Prior publication: None  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45 46 47 J o u r n a l P r e -p r o o f RVU: Relative Work Unit 10 VT: video synchronous telehealth 11   12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36 37 38 J o u r n a l P r e -p r o o f
To reduce the transmission of SARS-CoV-2, the cause of COVID-19, public health experts 17 recommended social distancing, and many states ordered the public to stay home. 18
Contemporaneously, federal and state authorities liberalized the use and reimbursement of 19 telehealth services. Following social distancing guidelines, both large healthcare organizations 20 and independent medical practices retooled to deliver outpatient care remotely utilizing 21 telehealth technology. 1 The technology predominantly used to replace in-person visits was real-22 time audio and video services. In some cases, the transition to a virtual practice occurred 23 overnight. 2 Telehealth allowed providers and organizations to diagnose and treat COVID- 19 24 infected outpatients at a distance while continuing to provide uninterrupted longitudinal care to 25 patients not directly affected by the virus. 26 J o u r n a l P r e -p r o o f critical access hospital-based renal dialysis center and satellites, skilled nursing facilities, and 1 community mental health centers. 9, 10, 14 Additionally, originating sites needed to be located in 2 rural health professional shortage areas, counties outside of a metropolitan statistical area, or a 3 site participating in a Federal telemedicine demonstration project approved by, or receiving 4 funding from, the Secretary of Health and Human Services (HHS) as of the end of 2000. 9,14 5 Legislation passed in 2018 expanded coverage for telehealth stroke care to include mobile 6 stroke units. 11 7 8 Beginning in 2019, Medicare reimbursed for communication technology-based services, which 9
included virtual check-ins, remote evaluation of video or recorded images, and subsequently, e-10 visits (Table 2) . 12, 15 Claims for communication technology-based services could be submitted for 11 established patients who consented to the service. Consent was required so beneficiaries 12 understood their responsibilities for cost-sharing (i.e. deductible and copay). 12, 15 Providers in 13
Rural Health Clinics and Federally Qualified Health Centers used the Healthcare Procedure 14
Coding System (HCPCS) code G0071 for 5 minutes or more of virtual communication or remote 15 evaluation of video/images when there was an in-person visit in the prior 12 months. 12 16 17 Beginning in 2020, CMS allowed Medicare Advantage plans to offer telehealth benefits 18 equivalent to those offered by Medicare fee-for-service without the restrictions Medicare fee-for-19 service placed on telehealth use. 16 Medicare Advantage plans were able to offer VT and 20 telephonic services without the requirement for an originating site outside of the home. 21
However, CMS also provided Medicare Advantage plans latitude to determine which telehealth 22 services were clinically appropriate each year, and not all Medicare Advantage plans included 23 comparable telehealth benefits. 17 
Medicare Changes for COVID- 19 26 J o u r n a l P r e -p r o o f In response to COVID-19, CMS allowed broader use of Medicare telehealth services (Table 3) . 1
The Secretary of HHS declared a public health emergency, and the president issued a 2 proclamation of national emergency under the National Emergencies Act. These actions 3 provided the Secretary of HHS broad authority to issue waivers and modifications under section 4 1135 of the Social Security Act affecting Medicare, Medicaid and the Health Insurance 5
Portability and Accountability Act (HIPAA). 18 Additionally, the Coronavirus Preparedness and 6
Response Supplemental Appropriations Act, enacted on March 6, 2020, waived Medicare 7 restrictions and requirements for telehealth services. 19 These waivers and modifications 8 expanded outpatient telehealth reimbursement, and thus, access to services for Medicare fee-9
for-service beneficiaries. 10 11 CMS announced expanded telehealth coverage on March 17, 2020, followed by two CMS 12 interim final rules, which were applied retroactively to March 1, 2020. 20,21 The contents of both 13 final rules applicable to outpatient telehealth are described below with a focus on telehealth as a 14 substitute for evaluation and management (E/M) services. CMS noted it would continue to add 15 telehealth services for the duration of the public health emergency. 20 The place of service code for a VT E/M claim is chosen based on the location where a 9
practitioner typically provides care in person, irrespective of practitioner's actual location when 10 VT is provided (Table 4 ). 21, 24 Historically, the place of service code 02 was used for traditional 11
Medicare telehealth services. According to CMS, the place of service code 02 should not be 12 used for practitioners newly providing VT as a replacement for in-person visits. Instead, the 13 place of service codes listed in Table 4 are used. 24 Claims submitted using the place of service 14 code 11 are reimbursed at the physician fee schedule non-facility rate. When place of service 15 code 19 or 22 is used for hospital outpatient departments, claims are reimbursed at the 16 physician fee schedule facility rate, which is lower than the non-facility rate. The facility may 17 then submit a claim to receive a facility origination site fee even when the practitioner delivers 18 VT from home. The CPT code for VT outpatient visits is based on medical decision making (MDM) alone 21 without consideration of history or physical exam components, or based on total time ( Table  22 5). 20, 25 Time-based coding includes all time spent on the day of the visit: pre-charting, visit, and 23 post-visit documentation. This change was already planned for 2021 but its introduction was 24 accelerated due to the pandemic. 25 for the time the teaching physician is present in the virtual encounter (Table 6 ). This does not 4 hold true for primary care centers. Through the primary care exception, which was expanded for 5 COVID-19, residents can provide all levels of E/M services without direct interaction between 6 the teaching physician and beneficiary, and bill using the modifier GE. When a teaching 7 physician interacts with a patient, according to CMS, documentation must describe whether the 8 teaching physician was present in person or through VT. 9
10
In the second interim rule written in response to COVID-19, CMS acknowledged that use of 12 telephonic visits as a replacement for outpatient E/M services was more prevalent than 13 expected. Therefore, CMS began providing reimbursement and work Relative Value Units 14 (RVUs) for telephonic CPT codes (Table 7) . 21 Based on this new reimbursement, the work RVU 15 for a 30-minute phone visit is coequal with a level 4 return patient visit. There is no current 16 reimbursement for telephonic visits longer than 30 minutes. furnishes services in a state where the emergency is occurring, and 4) is not excluded from 10 practicing in the state or any other state that is part of the emergency. 26 However, state 11 requirements for licensing still apply. 12
The public health emergency pushed some states to issue waivers allowing providers to deliver 14 telehealth from outside of the state, whereas, others required in-state licensure but would allow 15 out-of-state practitioners to obtain a license. 27 The need for medical licenses in multiple states to 16 provide telehealth poses a challenge for practitioners whose established patients live across 17 state lines. 18 19 Medicare Advantage 20 CMS allows Medicare Advantage plans to expand telehealth coverage for beneficiaries and 21 reduce or eliminate cost-sharing, but these changes are not required. 28 As an example, 22
telephonic E/M services may be reimbursed less frequently by Medicare Advantage plans due 23
to CMS handling of risk-adjusted payments. Normally, a Medicare Advantage plan receives a 24 monthly capitated payment from CMS based on the enrolled beneficiaries' health risk. 29 A 25 higher health risk results in a larger capitated payment. 29 Health risk is derived from diagnosis 26 J o u r n a l P r e -p r o o f codes documented at in-person or VT encounters. Unfortunately, diagnosis codes from 1 telephonic visits cannot be submitted for health risk adjustment, and therefore cannot contribute 2 to increased capitated payments from CMS. 30 This may disincentivize the coverage and 3 reimbursement of telephonic E/M visits and disproportionally limit telehealth access for patients 4 who would otherwise rely on telephonic visits, particularly, those aged 65 years and older. 21,31 5 6 Medicaid Prior to COVID- 19 7 Reimbursement for Medicaid telehealth services varied widely between states. A report from the 8
Center for Connected Health Policy published in 2020 using data from before the public health 9 emergency highlighted these differences. 5 All states had policies in place that required Medicaid 10 reimbursement for VT but reimbursement restrictions were placed on the service, provider 11 delivering the service, geographic location of beneficiary, originating site, and whether there was 12 reimbursement parity with similar in-person visits. Prior to the public health emergency, 5 states 13 placed geographic limitations on telehealth services and 19 states allowed the home to serve as 14 an originating site. 5 Though, home origination was not available for all services and could be 15 restricted to mental health services or beneficiaries with chronic conditions. 5 
Although coverage by Medicaid for VT has generally increased, variability between states 22 remains. Differences exist in services covered, complexity of outpatient covered services, 23
whether services could be offered to new or existing beneficiaries, and acceptability of HIPAA 24 noncompliant technology. [33] [34] [35] [36] Further complicating matters, not all states require equivalent 25 telehealth expansion by both Medicaid fee-for-service and Medicaid managed care 26 J o u r n a l P r e -p r o o f organizations. 37 Therefore, within the same state, a service provided through VT may be 1 covered by Medicaid fee-for-service but not covered by a Medicaid managed care organization. The submission of a VT service claim to Medicaid varies by state and does not align with 9
Medicare. Unlike Medicare, states may require the place of service code 02, indicating 10 telehealth services, with the addition of separate modifiers like GT (via interactive video and 11 audio) as a substitute for modifier 95, and/or the modifier CR (catastrophe/disaster related). 39 12 13 Commercial Insurance Prior to COVID- 19 14 Laws existed in 42 states governing insurance coverage by commercial insurers for telehealth. 5 15
The majority of these laws included a requirement for telehealth coverage parity but not 16 reimbursement parity. 40, 41 Insurance coverage parity laws state that a telehealth visit must be 17 The largest commercial payers in the United States increased access to telehealth, often for a 1 limited time specific to the declaration of a public health emergency. Telehealth coverage is 2 heterogenous based on plan, and reimbursement parity for VT or telephonic E/M services is not 3 guaranteed. 42 This variability and limited service underscores the need for state legislation 4 regulating commercial coverage and reimbursement of telehealth services including telephonic 5 visits. Many states enacted new rules broadening the use of telehealth but none were directed 6 at reimbursement parity other than Washington state. 36,38 7 8
The COVID-19 public health emergency has revealed the benefits of outpatient home 10 synchronous telehealth as a substitute for in-person E/M visits. In a matter of weeks, barriers 11 that prevented broader adoption of VT were removed: reimbursement regulations at the federal 12 and state level, 43 lack of patient and clinician acceptance, [44] [45] [46] and cost of implementation. 45 13 Organizations and practitioners without prior telehealth capabilities transitioned to delivery of 14 outpatient care through telehealth. Video and audio synchronous telehealth E/M visits increased 15 substantially in March 2020, offsetting the reduction in in-person services. 47 In April 2020, 43.5% 16 of Medicare primary care visits were provided through telehealth compared to 0.1% one year 17 prior. 48 Fair Health, which maintains a database of billions of commercial and Medicare claims, 18
reported an increase in telehealth claims from 0.15% in April 2019 to 13% in April 2020, an 19
increase of 8336%. 49 After reaching a peak in April, however, the percentage of telehealth visits 20 has continually declined. 47 Reasons for this decline include increased in-person visits as offices 21 reopened and uncertainty over the future of telehealth insurance coverage and reimbursement. 22 23 Overall, telehealth has been embraced by both patients and providers. Telehealth use improves 24 the patient experience through reduced travel and shorter visit wait times. 50, 51 Approval ratings 25
for VT as a replacement for in-person visits are high among both patients and providers. 50, 52 Of 26 patients surveyed in a gastroenterology/hepatology clinic after transition to VT in response to 1 COVID-19, 96% reported being somewhat/very satisfied with the medical care, 78% thought the 2 technology was easy to use, and 78% were somewhat/very satisfied with quality of the 3 experience. 52 However, building trust and rapport through in-person appointments remains 4
important. Patients are more willing to have a VT visit with a known provider rather than 5 someone with whom no in-person relationship has been established. 53 6 7 There are clear benefits to the use of outpatient synchronous telehealth to connect patients and 8
providers during the COVID-19 pandemic. New and existing patients are seen without leaving 9 their homes, and patients with COVID-19 receive care while isolated at home or after hospital 10 discharge. The benefits of outpatient telehealth before COVID-19 were centered around 11 increasing access to care, particularly in rural and underserved areas, and convenience of 12 receiving care. 54 Due to COVID-19, many providers connect with their own patients at home 13 utilizing VT when they previously did not. 14 15
To date, there is scant evidence demonstrating whether quality of provider-rendered diagnosis 16 and management for VT at home is equivalent to traditional in-person visits. Additionally, the 17 impact of increased telehealth use on malpractice claims is unknown. 55 To reduce risks for 18 misdiagnosis, providers can perform a limited exam during the visit and ask patients to return for 19 an in-person visit or further testing if feasible. 55, 56 Home VT telerehabilitation seems to have 20 equivalent outcomes when compared to in-person care. 57, 58 Evidence also exists for the 21 equivalence of VT used to provide telemental health, and to provide care for patients with 22 chronic illnesses such as heart failure and diabetes when combined with telemonitoring and/or 23 mobile health. 57 
The effect of greater telehealth use on health inequities is unclear. In 2017, an estimated 5.8 1 million people in the United States delayed medical care due to issues with transportation. 60 2
Transportation barriers disproportionally affect those with lower socioeconomic status, Latino 3 ethnicity, and functional limitations. 60, 61 VT at home reduces the need to travel for care and may 4 improve access for these vulnerable populations. However, VT at home requires both 5 broadband internet service and a mobile device or computer. Broadband internet access 6 reaches 97% of Americans in urban areas, 65% in rural areas, and 60% on Tribal lands. 62 7 Demographic factors associated with lower access to broadband internet include lower 8 socioeconomic status, lower education level, African American race, Latino ethnicity, and age 9 65 years and older. 31 For adults with incomes below 30,000 dollars a year, 29% do not own a 10 smartphone, 44% do not have access to broadband internet service, and 26% are dependent 11 on smartphones for internet access. 63 Therefore, expanded insurance coverage for home VT 12 may reduce transportation barriers while still resulting in less equitable access to healthcare for 13 underserved populations. 14 15
Before COVID-19, one of the most utilized outpatient home E/M telehealth services was direct 16 to consumer (DTC) telemedicine. DTC telemedicine differs from Medicare telehealth services, 17
prior to the pandemic, as it occurs directly between a patient and provider, and is initiated by a 18 patient rather than a provider at an originating site. 64 Consumers use DTC telemedicine for 19 access to on-demand primary or urgent care 24/7. 64-66 When a DTC telemedicine visit is 20 initiated, the practitioner reached may be someone with whom the patient has an existing 21 relationship, an associate provider within the same practice or health system, or a new provider 22
in a different organization. 53 DTC telemedicine service is offered by both health systems and 23 commercial DTC companies like Teladoc, MDLive, and AmWell. 64 in-person services. 70 One study found that commercial DTC telemedicine visits were used to 5 supplement, rather than substitute, in-person services. 70 In fact, a report by MedPAC stated that 6 commercial insurers covered DTC telemedicine due to employer request, competition from 7 other insurers in their markets, and state telehealth parity laws but not necessarily to reduce 8 costs. 66 9 10 Without further legislation at the state and federal level, the emergency waivers will eventually 11 expire resulting in the resumption of prior telehealth restrictions. To permanently expand 12 telehealth use, several bills have been proposed in Congress. 71, 72 Additionally, through 13
Executive Order, the president has requested that the Secretary of HHS propose a regulation 14 extending broadened telehealth services beyond the public health emergency, which has been 15 extended to January 31, 2021. 73,74 16 17
To meet the health needs of the U.S. population during the COVID-19 pandemic, federal and 19 state governments, together with commercial insurers, have removed barriers to telehealth 20 permitting clinicians and other practitioners to provide care at a distance. The patients who have 21 benefitted most from the greater availability of home telehealth services are those who have 22 difficulty leaving the home due to chronic illness, travel a long distance to see a specialist, or 23 live in an underserved location with poor access to care. It remains unclear whether the 24 expanded telemedicine services will persist beyond the pandemic. It is hoped that CMS and 25 commercial insurers will maintain these vital services while keeping restrictions in place to 26 prevent overuse. Further research is needed to better understand the quality and cost-1 effectiveness of outpatient E/M services delivered through video synchronous telehealth at 2 home. Finally, we need ensure those with the least access to internet and technology are not 3 left behind in this healthcare delivery revolution. 4 5
Financial Disclosures: none 7
The authors would like to thank Christina Hao Wang, MD, for writing assistance, language 8 editing, and proofreading. Virtual check -in 5-10 minutes of medical discussion between a physician, or other qualified healthcare professional, and patient using synchronous audio or video technology, not originating from an E/M service within the previous 7 days, nor leading to an E/M service in the next 24 hours or soonest appointment.
Remote evaluation of pre-recorded patient information
Remote evaluation of video and/or images (e.g. store and forward technology) for which the provider must document interpretation and respond to sender within 24 business hours using a telephone, video, secure text messaging, email, or a patient portal. The request cannot originate from an E/M service within the prior 7 days or lead to a related E/M service in the next 24 hours or soonest appointment. E/M = evaluation and management MDM = medical decision making * Limited beneficiaries included those enrolled in a next generation accountable care organization, who received home dialysis, or underwent treatment for a substance use disorder or co-occurring mental health disorder. On-campus is defined as the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider's campus.
Off Campus-Outpatient Hospital Department
A portion of an off-campus, hospital provider-based department, which provides diagnostic, and rehabilitation services to those who do not require hospitalization or institutionalization.
Off-campus does not meet the definition of on-campus.
Telehealth The location where health services and health related services are provided or received, through a telecommunication system. 02
J o u r n a l P r e -p r o o f Both the patient and physician will be at their respective homes during the visit. Typically, the physician would see this patient in an office setting.
The night before, the physician prepares by writing a basic note taking 10 minutes.
The day of the visit, there is another 5 minutes of preparation reviewing prior data.
The visit lasts for 25 minutes during which the physician discusses three stable chronic problems.
Later the same day, the physician spends 5 minutes finishing the note and another 5 minutes speaking with the referring primary care nurse practitioner.
Modifier 95
Place of service code 11
The physician spent a total of 40 minutes on the day of a synchronous audio and video telehealth visit. Using time-based billing, this corresponds to a 99215, or level 5 visit. The 10 minutes spent the day prior to the visit is not included.
The modifier alerts Medicare to this being a telehealth visit utilizing synchronous audio and video technology.
Submitting this claim using the place of service code 11 indicates to Medicare that this visit would typically take place in an office.
A fellow has a scheduled 60-minute new patient visit via synchronous audio and video telehealth.
The fellow, her supervising physician, and the patient will all be at their respective homes during the visit. Typically, the patient would be seen in hospitalassociated clinic that is located across the street from main hospital (100 yards).
On, the day of visit, the fellow spends 20 minutes preparing a note and reviewing data before the visit.
The visit lasts for 50 minutes, during which the supervising physician joins for 10 minutes. During the visit, a new lung nodule is discussed and there is a plan for PET-CT scan.
Later the same day, the fellow spends 20 minutes completing the note and the supervising physician spends 5 minutes attesting the fellow's documentation.
Modifier 95
Place of service code 22
The supervising physician spent a total of 15 minutes on the day of the audio and video synchronous visit. If a claim is submitted using time-base billing, the appropriate CPT code is 99202. Trainee time is not considered for time-based billing. Therefore, it is more appropriate to use MDM for this visit. When using MDM, the appropriate CPT code is 99204 which reflects a high complexity problem, low complexity data reviewed, and moderate complexity risk.
The modifier alerts Medicare to this being a telehealth visit utilizing synchronous audio and video technology.
Submitting this claim using the place of service code 22 indicates to Medicare that this visit would typically take place in an on campus-outpatient hospital department.
CPT = Current Procedural Terminology. Developed by the American Medical Association. MDM = medical decision making 