Charging for Remote & Virtual Services During the PHE

Feeling like your team just “can’t figure out” charging and billing for remote services under today’s waivers and flexibilities? You’re not alone. This article outlines the difference between telehealth and other remote services billing options and provides examples of potential payment losses if hospitals bill incorrectly.

This “Part 3 Remote & Virtual Services CDM Topics” article is another of our multi-part “ChargeAssist Update News” resource guide from Holliday & Associates, and summarizes common charging, coding, and regulatory updates currently being addressed by CDM and Revenue Cycle teams under the current public health emergency period. In addition to this article, please see our related “Remote Services Decision Tree” published in July to help understand process flow.

Still Unclear on Charging/Billing Remote Services?

We’ve witnessed providers and industry experts alike struggling for months to understand Medicare’s guidance throughout the COVID-19 Public Health Emergency (PHE). Despite the dedication of CMS staffers to convey details to the industry in calls and documentation, most believe their instructions have lacked timeliness and clarity. Some organizations have been unclear about the available remote service delivery options, while others have struggled with coverage, charging, and billing instructions.


The confusion with CMS rule stems from differing regulatory parameters and claims requirements for the varied types of remote healthcare services deployed to accommodate COVID-19 challenges. Many remote patient care options that were either unavailable or strictly limited prior to the PHE are currently available for providers.

Two primary alternatives have been offered by CMS on this front: 1) expanded telemedicine and 2) general flexibilities and waivers allowing providers to expand service locations. We believe this “Part 3 Remote & Virtual Services” guide will provide helpful details to help your team differentiate between setting, provider type, and CMS billing options for the most appropriate payment.

Now that we’re over five months into the Public Health Emergency, teams may wish to revisit decisions relative to coding and billing for remote services. Likewise, organizations may need to reconsider their strategic approach to remote care as CMS and other insurors propose permanent changes.

Priority 1 – Evaluate remote service success from a financial as well as clinical perspective

In addition to the clinical aspects of patient care and technology, organizations are likely evaluating the success of their remote service delivery as the PHE continues. Revenue Cycle evaluation is needed to ensure documentation, coding, charge capture, claims data, and remittance have been accurate. Likewise, Revenue Cycle involvement is essential for strategic planning for long term remote care delivery as CMS and other payer reimbursement options will evolve after the PHE.

Priority 2 – Assess the reimbursement impact of remote services

The industry has been pleased with the prospect of payment being the same for remote care. However, it hasn’t been immediately evident that hospital reimbursement may be jeopardized simply based on which flexibilities providers select. We believe many hospitals have billed certain services to Medicare as “telehealth” when they may have been more appropriately reimbursed using CMS PHE flexibilities such as “hospital without walls”.

For on-site outpatient visits, hospitals bill Medicare using G0463 plus other applicable charges, and the MD/NPP charges for their services separately. However, when services shift to Medicare Telehealth benefits, the reimbursement gap for facilities is dramatic: G0463 payment is $115.93 (National OPPS rate) while the 2020 payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge, or $26.65.

The charge amount for a hospital visit is also quite a bit lower than an originating site fee for telehealth: This is translated into losses in gross charges which may impact facilities with percent of charge reimbursement with commercial insurances. The lower-priced charge may also result in long term impacts to Critical Access Hospitals where cost-based payment is affected by gross charges at Cost Report settlement. The nationwide median price for G0463 in the 2019 Medicare Standard Analytical file was $255.33. In contrast, the median 2019 nationwide price for Q3014 originating site fee was $71.08.

Clearly, health systems’ concerns are well-founded as visit volumes were dramatically decreased over the past five months and still suffer. It’s important to evaluate whether the hospital without walls option may be available based on patient, hospital staff and provider location.

Priority 3 – Develop a team-based approach to consistently monitor payer resources

As we referenced in Part 1 (Resources) and Part 2 (Laboratory) of our Chargemaster Guide for the PHE, there are numerous Medicare and Health & Human Services reference sources outlining current coverage and billing rules. Since this affects many cost centers and support areas, organizations may need to establish a team approach to monitor and stay current on coverage and payment system rules.

CMS Office Hours calls have been an essential resource for clarification of current PHE coverage through call in questions and CMS staff answers. These calls have gone from twice weekly to twice a month. However, as participants ask questions and share their concerns about coverage and billing instructions, there’s been continued frustration when CMS responses appear to be partial or unclear. We believe this is because CMS has to frame their replies based on the broad and varying CMS coverage; and answers must be applicable to existing policies that have been modified under the waivers and flexibilities during the PHE.

For questions for which CMS has no immediate response, provider options include: contact the MAC, submit and await a response from CMS by e-mail, hope for clarification in another CMS Office Hours Call, or watch for written updates in CMS documentation. Although there were two detailed Interim Final Rule Federal Register documents published by CMS in response to the COVID-19 PHE, very few of the more challenging questions make their way into MLN Matters or Transmittals. Correspondingly, the PHE guidelines are not manualized in the CMS system. Instead, in follow up to the Office Hours calls, CMS posts dated answers within a Fee for Service (FFS) Frequently Asked Questions (FAQ) document posted on the COVID-19 Emergencies page and found here: COVID-19 FAQs Medicare FFS Billing

Priority 4 – Ensure PHE billing decisions have been correct

CMS’ flexibilities and waivers have been very much needed, but their full deployment may have been stifled due to a widespread lack of understanding. The evolution of CMS guidance on Remote Services during the PHE leads us to suggest that hospitals carefully evaluate their billing options. A retrospective review may be in order to assess possible claims errors. Key factors include confirmation of patient location, patient location, provider type, provider location, hospital department designation, Hospital department staff location, technology used, services provided, and claims data.

In the 7/28/20 FFS FAQ update, CMS confirmed that hospitals could bill the better-paid G0463 in some remote care scenarios using the Medicare “Hospital without Walls” waiver option if telehealth is not applicable. This was counter to past CMS answers in Office Hours calls, and prompted repeat audience questions nearly every session. As stated by CMS in the 7/28 FAQ, if the physician is located at the facility location and the patient is at their home during the PHE, the service can be billed as if the patient were at the facility.

CMS provides significant details about the remote patient location in its FAQ materials. Based on the hospital outpatient department designation, certain modifiers and emergency relocation request actions are necessary for OPPS-reimbursed facilities. CMS also noted in calls that when a provider is located in a separate space within the hospital for infection control reasons, the encounter would not lend itself to telehealth billing.

We know that many providers have struggled to understand the CMS remote service billing options. If your team determines that billing errors have occurred, it will be important to develop a plan of action with your MAC and other payers.

Priority 5 – Establish Internal Policies & Procedures for Remote Service Billing

Once past billing errors are remedied, internal protocol should be documented to solidify the organization’s Remote Service billing decisions. Remember, the protocol today during the PHE will need to be modified as coverage changes occur.

There’s no argument among hospitals or industry experts that the correlation of clinical scenarios and CMS options continue to be challenging despite dedicated attention to CMS instructions. In the following sections, we’ll explore some of CMS’s options currently available for remote services during the PHE…. (full article available upon request)

For more of this Part 3 Guide or other current COVID-19 PHE ChargeAssist materials, contact the author Rosemary Holliday, Managing Partner, Holliday & Associates at 530-550-0865 ext 1 or (800) 831-3323 ext 1 or reach out by e-mail to rholliday@chargeassist.com


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Author: Rosemary Holliday, MHA, Managing Partner, Holliday & Associates/ ChargeAssist

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