualized clinical assessment and physician certification.
Direct supervision by interactive telecommunications technology — teaching physician presence
Teaching physician virtual supervisionFor the duration of the PHE, teaching physician presence requirement may be met via real‑time interactive audio‑video telecommunications allowing the teaching physician to interact and provide direction to the resident during the key portion of the service.
ExceptionsPhysical presence remains required for certain high‑risk procedures (surgical, endoscopic, anesthesia) where appropriate.
Payment implicationAllows residents to furnish telehealth services under direct supervision via interactive telecommunications and for teaching physician payment when conditions are met.
CTBS — temporary allowances and therapy billing notes
CTBS temporary allowanceDuring the PHE, Communication Technology‑Based Services (CTBS) such as virtual check‑ins (G2012), remote evaluations (G2010), online digital E/M (99421‑99423, G2061‑G2063) may be furnished to new and established patients; consent may be obtained at time of service and documented by auxiliary staff.
Therapy billing noteCertain telephone codes (98966‑98968) designated 'sometimes therapy' require GO/GP/GN modifiers when billed by private practice therapy practitioners.
Bundling ruleCTBS that originate from a related E/M within previous 7 days remain bundled and not separately billable per existing rules.
MDPP supplier — temporary PHE flexibilities
MDPP supplier definition (PHE flexibilities)An entity enrolled in the Medicare Diabetes Prevention Program expanded model as of March 1, 2020 may be permitted temporary flexibilities during the PHE, including virtual delivery and expanded virtual make‑up sessions for enrolled beneficiaries.
Supplier obligationsVirtual delivery must follow CDC DPRP virtual standards and CDC‑approved curriculum; initial core session still requires in‑person body weight measurement unless waived.
Cohort rulesMDPP suppliers should not start new cohorts in affected geographic areas during the PHE; flexibilities apply only for enrolled beneficiaries during the emergency period.
CTBS 'sometimes therapy' designation — therapy billing note
CTBS 'sometimes therapy' designationCPT codes 98966‑98968 are designated as CTBS 'sometimes therapy' services; private practice therapy practitioners must append GO/GP/GN modifiers when billing these services.
PurposeFacilitates therapist billing for telephone/virtual assessment services during the PHE while indicating therapy context.
Relation to other CTBSThese codes are treated under CTBS rules, including consent and bundling provisions where applicable.
General supervision — definition and interim change
General supervision definitionGeneral supervision means the procedure is furnished under the physician's overall direction and control but the physician's physical presence is not required during performance; minimum general supervision applied for certain services during the PHE.
NSEDTS changeMinimum supervision for NSEDTS initiation changed to general supervision during the PHE to increase provider flexibility.
Relation to direct supervisionDirect supervision may still be met virtually via real‑time audio/video when indicated during the PHE.
Extreme and uncontrollable circumstances policy — definition and application
Extreme & uncontrollable circumstances policyShared Savings Program's extreme and uncontrollable circumstances policy was revised to allow relief when disasters occur during extended reporting periods; applied to PY 2019 quality reporting to assist ACOs impacted by the PHE.
MIPS applicationMIPS automatic extreme and uncontrollable circumstances policy applied to 2019 performance period/2021 payment year with extended application deadlines.
PurposePolicy revisions aim to mitigate reporting/quality measure impacts from the PHE across CMS models and programs.
CAHPS — definition for Star Ratings context
CAHPS definitionConsumer Assessment of Healthcare Providers and Systems (CAHPS) is the standardized patient experience survey used in Star Ratings.
UseCAHPS survey data contribute to measure calculations in Part C and Part D Star Ratings; 2021 CAHPS measures use prior‑year survey data per interim rules.
Measurement timingCAHPS survey data collection timing was adjusted due to the PHE (March–May 2019 data used for 2021 where applicable).
HEDIS — definition for Star Ratings context
HEDIS definitionHealthcare Effectiveness Data and Information Set (HEDIS) is a set of clinical and utilization measures used in Star Ratings; 2021 HEDIS measures use 2018 performance year data per interim rules.
CalculationHEDIS measures are calculated by CMS via contract with NCQA; many measures require medical record review or physician office data collection.
Impact of PHEDue to PHE disruptions, HEDIS data collection/submission requirements for 2020 measurement year were suspended for 2021 Star Ratings.
HOS — definition and PHE administration timing
HOS definitionHealth Outcomes Survey (HOS) is a beneficiary outcomes survey used for certain Star Ratings measures (physical/mental health, falls risk, bladder control, physical activity monitoring); HOS administration moved to late summer due to the PHE.
Fallback provisionIf HOS cannot be administered, CMS may use prior‑year measure scores for HOS‑derived measures in subsequent Star Ratings (2021 to inform 2022 as needed).
Measures impactedMeasures include Improving/Maintaining Physical Health, Improving/Maintaining Mental Health, Reducing Fall Risk, Improving Bladder Control, and Monitoring Physical Activity.
Categorical Adjustment Index (CAI) — definition
CAI definitionCategorical Adjustment Index (CAI) adjusts for average within‑contract disparities associated with percentages of enrollees who receive LIS/are dual eligible and/or have disability status; used in Star Ratings calculations.
Calculation basisCAI values calculated based on the enrollment year associated with the year of data being used for each measure (e.g., 2018 enrollment year for HEDIS/CAHPS measures when using prior data).
No regulatory changeAlthough CAI continues to apply, CMS provided explanatory text to avoid uncertainty given other interim changes.
New MA plan — temporary definition for 2022 QBP
New MA plan (temporary)For 2022 QBP calculations only, a new MA plan is treated as new if offered by a parent organization that has not had an MA contract for the previous 4 years (modified from 3 years) due to PHE data disruptions.
ReasonChange accounts for plans that began in 2019 and lack HEDIS/CAHPS submissions for 2020 used in 2021 Star Ratings because of elimination of those submissions.
ScopeTemporary change applies only to 2022 QBP ratings based on 2021 Star Ratings.
Routine services — definition and interim under‑arrangements change
Routine services definitionRoutine services in the hospital setting are those ordinarily furnished by the hospital (bed/board, nursing, related services) under sections 1861(b)(1) and (b)(2) of the Act.
Under‑arrangements policy changeDuring the PHE, hospitals are allowed broader flexibility to furnish routine inpatient services under arrangements outside the hospital when the hospital exercises sufficient control and responsibility over resources.
Effective dateInterim policy changes effective for admissions/discharges during the PHE beginning March 1, 2020 as described in the IFC.
MIPS automatic extreme and uncontrollable circumstances policy — definition and application
MIPS automatic policy definitionThe MIPS automatic extreme and uncontrollable circumstances policy provides relief (reweighting) for clinicians impacted by disasters; CMS applied it to the 2019 performance period/2021 payment year and extended application deadlines to April 30, 2020.
Application detailsIndividual clinicians, groups, and virtual groups may submit applications demonstrating adverse effect from the PHE; exceptions created so submitting some MIPS data will not void an approved reweighting application.
Deadline extensionApplication deadline extended to April 30, 2020 (or later specified date) for clinicians affected by the PHE.
Public Health Emergency (PHE) — regulatory definition reference
Regulatory definition (PHE)Public Health Emergency (PHE) defined at §400.200 as the nationwide PHE determined to exist as of January 27, 2020 by the Secretary under section 319 of the Public Health Service Act, including renewals.
Trigger for flexibilitiesThis regulatory PHE definition is the basis for the interim flexibilities and temporary amendments across CMS programs described in the IFC.
Nationwide scopeDefinition references the nationwide nature of the COVID‑19 PHE that prompted the IFC.
Policy Summary
PayerWellCare
PolicyMedicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
Policy CodePolicy CMS-1744-IFC
Change TypeInterim final rule — multiple temporary PHE flexibilities
Effective DateMar 1, 2020
Last ReviewMar 24, 2020
Next Review DateN/A
Key ActionMedicare will pay for telehealth services furnished to beneficiaries located anywhere in the country, including in a patient's home, under section 1135 waiver authority beginning March 6, 2020.
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