Answers to practicing psychologists’ latest questions about providing telehealth services

Psychologists are asking a lot of important questions as the COVID-19 crisis continues. APA Services, in collaboration with the California Psychological Association, provide a follow-up to our previous FAQs practicing psychologists have about COVID-19.

APA’s Ethics Code calls for psychologists who plan to provide services, teach or conduct research using new technologies should “undertake relevant education, training, supervised experience, consultation or study” [Standard 2.01(c)]. So, before offering telehealth services, psychologists should take steps to ensure competence in this area, such as by studying APA’s Guidelines for the Practice of Telepsychology, taking a relevant continuing-education course and learning more about HIPAA-compliant videoconferencing platforms.

Psychologists should also consult with their malpractice carrier to ensure that their policies cover the provision of telehealth services in their state of licensure and any other jurisdictions to which — or from which — they plan to provide telehealth services.

When deciding whether to initiate care with a new patient via telehealth, psychologists should rely on their clinical judgment, check their payer policies for coverage, visit the temporary changes to federal Medicare telehealth policies page, and consult their state’s telehealth laws and emergency orders.

Psychological services are often initiated using a videoconferencing platform with both audio and visual features but are not typically started using audio-only phone calls. It can be challenging to conduct a thorough mental status exam without video because the psychologist may miss important behavioral observations that are essential to the typical intake process.

During the COVID-19 public health emergency, however, initiating treatment using audio-only phone may be the only way for some patients to access care. Psychologists will want to find ways to creatively assess for indications typically identified through visual observation and note any limitations in their clinical records.

Telehealth policies for Medicare are issued by CMS. Since Medicare is a federal program, state telehealth laws and state emergency orders do not apply. For traditional telehealth, telephones may be used only with audio and video functions that provide two-way real-time interactive communication. On April 30, 2020, following recommendations from APA, CMS announced that many telephone only psychological services will be reimbursed.

At this time, the telehealth services covered by Medicare during COVID-19 fall into two categories: 

Services Allowed via Phone Only and Traditional Telehealth

• Psychiatric diagnostic interview (90791, -92)
• Psychotherapy, including individual (90832, -34, -37), group (90853), family (90846, -47) and psychotherapy for crisis (90839, -40)
• Psychological and neuropsychological testing (96130–96133 and 96136–96139)
• Health behavior assessment and intervention services, individual and group (96156, -58, -59, -64, -65, -67, -68, -70, -71)
• Psychoanalysis (90845)
• Neurobehavioral status examination (96116, -21)
• Interactive complexity (90785)
• Behavioral Screening (96127)
• Screening, Brief Intervention, and Referral to Treatment (G0396, G0397)

Services Allowed via Traditional Telehealth Only

• Developmental Screening and Testing (96110, -12, -13)
• Adaptive Behavior Assessment (97151, 97152, 0362T)
• Adaptive Behavior Treatment (97153-97158, 0373T)

Visit the temporary changes to federal Medicare telehealth policies page for more information on how to bill for psychological telehealth services covered by Medicare.

If you have not received guidance from an individual insurer, check their website or call the provider relations department for each patient’s policy. Insurance companies vary regarding the services they cover and their billing and coding policies.

Fully-insured plans are subject to state’s telehealth laws and emergency orders that provide additional telehealth coverage beyond state law requirements.

Self-insured plans, often used by large corporations, are not subject to state telehealth laws or state emergency orders. Instead, they are regulated by the U.S. Department of Labor under the federal Employment Retirement Income Security Act (See APA’s previous FAQ for more details and information about APA’s advocacy regarding these plans).

Many insurance companies’ telehealth policies that were developed in response to the crisis may not apply to self-insured plans because the insurance company does not have the authority to change the provisions of the corporation’s plan as they administer it.

If you don’t know whether a patient’s coverage is fully insured or self-insured, check with the insurer.

APA is developing resources on major insurance companies’ policies. In the meantime, you can find links to telehealth policies of national insurers, such as Aetna and United/Optum, as well as state/regional insurers at the America’s Health Insurance Plans’ Health Insurance Providers Respond to Coronavirus webpage and the Inter Organizational Practice Committee’s State by State Tele-Neuropsychology Resources.

These resources also cover many insurance companies’ policies for managed Medicaid and Medicare Advantage plans. State Medicaid policies are also found in your state’s telehealth laws and emergency orders.

Medicare

Telehealth services should be billed using the place of service (POS) that would have been reported if the service had been furnished in-person (e.g., 11 for office) and modifier 95 to indicate telehealth.

Commercial insurance, in-network

Most insurers require POS 02 (telehealth) and modifier 95 (audio-visual telehealth service) or GT. If you have not received guidance from the insurer, check the insurer’s website or call their provider relations department.

Commercial insurance, out-of-network

You or your patient should check with the insurer about its coverage and billing policies. Most commercial insurers’ COVID-19 telehealth policies do not include out-of-network services, but APA Services advocacy with state, provincial and territorial psychological associations is pushing for these services to be covered. If you will be giving your patient a superbill, it should clearly indicate the service was provided using telehealth (e.g., by adding -95 to the CPT code).

Medicare

Following recommendations from APA, effective April 30, 2020, psychologists can now provide many of their typical services by audio-only telephones to Medicare beneficiaries. Psychologists should review more detailed information on the Practice Resource Hub.

Commercial insurance, in-network

Most insurers did not cover audio-only phone services prior to the coronavirus outbreak and many still do not. If you have not received guidance from the insurer, check their website or call the provider relations department for billing policies as some insurers indicate that audio-only phone should be billed as regular in-person visits, while others may have different requirements.

Commercial insurance, out-of-network

You or your patient should check with the insurer about its coverage and billing policies. If you will be giving your patient a superbill, clearly indicate that the service was provided using audio-only phone (e.g., POS 02 and a description of services indicating audio-only phone).

Despite CMS guidance relaxing HIPAA enforcement for telehealth provided during the crisis, APA and CPA still recommend that practitioners use a telehealth platform vendor that will sign a Business Associates Agreement and that claims to be HIPAA compliant (“HIPAA Platforms”). For more details, see the previous FAQ.

While APA and CPA cannot recommend or endorse any HIPAA-compliant videoconferencing platform vendors, psychologists could consider the following resources:

The HHS Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency lists the following 10 vendors:

• Skype for Business/Microsoft Teams
• Updox
• VSee
• Zoom for Healthcare
• Doxy.me
• Google G Suite Hangouts Meet
• Cisco Webex Meetings/Webex Teams
• Amazon Chime
• GoToMeeting
• Spruce Health Care Messenger

APA Services’ December 2019 article compared three of latest telehealth solutions:

• Doxy.me
• thera-LINK
• Zoom for Healthcare

The federal government has identified psychologists as critical, essential workers in response to COVID-19. This does not mean that psychologists must provide services in person. Essential psychological services can, and in many cases should, be delivered through telehealth.

To meet the needs of their patients and communities, without increasing the risk of contagion, psychologists should strongly consider providing services through telehealth during this public health emergency, especially if:

• You or your patient are in a high-risk category for developing severe illness (e.g. over 65, with underlying health conditions).
• You have patients with a high risk of exposure (e.g., health-care workers, first responders).
• You are in a part of the country with high or increasing rates of infection.
• Your office set-up does not provide enough space between you and your patient, or does not allow proper distancing for patients who are waiting for their appointments.

In making decisions about whether to offer in-person services, keep in mind the health and safety of both you and your patients. If you contract the virus, you may unwittingly spread it to other patients, and may be unable to serve any patients until you recover.

If, in your professional judgment, you decide to provide services in person, be sure to take the proper steps to mitigate the risk of exposure. The Centers for Disease Control and Prevention has tips for protecting yourself and others, including sanitizing the area before and after the session, having both you and the patient wear cloth masks and maintaining appropriate distance. APA Services also published guidance for psychology practices and factors to consider before reopening your office.

Co-pay and deductible requirements — collectively known as “cost-sharing” — are dictated by the third-party payers, e.g., Medicare, Medicaid and commercial insurance carriers. Normally, psychologists are not allowed to routinely waive cost-sharing requirements for Medicare or Medicaid beneficiaries; commercial insurers generally prohibit routine waivers as well.

But many payers have relaxed cost-sharing rules during the pandemic. Here is a sample of these policies:

Medicare

CMS issued guidance (PDF, 399KB) in March allowing providers to waive co-payments for telehealth services for beneficiaries in traditional Medicare. (For Medicare Advantage plans, check the COVID-19 telehealth policies of the insurance company managing the plan).

Medicaid

Many states are implementing blanket co-pay waivers for Medicaid, and some commercial insurers that manage Medicaid programs (such as Optum) now waive these requirements. Check with your state Medicaid agency for guidance on cost-sharing.

Commercial insurance

Many large companies, including Anthem and United Health/Optum (PDF, 48KB), have waived cost-sharing requirements for members (your patients) who receive telehealth services. Some policies require psychologists to use the company’s telehealth platform in order for the waivers to apply. Psychologists should review their payers’ policies since individual plans may differ.

Patient cost-sharing

If the payer has not waived patient cost-sharing, we recommend that you make these decisions based on each patient’s circumstances. For example, there would be insufficient justification to waive co-pays for a patient who is still employed and who has not otherwise suffered severe economic harm from the crisis.

Psychologists may wish to develop a simple policy in advance for how you will make these decisions. Your policy should list basic criteria that you will apply to all patients when making these decisions.

Reduced fees

This approach (also called sliding-fee scales) is another way to be responsive to job loss or other financial pain that your patients may be suffering during the crisis. As with waiving co-pays, we recommend that you have a policy describing the basic criteria that you will employ. If you are considering both waiving co-pays and reducing fees, you can have a combined policy using the same criteria for considering patients’ financial circumstances.

If, in your professional judgment, you believe that you can do so legally and ethically (see APA’s Guidelines for the Practice of Telepsychology), you can provide needed services via telehealth to patients, even if reimbursement is unlikely or uncertain.

From an ethics perspective, you should consider and discuss with your patient whether not getting reimbursed could result in any cost to the patient (for example, if your patient agreement requires payment out of pocket for services that are not reimbursed by insurance) and any limitations you are placing on your services while reimbursement remains in question. See APA’s Ethics Code Standard EC 6.04(a) and (d).

If patients routinely self-pay but seek reimbursement from their insurer, discuss with them the possibility that reimbursement for telepsychology may be different from reimbursement for in-person services.

You may also consider offering pro bono services to patients who have been financially affected by the coronavirus. You should have a standard policy about who would qualify for pro bono services and make clear to those patients that they will not be financially responsible for your services.

Please note: These FAQs focus on care provided during the COVID-19 public health emergency. Billing, coding and reimbursement requirements may change after the emergency has ended.