ASTRO Guidance on CMS COVID-19 Telehealth and Supervision Policies

The Centers for Medicare and Medicaid Services (CMS) has issued several guidance documents to provide physicians with the flexibilities necessary to continue treating patients during the COVID-19 Public Health Emergency (PHE).

On March 17, 2020, CMS announced a temporary expansion of telehealth coverage for health care services. This effort was followed by an interim final rule (IFR) issued on March 30. The Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency IFR authorized CMS to waive traditional Medicare telehealth requirements, increasing access to telehealth services and establishing payment for patient visits rendered via telehealth, thus reducing the need for patients to appear in person at clinics and hospitals. The March 30 IFR also included policy changes associated with physician supervision in the freestanding and hospital outpatient setting, again allowing for flexibilities to reduce exposure to COVID-19.

On April 30, 2020, CMS issued Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (PHE) and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program, interim final rule with comment period (IFC) providing additional clarifications regarding the application of telehealth services and addressing payment issues associated with telephone only services.

Finally, in December 2020, CMS issued the Medicare Physician Fee Schedule final rule with additional provisions regarding the use of telehealth services. The Agency finalized the addition of several services to the Medicare telehealth list, including newly implemented HCPCS codes G2211 Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M) and G2212 Prolonged Services. Below is a summary of the telehealth guidance provided by CMS and its application to radiation oncology services.

Note: Unless otherwise noted, the guidance below is only effective during the COVID-19 PHE and retroactively applicable to March 1, 2020. The Consolidated Appropriations Act of 2022, which became law on March 15, 2022, extended the telehealth flexibilities of the PHE, including those related to supervision, for 151 days after the end of the PHE. On January 30, 2023, the Biden Administration announced that the PHE will end on May 11, 2023. However, on February 24, 2023, CMS issued new guidance to assist practices in preparing for the end of the PHE, and it provides that “virtual presence” flexibility for direct supervision will be in place until the end of calendar year 2023. Direct supervision requirements will return to pre-PHE rules on January 1, 2024.

I. Initial Patient Consult and Follow-Up Care

The expansion of telehealth establishes three distinct categories of services for use during the COVID-19 PHE. ASTRO believes that most practices will want to consider the application of Medicare Telehealth Visits to existing initial consults and follow-up care. However, practices may also utilize Virtual Check-Ins and E-Visits when appropriate.

1. Medicare Telehealth Visits for new or established patients require the provider to use an interactive audio and video telecommunications system for real-time interactive communication between the physician and the patient, including the use of telephones that have audio and video capabilities, desktop or mobile computing devices with audio and video capabilities allowing for two-way communication. Health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video or Skype, to provide telehealth.  This flexibility will expire at the end of the PHE.

   Note: Under this Notice, public facing video communication applications such as Facebook Live, Twitch, TikTok and similar video communication applications should not be used in the provision of telehealth by covered health care providers.

   Medicare Telehealth Visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. These telehealth interactions apply to specific codes, including the Office/Outpatient Visit codes (99202-99215) for new and established patients.  View a complete list of codes.

   As an additional resource to the files that CMS provided, please refer to “Appendix P - CPT Codes That May Be Used For Synchronous Telemedicine Services” of the 2023 CPT Professional Code Book for more information on approved telehealth codes. This listing is a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier -95.

2. Virtual check-in visits (CPT codes G2010 and G2012) for new or established patients allow patients to have a brief check-in with their practitioner via a broad range of communication methods, including the telephone (no video requirement), audio/video, text messaging, email or use of a patient portal. These services may only be reported if they do not result in a visit, including a telehealth visit.

   Note: In instances when the brief communication technology-based service originates from a related E/M service (including one furnished as a telehealth service) provided within the previous seven days by the same physician, this service would be considered bundled into that previous E/M service and would not be separately billable.

3. E-Visits for new or established patients involve a communication between an established patient and provider through use of an online patient portal. The patient must initiate the initial inquiry through the patient portal. Communications may take place over a seven day period. There are three time-based E/M codes specific to this service (99421-99423).

The chart below summarizes the distinct types of telehealth that may be provided during the COVID-19 PHE:

*To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship exists for claims submitted during this public health emergency

More information about the use of these codes can be found on the CMS Fact Sheet and FAQ issued on March 17, as well as in the 2021 MPFS final rule fact sheet issued on December 2.

II. Telephone Evaluation and Management (E/M) Services (99441-99443)

Physicians can also use CPT codes 99441-99443 for Telephone Evaluation and Management Services for new or established patients during the COVID-19 PHE. On an interim basis, these codes will be reimbursed by CMS for E/M visits provided via audio-only telephone at the same rate as if the services had been provided in person. CMS is crosswalking CPT codes 99212, 99213, and 99214 to CPT codes 99441, 99442, and 99443 respectively. This results in a work RVU of 0.70 for CPT code 99441, 1.30 for CPT code 99442, and 1.92 for CPT code 99443. Payment for these codes is $56.25, $90.82, and $127.75 respectively.

• 99441- Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

• ​99442 - Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.

• 99443 - Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

In the 2021 MPFS final rule, CMS recognizes the value of audio-only services given the widespread support for the continuing need for audio-only conversations with patients. To address this need the Agency is establishing HCPCS code G2252 Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion. G2252 will have a direct crosswalk to CPT code 99442, the value which most accurately reflects the resources associated with a longer service delivered via synchronous communication technology, which can include audio-only communication.

III. Selection of E/M Levels

On an interim basis, office/outpatient E/M level selection when furnished via telehealth can be based on medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter. Any requirements regarding documentation of history and/or physical exam in the medical record have been removed. CMS established that the times listed in the code descriptors are the most appropriate for the purpose of E/M level selection.

This policy only applies to office/outpatient visits furnished via Medicare telehealth, and only during the COVID-19 PHE.

IV. Radiation Oncology Treatment Management During COVID-19

During the COVID-19 PHE, telehealth flexibilities are broadened to include in-person, face-to-face interactions associated with radiation oncology on-treatment visits (OTVs) under CPT Code 77427 – Radiation Treatment Management, 5 treatments, recognizing that practices will need flexibility to ensure that both care teams and patients are protected from exposure to the virus. The telehealth OTV requires the provider to use an interactive audio and video telecommunications system for real-time interactive communication between the physician and the patient, including the use of telephones that have audio and video capabilities, desktop or mobile computing devices with audio and video capabilities allowing for two-way communication. Physicians should use the option to utilize virtual two-way communication in the office judiciously and only during this emergency when the radiation oncologist deems that a regular face-to-face interaction would put the patient or physician at risk for COVID-19 infection. CMS will discontinue the application of telehealth for the OTV of 77427 at the end of 2023.

For Medicare telehealth services, physicians are instructed on an interim basis to apply the CPT telehealth modifier -95 Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System to claim lines that describe services furnished via telehealth. Physicians should report the POS code based on the location in which they would have normally provided the service and then append modifier -95 to indicate that the service was delivered during the COVID-19 PHE.

VI. Supervision Policies During COVID-19 Public Health Emergency

On an interim basis, CMS relaxed certain Medicare supervision policies to support radiation oncologists’ ability to continue treating patients during the PHE.

ASTRO has heard from members with questions regarding the IFR’s revised supervision policies and their application to radiation oncology services in hospitals and freestanding centers. This guidance represents ASTRO’s interpretation of the IFR and is intended for application only during the COVID-19 PHE.

Freestanding Supervision Policy During COVID-19

The IFR temporarily changes Medicare supervision policy for freestanding centers during the PHE.

Medicare policy for 2020 requires adherence to “direct supervision” for radiation oncology services paid under the Physician Fee Schedule in the freestanding setting. “Direct supervision” requires that the physician be immediately available to provide assistance throughout the duration of the procedure.

However, given the circumstances of the COVID-19 public health emergency, CMS stated in the IFR that it recognizes that in some cases, the physical proximity of the physician might present an additional exposure risk. According to the IFR, CMS states:

"In some cases, technology would allow appropriate supervision without the physical presence of a physician. In the context of the PHE for the COVID-19 pandemic, given the risks of exposure, the immediate potential risk to needed medical care, the increased demand for health care professionals in the context of PHE for the COVID-19 pandemic, and the widespread use of telecommunications technology, we believe that the individual practitioners are in the best position to make decisions based on their clinical judgement in particular circumstances.”

In the IFR, the Agency is revising the definition of direct supervision, for the duration of the COVID-19 PHE, as follows:

“Necessary presence of the physician for direct supervision includes virtual presence through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider.”

Furthermore, the IFR states that while physical presence may not be required during the PHE, the remotely supervising physician must still be immediately available to provide assistance and direction:

“We believe that telecommunications technology could be used in a manner that would facilitate the physician’s immediate availability to furnish assistance and direction without necessarily requiring the physician’s physical presence in the location where the service is being furnished, such as the office suite or the patient’s home.”

ASTRO interprets the revised definition to apply to all radiation oncology services delivered in the freestanding setting for the duration of the PHE. For additional information regarding the policy, practices are encouraged to review Section II. E. Direct Supervision by Interactive Telecommunications Technology in the IFR.

Hospital Supervision Policy During COVID-19

CMS also is adopting temporary flexibilities to diagnostic services provided in hospital outpatient settings.

Effective January 1, 2020, CMS requires hospitals to adhere to general supervision for many therapeutic services; however, this change did not apply to radiation therapy image guidance services, which are designated by CMS as diagnostic services and are assigned supervision levels according to their CPT codes. For example, CMS requires direct supervision for CT Image Guidance (CPT 77014).

However, in the IFR, CMS recognizes that given the circumstances of the COVID-19 PHE, hospitals should have the most flexibility possible to provide the services Medicare beneficiaries need. CMS states:

“We recognize that in some cases, the physical proximity of the physician or practitioner might present additional exposure risks, especially for high risk patients isolated for their own protection or cases where the practitioner has been exposed to the virus but could otherwise safely supervise from another location using telecommunications technology. In these cases, we believe that the current definition would necessarily limit access to diagnostic procedures and tests that could be appropriately supervised by a physician, including one who is isolated for purposes of limiting exposure to COVID-19.”

CMS is allowing for the direct supervision of hospital outpatient diagnostic services to be met through the virtual presence of the physician through audio/video real-time communications technology, when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider during the COVID-19 PHE.

ASTRO interprets the revised policy to apply to both CT Image Guidance (CPT code 77014) and Stereoscopic X-Ray Guidance (CPT code 77421) for the duration of the PHE. For more information regarding the hospital outpatient policy, practices are encouraged to review Section II.E.1. Supervision Changes for Certain Hospital and CAH diagnostic and Therapeutic Services in the IFR.

Finally, in the 2021 MPFS final rule, CMS is finalizing policy revisions related to the scope of practice for physician fee schedule services that would allow NPs, CNSs, PAs and CNMs to provide the appropriate level of supervision assigned to diagnostic tests, to the extent authorized under State law and scope of practice. In accordance with statute, these NPPs would be working either under physician supervision or in collaboration with a physician. According to CMS, this flexibility is designed to increase the capacity and availability of practitioners who can supervise diagnostic tests, which would alleviate some of the demand on physicians as the only source to perform this specific function. This provision is permanent and will not expire at the end of the PHE. ASTRO remains concerned regarding the impact this policy will have on patient safety.

VII.Hospital Services Accompanying a Professional Service Furnished Via Telehealth

According to guidance issued by CMS in the March 30 COVID-19 IFR, when a physician who ordinarily practices in an Hospital Outpatient Department (HOPD) furnishes a telehealth service to a patient who is located at home, they would submit a professional claim with the place of service code indicating the services were furnished in a HOPD and using the CPT telehealth modifier-95.  Medicare pays the physician under the Physician Fee Schedule at the “facility” rate as if the service were furnished in the HOPD. The March 30 IFR did not provide any guidance regarding whether the hospital should submit claims associated with the service under this scenario.

In the April 30 IFC, CMS acknowledges that hospitals still provide some administrative and clinical support for services that are provided via telehealth. During the COVID-19 PHE, when telehealth services are furnished by a physician who ordinarily practices in the HOPD to a patient who is located at home, CMS will permit the hospital to bill and be paid the originating site facility fee amount for those telehealth services. The facility fee may be billed only if the HOPD is an excepted off-campus provider based department (PBD) that furnished services prior to November 2, 2015, and obtained an extraordinary circumstances relocation exception. ASTRO urges HOPD practices to confirm that these requirements have been met prior to billing the facility fee. Additionally, hospitals that meet the requirements may bill the facility fee if the physician is at a distant site and the patient is located in an excepted off-campus PBD. CMS requires documentation in the medical record of the reason for the visit and the necessity of the visit.

VIII. Guidance on Private Payer/Medicaid Coverage for Telehealth Services

Private payers and state Medicaid plans operate under their own payment policies and are not obligated to follow Medicare's policies (except for Medicare Advantage plans that are required to follow Medicare denial/appeal rules). Many regional/national insurance plans have announced expanded coverage for select electronic services during the public health emergency, specifically virtual check-ins, e-visits and CPT 99211-99215 telehealth visits. These claims should include the -95 modifier (see Section III) indicating that a telehealth service was delivered.

Below are links to current private payer policies. ASTRO will provide updates as more information becomes available.

• BCBS Commitment on telehealth
  • Regence plans, owned by BCBS, applies this policy
• United Healthcare COVID-19 telehealth policy
  • United Healthcare Medicare Advantage COVID-19 telehealth policy
    • Oxford Health, owned by United Healthcare, applies these policies
• Aetna COVID-19 Telemedicine FAQs
• Humana COVID-19 Telehealth - Expanding access to care
• Cigna's response to COVID-19
• Anthem COVID-19 Information for Providers
  • WellPoint, owned by Anthem, applies this policy
• Highmark COVID-19 Telemedicine and Virtual Visits

CMS encourages states to use available flexibilities under the Medicaid program to consider telehealth modalities of care delivery to ensure continued access to care while also combating the COVID-19 pandemic. CMS has also issued guidance in a few states (including Illinois, Michigan, Ohio, Rhode Island, and New York as of this writing), in coordination with agencies in those states, to permit flexibility in Medicare-Medicaid Plans (MMPs) to substitute telehealth services for face-to-face interactions where appropriate. This flexibility extends either through May 31, 2020, or until the particular state’s declaration of public health emergency has lifted.

IX. HIPAA Compliance

During the COVID-19 PHE, covered health care providers subject to the HIPAA Rules may seek to communicate with patients, and provide telehealth services, through remote communication technologies. Some of these technologies, and the manner in which they are used by HIPAA covered health care providers, may not fully comply with the requirements of the HIPAA Rules. OCR will allow the use of popular applications for video chats, including Apple FaceTime and Google Hangouts, to provide telehealth, but will not allow applications that are public-facing, such as Facebook Live, Twitch and TikTok. View OCR’s complete discussion of applications and recommendations for improving privacy. Providers are encouraged to notify patients that third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.

OCR (Office of Civil Rights) will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 PHE. 

CMS will also use enforcement discretion related to copays to decrease cost barriers for beneficiaries receiving care.

Please view the HIPAA enforcement notice for more information.

Radiation oncology clinics are making widespread and unprecedented practice changes to continue treating cancer patients and support broader health care system efforts to stop COVID-19. This is an ever-evolving situation and ASTRO will continue to provide updates as they become available.