Expansion of telehealth services during the COVID-19 pandemic has been critical to maintaining continuity of care and enabling providers to connect with patients virtually during a time when in-person interactions raise the risk of infection. During this time, many public and private payers have broadened their telehealth coverage beyond video visits to include services delivered over the telephone. Coverage for telephonic services has been essential to maintaining access during the public health emergency (PHE) period, especially for patients unable to access video-based telehealth, but has sparked many questions related to clinical appropriateness, how best to operationalize these services, patient privacy, and the potential coverage approaches payers may take in a post-COVID-19 world. This document seeks to answer some of these common questions.
1. What are telephonic services? How do telephonic services differ from a video visit?
“Telephonic services” refers to the use of telephone or other audio-only technologies (e.g., Google Voice, FaceTime Audio) that enable providers to connect with patients to discuss their care or treatment plans in real time.
Telephonic services differ from video visits because they do not include a visual component; video visits occur over a live connection with both audio and video capabilities that enable a provider to visually assess and speak with a patient.
2. Are there certain types of services that are most appropriately delivered via telephonic services?
During the COVID-19 pandemic, telephone and audio-only technologies have been used to deliver services that do not require a physical or visual exam, such as select behavioral health services, speech/language therapy, nutrition counseling and certain preventive services (e.g., smoking cessation). It is common for payers to limit telephonic coverage to only those services that can be delivered via telephone in a clinically appropriate manner. To date, behavioral health services have gained the most traction among payers, with many choosing to cover select behavioral health services such as psychotherapy counseling via video or audio visit in order to expand access to these vital services.
3. What are the benefits of telephonic services?
Telephonic services can help improve access to services for individuals who lack access to broadband Internet services. Since 44% of low-income Americans don’t have access to broadband Internet at home, telephonic forms of telehealth may be the only achievable modality for accessing care virtually.
In addition, some patients who receive behavioral healthcare services via telehealth may feel more comfortable connecting with their providers over the telephone without a live video component.
4. What are the different ways a provider may bill for services delivered over a telephone call?
It depends on what specific audio-only services each payer covers; however, there are two primary types of telephonic services that a provider may be able to bill for—telephonic services in lieu of video visits, and brief check-ins.
|Telephonic Service Type
||Description and Examples
||Commonly Used CPT Codes
|Telephonic Services in Lieu of Video Visits
||If a telephone call is used in lieu of a video visit for the delivery of physical or behavioral health services, a provider may be able to bill the typical CPT code.
Example: Coding instructions differ by payer, and not all payers will reimburse for telephonic services in lieu of video visits; however, during the COVID-19 pandemic period, Medicare, some state Medicaid programs and some private payers have enabled providers to bill for telephonic services in light of social distancing guidelines, and some are at least temporarily reimbursing for these services at parity with in-person care.
For example, within its temporary COVID-19 telehealth policy, New York’s Medicaid program is instructing providers to bill the typical CPT codes with modifier GQ (used to indicate services delivered via an asynchronous telecommunications system). If a provider were to complete a 60-minute psychotherapy session with a Medicaid enrollee in New York State, the provider would bill the typical 90837 psychotherapy code and append the GQ modifier.
|Same as video visit codes
||If a telephone call is linked to a related evaluation and management (E/M) visit in the previous 7 days or next 24 hours (or soonest available appointment), it is considered part of that E/M visit and is not separately payable under any of the above codes.
Example: Within its temporary telehealth policy, North Dakota’s Medicaid program covers telephone evaluation and management services (CPT codes 99441–99443).
(Telephone evaluation and management for physicians)
(Telephone assessment and management for qualified nonphysicians)
(Virtual check-in for physicians and other eligible providers)
(Virtual check-in for Federally Qualified Health Centers and Rural Health Clinics)
5. How has Medicare historically covered telephonic services? During the COVID-19 pandemic?
For the first time in 2019, CMS added Medicare coverage for services delivered via telephone call by adding the virtual check-in code (G2012) to the physician fee schedule final rule. It is important to note that virtual check-ins were classified by CMS as a form of “communication technology-based services,” which are distinct from other Medicare-covered telehealth services in that they (a) are not intended to replace in-person care and (b) are detailed in guidance, not statute; therefore, it could be easier to amend or expand the scope of, and rules applied to, these services. CMS designed these services as a way to work around the statutory restrictions applied to Medicare-covered telehealth services.
In response to the COVID-19 pandemic, CMS added temporary coverage for telephone evaluation and management services (CPT codes 99441–3) and telephone assessment and management services (98966–8) through an interim final rule with comment period. Additionally, CMS has indicated where telephonic services in lieu of video visits are permitted within its list of telehealth-eligible services for select CPT codes during the public health emergency.
6. How are state Medicaid programs covering telephonic services during the COVID-19 pandemic?
Many state Medicaid programs have aligned with Medicare and expanded their telehealth coverage policies to include telephonic services, adding coverage for brief check-ins (e.g., telephone evaluation/assessment management) and in some cases telephonic services in lieu of video visits. As of August 6, all state Medicaid agencies had issued guidance to allow for a form of audio-only telehealth services.
7. How might Medicare continue to cover telephonic services post-pandemic?
On August 3, CMS issued the CY 2021 physician fee schedule (PFS) proposed rule, which proposes several changes to the Medicare Part B telehealth payment policy and gives us a sense of what to expect in the future in terms of telephonic service coverage in Medicare and beyond. Within the CY 2021 PFS, CMS has proposed1 to take the following actions at the end of the public health emergency:
- End coverage for telephonic evaluation and management (E/M) services; and
- Discontinue its temporary coverage of telephonic services in lieu of video visits for select services.
If the proposed rule is finalized, Medicare would revert back to its pre-COVID-19 policy of covering only code G2012 for brief 5-to-10-minute check-ins; however, it is notable that CMS has requested public comment on whether to add new virtual check-in codes that would provide coverage for virtual check-ins that last beyond 10 minutes, so we may see the addition of new virtual check-in codes in the future.
Manatt recently summarized the telehealth-related changes within the CY 2021 physician fee schedule for Insights@ManattHealth, Manatt Health’s premium subscription service. For more information on becoming a subscriber, please contact us.
8. What about other payers?
As permanent telehealth policies begin to take shape, we are seeing some payers straddle the line between covering brief check-ins and covering telephonic services in lieu of video visits. For example, Blue Cross Blue Shield of Tennessee is one of the only major private payers to announce their permanent post-COVID-19 telehealth policies. The plan has opted to permanently adopt its temporary COVID-19 policy, which provides coverage and reimbursement for brief check-in services (telephonic E/M), as well as telephonic service in lieu of video visit coverage for traditionally in-person office/outpatient evaluation and management codes (99201–99215).
9. Does the delivery of telephonic care potentially violate HIPAA privacy laws?
For the most part, the answer is no. A provider can engage in a phone call with a patient in compliance with HIPAA so long as the provider adheres to the following two rules:
1. Does not allow the cellphone company to access or store the information discussed during the call absent a business associate agreement (e.g., no electronic voicemails)
a. Rationale: Providers are not required to enter into a business associate agreement (BAA) with a covered entity unless the vendor has access to protected health information (PHI) on the provider’s behalf. According to the HIPAA “conduit exception,” “entities providing mere courier services, such as the U.S. Postal Service or United Parcel Service and their electronic equivalents, such as Internet service providers (ISPs) providing mere data transmission services,” are not considered business associates, and therefore covered entities do not need to enter into BAAs with those organizations, so long as these couriers do not access or store the PHI. In other words, a provider does not need to enter into a BAA with Verizon to engage in telephonic services so long as Verizon does not access or record the call.
2. Does not share any information that existed in electronic form immediately prior to the call
a. Rationale: Under the HIPAA security rule, a covered entity needs to assess the security practices of its vendors, and typically needs to assess whether they encrypt data; however, this applies not to all PHI but rather only to “electronic PHI,” which specifically does not include transmissions via voice or telephone call (ePHI). In other words, if a provider shares PHI over the phone, that PHI won’t be considered ePHI—and therefore won’t be subject to HIPAA security requirements at all—so long as that information did not exist in electronic form immediately prior to the call.
Other HIPAA issues may arise if a provider delivers care over the telephone when others are within earshot of the provider or patient. Providers should take precautions to ensure patient privacy when delivering telephonic services.
10. Are providers required to obtain the patient’s consent to the receipt of telephonic services prior to delivering those services? If so, what type of consent is commonly required?
Patient consent requirements will differ by payer and by state. Taking Medicare as an example—prior to COVID-19, CMS required that a patient verbally consent to receive virtual check-in services. Within Medicare’s temporary COVID-19 policy, CMS stated that “beneficiary consent should not interfere with the provision of non-face-to-face services. Annual consent may be obtained at the same time, and not necessarily before the time, that services are furnished.”
1 CMS has only proposed to end telephonic E/M services on a permanent basis. Because of the statutory nature of most of the Medicare telehealth restrictions, extending these key flexibilities beyond the PHE ultimately will require congressional action.