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Business of Practice

Recent changes in CMS guidance for telehealth regarding the in-person visit requirement and place of service codes

New rules reflect a forward-looking framework but may cause some confusion in the context of the temporary rules created for the COVID-19 public health emergency.

Cite this
American Psychological Association. (2022, February 8). Recent changes in CMS guidance for telehealth regarding the in-person visit requirement and place of service codes. https://www.apaservices.org/practice/clinic/cms-telehealth-service-codes

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With recent changes in telehealth coding guidance put forth by the Centers for Medicare & Medicaid Services (CMS) and alterations to guidance relating specifically to the ongoing COVID-19 public health emergency (PHE), proper coding can be a challenge.

APA has noted confusion around Point of Service (POS) coding for telehealth during the PHE. In addition, CMS recently released new information about the in-person visit requirement for mental health services added through federal legislation.

Some of the confusion relates to CMS putting forth guidance regarding POS codes for telehealth, but not placing this in the context of how providers in Medicare have been instructed to bill for telehealth during the PHE, which has been extended until April 16, 2022, and may be extended further.

In Medicare, telehealth providers have been instructed to use POS 11 along with modifier 95 during the PHE. This is to insure that during the PHE providers are reimbursed at the higher nonfacility rate. For details about facility versus nonfacility rates, please see: Telehealth after the pandemic: CMS outlines proposed changes.

APA believes the intent of CMS’s recent change (Change Request 12427) is to provide a standard code set for differentiating between telehealth received at a typical originating site (POS 02) versus telehealth received in the home (POS 10). These POS options can also be used by other payers to differentiate where the service is received. Please check directly with commercial insurers and Medicaid to determine their policies about POS coding for telehealth. 

Changes to the POS codes for 2022 are outlined below.

02 Telehealth provided other than in patient’s home

The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.

Effective January 1, 2017.

Description change effective January 1, 2022, and applicable for Medicare April 1, 2022.

10 Telehealth provided in patient’s home

The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

This code is effective January 1, 2022, and available to Medicare April 1, 2022.

Medicare has communicated that Change Request 12427 is not requiring Medicare providers to change anything on how they are currently billing their telehealth claims during the PHE.

In-person requirement

In MLN Matters article no. MM12549 (PDF, 170KB) (January 14, 2022), CMS discusses the in-person visit requirement required under the Consolidated Appropriations Act of 2021 for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders which takes effect after the official end of the PHE.

CMS explains that after the PHE ends, patients receiving telehealth mental health services must have an in-person, face-to-face (i.e., nontelehealth) visit within six months of the initial telehealth mental health service. Patients must then have another in-person, face-to-face visit within 12 months of the date of the initial six-month in-person visit. For patients who began receiving mental health services through telehealth during the PHE there must be an in-person visit no later than six months after the PHE ends.

CMS notes that there can be exceptions to the subsequent 12 month in-person visits, which must be documented in the patient’s medical record and provide the reason for the exception. Examples given by the agency include travel hardship and unreliability of the patient in scheduling. If the patient’s original telehealth provider is unavailable for the face-to-face visit a colleague in the same subspecialty and in the same group practice may provide the in-person service.

New modifiers

In the same MLN article CMS also introduces two new modifiers for use when billing for telehealth services. Of most interest to psychologists is modifier FQ, for when the telehealth service is furnished using real-time audio-only communication technology. Medicare is not requiring the use of this new modifier at this time.

A second new modifier, FR, indicates a supervising practitioner was present through real-time, audio-visual communication technology. The FR modifier will not be used by psychologists in Medicare since psychologists cannot bill for services provided by trainees.

Psychologists should continue to watch for communication from their MACs regarding any updates for billing Medicare. Psychologists should also check with commercial payers and Medicaid to determine how to bill for telehealth during the PHE and for implementation of the FQ modifier.