This article was originally published on March 27th and has been updated as of April 30th. It will continue to be updated as new information becomes available.

Can RHCs and FQHCs bill for telehealth?

On March 27, 2020, President Trump signed the CARES Act into law. The CARES Act includes language that does allow RHCs and FQHCs to serve as the distant site for telehealth services. This means that the RHC/FQHC provider, located at the RHC/FQHC may provide telehealth visits to a Medicare beneficiary. The expansion of telehealth under the 1135 waiver, released earlier in March, expanded the definition of the originating site: patients do not have to be located in a rural area, and patients can be seen for telehealth services from their home or place of residence. A pre-existing relationship with the patient is not required in order to provide telehealth services during this national emergency.

RHCs and FQHCs may furnish distant site services so long as the service is provided by a qualified RHC/FQHC provider operating within the scope of their license. Services may be provided from any location, including the provider’s home, for the duration of the COVID-19 public health emergency. Providers may provide any telehealth that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS). Here is a link to the approved services, update April 30.

Services may be provided by any provided in the RHC or FQHC working within the scope of their license. This does include Registered Nurses (RNs) performing nursing only visits under CPT code 99211. During the emergency period, these qualify for telehealth reimbursement at the newly established payment rate.

Depending on your state’s Medicaid policies, RHCs, and FQHCs may be able to bill telehealth services to Medicaid patients. Both Kentucky and Indiana allow RHCs and FQHCs to bill as the distant site for Medicaid patients. The reimbursement for a distant site telehealth service under Medicaid is equivalent to the same service provided in person. Here is a link to the Center for Connected Health Policy which provides information on state-specific telehealth policies.

What is the reimbursement for telehealth for RHCs and FQHCs?

On April 30th, CMS released updated reimbursement information for telehealth distant site services furnished by RHCs and FQHCs. The new payment rate has been increased to $92.03.The expansion of telehealth for RHCs and FQHCs released on March 27th required that CMS develop payment rates for these services that is similar to the national average payment rates for comparable telehealth services allowed under the PFS. This new payment amount is the average amount for all PFS telehealth services adjusted by CMS for volume of those services reported under the PFS.

For those telehealth distant site services provided between January 27, 2020 and June 30, 2020, CMS will pay RHCs their All-inclusive rate (AIR) and will pay FQHCs based on the Prospective Payment System (PPS) rate for telehealth distant site services. Once the Medicare claims processing system is update on July 1, 2020 with the new payment rate ($92.03), these claims will automatically be reprocessed with the appropriate payment adjustment.

For those RHCs with an AIR that is less than $92.03, CMS will make an additional payment for the difference between your AIR and the newly established payment rate for all applicable claims. For those RHCs and FQHCs with rates higher than $92.03, CMS will recoup money for all applicable claims to account for the payment difference.

Telehealth distant site services provided on or after July 1, 2020, RHCs/FQHCs will be paid the newly established payment rate of $92.03. This will remain in effect until the end of the COVID-19 public health emergency. Should the COVID-19 public health emergency extend after December 31, 2020, the payment rate will be updated based on 2021 PFS payment rates, adjusted for volume of these services reported under the PFS.

Since these telehealth distant site services are not paid under the RHC AIR, or the FQHC PPS rate, Medicare wrap-around payment are not applicable for these services. Any wrap-around payments submitted to MA plan for telehealth distant site services will be adjusted.

Here is a link to the updated MLN Matters article published by CMS on April 30th.

How should RHCs and FQHCs bill for telehealth services?

CMS released update telehealth billing guidance on April 30th:

For RHCs:

For those telehealth distant site services furnished between January 27, 2020 and June 30, 2020, RHCs must use the newly established G code, G2025 with the CG modifier. Reporting modifier 95 is optional. RHCs will continue to use the appropriate revenue codes.

Once the Medicare claims processing system is updated on July 1^st, 2020 with the newly established payment rate, RHCs should no longer include the CG modifier with G2025. Modifier 95 will still remain optional. This requirement will remain in effect until the end of the COVID-19 public health emergency.

For FQHCs:

For those telehealth distant site services furnished between January 27, 2020 and June 30, 2020, FQHCs will report three (3) HCPCS/CPT codes:

1. The appropriate FQHC PPS specific payment code (G0466, G0467, G468, G0469, or G0470);
2. The appropriate HCPCS/CPT code that describes the telehealth service provide, with a modifier 95;
3. The newly established G code, G2025, with a modifier 95.

If an FQHC furnishes services via telehealth that are not FQHC qualifying visits, FQHCs should hold these claims until July 1, 2020. At that time, FQHCs should bill these services with the newly established G code, G2025. The modifier 95 may still be reported, but is not required after June 30, 2020. Starting July 1, 2020, FQHCs will only be required to submit G2025 for telehealth distant site services, and modifier 95 will be optional. Again, this requirement will remain in effect until the end of the COVID-19 public health emergency.

For Medicaid and commercial payors who allow RHCs and FQHCs to bill telehealth distant site services, you will bill using POS 02, the appropriate CPT code for the service provided, and modifier GT or 95, depending on the specific payor’s policies. We have been informed that some commercial payors are requiring some unique modifiers in order to pass their system edits. You would need to reach out to the individual payor to know what modifiers they are requiring for telehealth services.

The link to the CMS update released on April 30th can be found here.

What if a patient does not have video capabilities? Are we able to provide for audio/telephone only services and bill for them?

Announced in a CMS update released on April 30: Effective March 1, 2020, the approved list of telehealth services now included CPT code 99441, 99442, and 99443. These are defined as audio-only telephone evaluation and management (E/M) services. RHCs and FQHCs may furnish these services and should bill for these services using the newly established G code, G2025. RHCs and FQHCs must meet all requirements for these services in order to bill. This means a physician or qualified health care professional who may report E/M services, must provide at least five (5) minutes of telephone E/M services to an established patient, parent, or guardian. These services may not be billed if they are related to a previous E/M service provided within the past 7 days, and may not leave to an E/M service or procedure within the next 24 hours or the soonest available appointment.

Several state Medicaid agencies are also allowing audio-only services to qualify as telehealth services and be billed as telehealth services. The patient chart must note that the patient does not have video capabilities and therefore the encounter took place via telephone only connection.

What other options do RHCs and FQHCs have for checking in with patients outside of telehealth; that do not require a visit to the office?

RHCs and FQHCs have a few additional options for checking in with patients without requiring an in-person visit.

Virtual Communication Services (G0071) – This is a time-based service requiring a minimum of 5 minutes of communication between a Medicare beneficiary and a provider in the RHC or FQHC. This communication must be patient initiated and may take place via phone call, store-and-forward method such as text message, patient portal, or integrated audio/video system. The medical discussion cannot be related to a condition in which the patient was seen at the RHC/FQHC within the previous 7 days, and cannot result in a visit to the RHC/FQHC within the next 24 hours or the soonest available appointment. Here is a link to the CMS FAQ released in December 2018 about Virtual Communication Services.

The reimbursement rate for G0071 will be temporarily increased to $24.76 to account for the additional of e-visits in the average payment calculation. This is effective with dates of service beginning March 1, 2020. This increased payment rate is an average of the national fee for service rates for the following codes: G2010, G2012, 99421, 99442, 99443. Note that G2061 – G2063 are NOT included and should not be billed by the RHC/FQHC to Medicare. MACs will automatically reprocess any claims reporting G0071 for dates of service on or after March 1, 2020 that were paid at the incorrect rate before the Medicare claims processing system was updated.

Here is a link to the interim final rule published on March 30th.

When should we report the new “CS” modifier on our claims?

According to an updated CMS release dated April 30th: For services furnished on March 18, 2020, and extending until the end of the COVID-19 public health emergency, CMS will pay all reasonable costs for specified categories of E/M services if they result in an order for or administration of a COVID-19 test and relate to the furnishing or administration of such test or to the evaluation of an individual for purposes of determining the need for such test. This does include applicable telehealth services.

For those services, as detailed above, to qualify, RHCs and FQHCs must waive collection of beneficiary coinsurance. For those services in which the RHC or FQHC waive coinsurance, a modifier “CS” should be reported with the related claim line. Because this also applies to telehealth services, RHCs may potentially have instances where both a modifier CG and a modifier CS are reported on the same claim line. Similarly, FQHCs may potentially have instances where both modifier CS and modifier 95 will both be reported on the same claim line.

RHCs and FQHCs claims with the CS modifier will be paid with coinsurance applied until July 1, 2020, at which time the Medicare Administrative Contractors (MACs) will automatically reprocess these claims. claims.

How should providers document these telehealth services?

Here are a few important documentation tips:

• Patient consent should be obtained for any non-face-to-face services provided, including virtual communication services, and telehealth services. It is acceptable for consent to be obtained at the time of the service, even if that consent is only able to be obtained verbally. Consent is able to be obtained by auxiliary personnel working under the general supervision of a RHC/FQHC provider. Document the patient’s consent in the patient’s medical record for the visit.
• As with a face-to-face visit, the documentation for a telehealth service should support the type and level of service provided.
• It is encouraged to record start and stop times for any telehealth, virtual communication, or e-visit service completed since these are time-based services.
• If your RHCs/FQHCs are choosing to use a non-HIPAA compliant platform to provide telehealth services, you should obtain the patient’s verbal consent to using said platform, and document that consent in the encounter note. It is also recommended that providers document that the service is being provided via telehealth.
• All documentation should be finalized within 48-hours of the service being provided. Some states have different requirements – either way, timely and accurate completion of medical records is always recommended.
• Some EHR systems have a separate telehealth documentation platform to ensure providers are documenting all necessary elements of a telehealth encounter. We encourage you to reach out to your EHR vendor to have this feature turned on if it is available. If your EHR system does not have this feature, providers may consider creating a specific telehealth template to ensure they are capturing all necessary elements of the telehealth encounter.

Can our RHC/FQHC providers provide telehealth services from their home?

During the COVID-19 public health emergency, CMS has waived the requirement for providers to update their provider enrollment records to reflect their homes as a site of service. RHC and FQHC providers are authorized to provide approved telehealth services from any location, including their home.

Will this pandemic impact our clinic’s productivity standard calculation?

Yes, likely. We are aware of many clinics seeing reductions in visits due to cancellations or redirected patients. We recommend clinics have practitioners perform time studies breaking out time between direct patient care time, direct COVID-19 patient care time, telehealth time, downtime (no patients), and PTO (vacation, sick, holiday, etc.). We believe this will allow clinics to identify time accurately to assist with any future visit calculations.

Will our uncapped all-inclusive rate be impacted if our hospital needs to increase beds over the currently thresholds during the COVID-19 national emergency?

Due to the COVID-19 pandemic, CMS issued a blanket waiver on April 30, 2020, stating they will use the number of beds from the cost reporting period prior to the start of the PHE. This will allow hospitals to increase their bed capacity to more than 50 beds and still receive the uncapped AIR. The effective start date in the blanket waiver for the COIVD-19 PHE is January 27, 2020.

If we provide telehealth service, should we track the expenses and time related to these services separately?

Yes. The cost report includes a cost center for these services. We recommend creating a new department to identify the expenses and track the visits and hours the practitioners perform these services separately. Language in the CARES Act confirms that costs associated with telehealth services should not be used to calculate the RHC all-inclusive rate.

If we treat a suspected COVID-19 patient, should we separately track the expenses and time related to treating these patients?

Yes. We believe these services will not be reimbursed at the all-inclusive rate and therefore recommend each clinic separately to identify the direct patient care expenses and visits related to these services. We also recommend the clinic set up a separate department to identify these expenses. Be sure to include any contract expenses for these services as well.

What are best practices for treating patients during the COVID-19 emergency?

If a patient has COVID-19 symptoms, or possible exposure to a COVID-19 patient, you should NOT bring that patient into your RHC/FQHC. Try to encourage a telehealth visit, when possible, to reduce exposure. You can also direct them to your state’s COVID-19 hotline or the local health department to determine if they qualify for testing.

For any patient who is acutely ill, encourage a telehealth visit, if possible. If the patient wishes to be seen by a provider, and they have symptoms of fever, cough, or shortness of breath, consider setting up a “parking lot visit” rather than bringing the patient into the RHC/FQHC. Since the parking lot is part of your clinic, and assuming all other elements of a qualified RHC/FQHC service are met, these visits can still be billed as RHC/FQHC encounters. Of course, you can also do these “parking lot visits” for patients who have other symptoms as well.

Providers and any staff interacting with a patient exhibiting any of the symptoms of COVID-19, should always wear appropriate PPE to reduce exposure.

For well-child visits: If the child is under the age of 1, or in need of a required vaccine (not just a booster), the American Academy of Pediatrics is still encouraging providers to see those patients so that they are able to get their vaccines. If the child is current on all required vaccines, consider rescheduling to a later date.

For any patient being seen in your RHC/FQHC, is it recommended to limit the number of visitors allowed during the visit. For children being seen, limit the number of visitors to one (1) parent or guardian. For adults, limit visitors to only the patient. Even if the patient has to have someone else drive them to the appointment, that person should remain in their vehicle rather than coming into the RHC/FQHC. You can encourage them to call the front desk when they arrive and a staff member may assist the patient inside. When the patient’s visit is over, a staff member may assist that patient back out to their vehicle. This will reduce the number of exposures and potential contacts.

Can we change our RHC/FQHC hours of operation to relocate providers to areas of need or account for high volume in cancelations or re-directed patients?

The CMS conditions for participation for RHCs and FQHCs do not specifically require outpatient healthcare facilities to remain open during certain hours, however, certain states do have a “minimum operating hours” requirement. We believe the clinic should make the decision based on the resources it needs during this national emergency. If the change in hours is temporary we recommend the clinic post signage at the entrance and post the change on its website or any social media. We recommend contacting your state Office of Inspector General to communicate any change in hours, even if only temporarily, and to verify whether or not your state has a “minimum operating hours” requirement.

If there is a change in hours or temporary closure of your RHC or FQHC, the clinic should take all necessary steps to notify patients and the general public of these changes. Post signage at your clinic, post on websites and social media outlets, and send out letters to patients, if necessary. If any of your contracts contain language regarding call coverage, you will need to contact that specific payor to discuss a temporary change to your contract, or ensure that adequate call coverage is provided, per your contract language. Document any and all changes your RHC or FQHC makes operationally during this national emergency.

If the clinic decides to keep normal operating hours, we recommend having the clinic document practitioners time by performing time studies breaking out time between direct patient care time, direct COVID-19 patient care time, telehealth time, down time (no patients), and PTO (vacation, sick, holiday, etc.).

Are there any extensions to the Medicare cost report due dates?

Yes. If your fiscal year-end is October 31, 2019, or November 30, 2019, the due date to file your cost report has been extended to June 30, 2020. If your fiscal year-end is December 31, 2019, the due date to file your cost report has been extended to July 31, 2020.

What other provisions of the CARES Act might apply to RHCs/FQHCs?

Under the CARES Act, there are a few different pieces of the legislation the RHCs/FQHCs should take advantage of, or at least consider:

• Beginning May 1, 2020, Medicare will temporarily suspend the 2% sequestration reduction to Medicare payments. This will continue through December 31, 2020.
• The law expands the CMS accelerated payment policy in an effort to get payments to hospitals more quickly. Currently, CMS has an accelerated payment policy for extraordinary circumstances that allows hospitals to receive an advance on Medicare payments if they have experienced financial difficulties due to a delay in payments or in other exceptional situations. The CARES Act makes revisions to this program, including:
  • Increasing the prepayment amount from 70% to 100% (125% for critical access hospitals) of expected Medicare payments
  • Increasing the length of time accelerated payments may cover from three to six months
  • Delaying the start of recoupment of any overpayments from 90 to 120 days
  • Extending the due date for any outstanding balances from 90 days to one year.

(*Please note that CMS is currently in the process of reviewing the Accelerated Payments Program.)

There are likely other tax-related benefits or business operations considerations within the CARES Act or other previously released regulations that might apply to your RHC or FQHC. Please visit our Coronavirus Resources & Information for additional guidance on related items. 

If you have further questions, please contact one of our RHC and FQHC team members.