Telehealth, Virtual Visits, e-Visits, and Remote Care for Nursing Homes during the COVID-19 Public Health Emergency (PHE)

April 23, 2020 Rebecca Gwilt

Skilled Nursing Facilities and Nursing Homes turn to Virtual Care and Remote Communications Solutions to Treat Patients and Control Infections

The burden on the staff and residents of long-term care facilities, including nursing homes and skilled nursing facilities, has increased significantly around the country during the coronavirus pandemic. Hospitals in many locations are looking to discharge more patients to these already filled facilities, and the COVID-19 virus is severely impacting the nursing home population in particular because their generally older and sicker residents are much more likely to die or become severely ill from the virus than people in the general population. In addition, they’re having trouble sourcing PPE and social distancing is difficult or impossible in many facilities.

The Centers for Medicare and Medicaid Services (CMS) has responded to feedback from industry stakeholders by using the 1135 waiver authorities granted in the Coronavirus Preparedness and Response Supplemental Appropriations Act to implement several policy changes enabling practitioners to provide remote virtual services to skilled nursing facilities and to remotely supervise on-site providers. In addition, CMS is encouraging facilities to adopt remote solutions for visitors to nursing home residents. In its March 13 letter on infection control and prevention of COVID-19 in nursing homes, CMS stated: “In lieu of visits, facilities should consider…offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.” This has created a new opportunity for the growth of remote or virtual care solutions for long term care facilities and the practitioners who serve them.

Telehealth and Virtual Communications Services for Skilled Nursing Facilities

Generally, physician visits to a patient in a skilled nursing facility are required to be in-person unless specifically exempted. However, CMS’ Blanket Waivers implemented during the COVID-19 Public Health Emergency (“PHE”) also include a waiver allowing a physicians and other practitioners to conduct visits to nursing home residents via telehealth or other virtual communications platforms as appropriate. Effective retrospectively to March 6, 2020 and for the duration of the COVID-19 PHE, Medicare will make payment for virtual services furnished to beneficiaries in any healthcare facility —including nursing homes—or in their home. This means that virtual services for nursing home residents can include any reasonably and appropriate practitioner E&M codes, and telehealth services will be paid at the same rate as regular, in person visits.

The categories of virtual services practitioners may provide to facility residents include (1) Telehealth Visits, (2) E-Visits, (3) Virtual Check-Ins, (4) Remote Patient Monitoring, and (5) Telephone-Only Services. These services may be billed to any resident as long as the services are reasonable and necessary. Importantly, these waivers are not restricted to patients with a COVID-19 diagnosis.

Medicare Telehealth Services. You can find a list of the telehealth codes reimbursable by Medicare HERE. Currently, practitioners providing services to nursing homes via telehealth can bill CPT codes 99307-99310* for nursing facility subsequent visits, and CPT codes 99497-99498 for advanced care planning services. In addition, the following G codes are available for services delivered via telehealth:

G0425-G0427: Initial Inpatient Telehealth Consultation
G0406-G0408: Follow Up Inpatient Telehealth Consultation**

*During the PHE, the telehealth frequency limitation has been eliminated for these codes. However, once the PHE ends, the practitioner will again be restricted from billing the 99307-99310 codes to once per 30 days.

**If a physician is serving as attending physician, that physician is NOT permitted to bill the initial and follow up consultation G codes.

CMS has expanded this list of reimbursable telehealth services for the duration of the PHE to include the following services which may be relevant to services delivered to a long-term care facility’s residents.

CPT codes 99304-99306: Initial nursing facility visits (Low, Moderate, and High Complexity)
CPT codes 99315-99316: Nursing facility discharge day management
CPT code 99483: Care Planning for Patients with Cognitive Impairment
CPT codes 96130- 96133; 96136- 96139: Psychological and Neuropsychological Testing
CPT codes 97161- 97168; 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507: Therapy Services, Physical and Occupational Therapy

Qualified healthcare providers (QHCP) who are permitted to furnish Medicare telehealth services during the PHE include physicians and certain non-physician practitioners such as nurse practitioners, physician assistants, licensed clinical social workers, and clinical psychologists. During the PHE, these providers need not have a prior established relationship with the patient. Practitioners who bill for Medicare telehealth services should report the place of service (POS) code that would have been reported had the service been furnished in person. Modifier 95 should be applied to claims that describe services furnished via telehealth.

Telehealth Facility Fees. Long term care facilities are also eligible to bill for an originating site facility fee, which is reported under HCPCS code Q3014. Generally, Skilled nursing facilities (SNFs) bill their A/B/MAC (A) for the originating site facility fee using TOB 22X or 23X. For SNF inpatients in a covered Part A stay, the originating site facility fee must be submitted on a 22X TOB. All SNFs must use revenue code 078X when billing for the originating site facility fee. The SNF serving as an originating site must bill for HCPCS code Q3014 on a separate revenue line from any other services provided to the beneficiary

Read more about the Medicare Telehealth Waivers HERE.

Virtual Communications: E-Visits, Virtual Check-Ins, Remote Patient Monitoring, and Telephone-Only Services For more information on these topics, please read our latest article on changes to these services following the PHE declaration. See also our non-PHE articles on E-Visits, Virtual Check-Ins, and Remote Patient Monitoring.

Telehealth and Virtual Communications Copay Waiver. According to a March 17, 2020 policy statement by OIG, healthcare practitioners will not be subject to administrative sanctions for reducing or waiving cost-sharing for telehealth services during the public health emergency as long as the services are furnished consistent with current coverage and payment rules.

Telehealth HIPAA Waiver.

The HHS Office for Civil Rights (OCR) has announced that it will exercise enforcement discretion to waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. Your long-term care facility will still need to have someone managing the technology from the facility side, but cell phones and tablets using consumer video-conferencing technology are permissible modalities during the PHE. This reduces significantly the barriers to technology adoption, which is a basic challenge of implementing a telemedicine program to enable remote healthcare delivery.

Physician Delegation

Generally, federal law requires that (1) each skilled nursing facility resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter; and (2) the facility must provide or arrange for the provision of physician services 24 hours a day in case of an emergency. However, for the duration of the public health emergency (PHE), CMS waived the requirement in 42 CFR § 483.30(e)(4) that prevents a physician from delegating a task that, under normal circumstances, the physician must perform personally. In these Blanket Waivers, CMS announced it will permit physicians to delegate any required physician visit (including those listed above) to a nurse practitioner (NP), physician assistant, or clinical nurse specialist (CNS) who is 1) not an employee of the facility; 2) working in collaboration with a physician; 3) licensed by the relevant state; and 4) performing within that state’s scope of practice laws. Any task delegated under this waiver must continue to be under the supervision of the physician, but that supervision may be remote. This delegation authority might allow a company to scale its remote services (and thus increase access to care) using non-physician staff. Scalability begets growth in the telemedicine space, which begets better access to services, which begets better patient outcomes.

Remote “Direct” Supervision.

CMS has revised the definition of direct supervision the duration of the PHE for the COVID-19 pandemic to allow direct supervision by a physician of another QHCP or clinical staff to be provided remotely using real-time interactive audio and video technology. This change will further enable the scalability of clinical services, by permitting physicians to supervise non-physicians who are geographically separated. It also means that a single clinician can work in multiple facilities in multiple states (as long as she is licensed to do so), under the same supervising physician. These flexibilities are key to promoting the growth of remote services.

FCC Telehealth Program Funding.

On March 31, 2020, the Federal Communications Commission released a report and established a $200 million emergency COVID-19 Telehealth Program to ensure access to connected care services and devices in response to the surge in demand for connected care during the PHE. The support provided through the COVID-19 Telehealth Program is available to public and non-profit skilled nursing facilities to purchase telecommunications services and devices necessary to provide critical connected care services — whether for treatment of coronavirus or for other health conditions during the PHE. Applications are now open and funds are available on a first-come, first-served basis until they are exhausted.

If you are a skilled nursing facility or a nursing home in need of guidance on implementing a telehealth and virtual communications program, please contact us.

Additional Resources for Long Term Care Facilities unrelated to Telehealth/Virtual Care

Please watch our webinar on Reimbursement and Implementation of Telehealth and Virtual Communications During COVID-19 and Beyond, and read our post on the CMS Interim Final Rule as it relates to Telehealth and Virtual Communications.

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