The coronavirus pandemic demands that health care providers rethink how they deliver care in ways that reduce risk of further spreading infection.
The use of telehealth is one approach that can help keep both patients and providers safe, but PTs and PTAs need to understand the current regulatory and payer telehealth landscape to decide whether telehealth is right — or even a possibility — for them.
The information below can help you get a better sense of the issues surrounding physical therapy and telehealth, particularly related to the current viral outbreak. Keep in mind that circumstances are constantly changing and this information is current as of the publication date.
- We recently updated our resources on telehealth related to areas such as legislation and regulation, risk management considerations, billing and coding considerations, and implementing telehealth in practice. You will find these on the APTA Telehealth webpage.
- We also published a blog post, "Challenges and Opportunities in Telehealth: a Q&A."
- We have received several questions related to Congress' coronavirus legislation signed into law last week. It gives the Department of Health and Human Services authority to waive certain Medicare telehealth restrictions (with stipulations) and continues to limit provider types who can furnish telehealth to Medicare beneficiaries. Physical therapists are not included as a provider type that can furnish telehealth as a covered service to Medicare beneficiaries under this legislation. Due to a number of questions related to this legislation, APTA issued a March 9 news advisory on telehealth.
- A CMS fact sheet describes regulatory flexibilities and other actions the agency implemented in March to help health care providers and states respond to and contain COVID-19. The actions did not include expanding Medicare coverage to include telehealth services furnished by physical therapists. The actions did include temporarily waiving Medicare and Medicaid requirements that out-of-state providers hold licenses in the state where they are providing services. The requirement is waived as long as the provider has an equivalent license from another state — but keep in mind this does not waive state or local licensure requirements. Also, the waiver does not allow for payment for otherwise non-covered services — such as telehealth services provided by physical therapists.
- In addition, the Center for Connected Health Encounters offers "Billing for Telehealth Encounters: An Introductory Guide on Fee-for-Service (.pdf)," a 21-page document that outlines billing procedures.
- Note that other terms, such as telerehabilitation, telerehab, telemedicine, and telepractice are being used by various entities. They all can refer to use by PTs and PTAs; this article generally uses "telehealth."
Practice via Telehealth
Regardless of the payer or policy, PTs and PTAs must ensure that when providing telehealth services or billing for them, they are practicing legally and ethically, and are adhering to state and federal practice guidelines and payer contract agreements. You review and understand your state's practice act regarding the delivery of physical therapist services via telehealth.
Per APTA's ethics documents (www.apta.org/Ethics/), we recommend that physical therapists use their discretion as to the nature and frequency of using telehealth, and do so within their scope of practice while abiding by any state practice act restrictions as well as their obligations to the physical therapy profession.
Although telehealth is not specifically codified within the APTA "Code of Ethics for the Physical Therapist" or the "Standards of Ethical Conduct for the Physical Therapist Assistant," the entirety of the code applies to telehealth services delivered by PTs and PTAs. Ethical practice in telehealth must account for the biological, social, psychological, and cultural needs of the patient while working to improve their health. Additionally, knowing when to urge and how to persuade the patient to seek a face-to-face level of care is key. Before providing telehealth, ensure that you meet all local, state, and federal laws and regulations. To achieve the potential for patient benefit, you must consider the associated ethical issues; specifically, carefully assess the effect on relations between clinicians, patients and clients, and their families and/or caregivers.
Telehealth provision or use does not alter a covered entity's obligations under HIPAA, nor does HIPAA contain any special section devoted to telehealth. Therefore, if a covered entity is utilizing telehealth that involves PHI, the entity must meet the same HIPAA requirements that it would if the service was provided in-person.
The House of Delegates position on telehealth (.pdf), last updated in 2019, recognizes telehealth as a well‐defined and established method of health services delivery that enhances patient and client interactions. APTA also recognizes the value of advocating for state and federal telehealth policies to reduce cost, disparities, and shortages of care, and to enhance physical therapist practice, education, and research.
Through the Physical Therapy Compact, a compact privilege allows the holder to provide physical therapist services in a remote state under the scope of practice of the state where the patient or client is located, whether the practice is in-person or via telehealth. Compact privilege holders should consult the rules and laws for the state in which they seek to provide services to determine the specific telehealth requirements.
Physical therapists are not statutorily authorized providers of telehealth under Original Medicare, and physical therapy services are not on the list of services covered under the Medicare physician fee schedule when furnished via telehealth. (See the Private Payer section below for information on services provided under Medicare Advantage plans.) APTA has continued to advocate for the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019 (H.R. 4932/S. 2741), legislation that would expand the use of telehealth services and ease restrictions on telehealth coverage under the Medicare program. Our position paper outlines APTA's stance on the legislation. The COVID-19 pandemic makes our position all the more relevant; health care providers and payers must reconsider how care is delivered to reduce the risk of further spreading infection. Access to telehealth has become of paramount importance to ensure the safety of patients and their physical therapy providers.
APTA also has compiled research studies on telehealth (.pdf) and testimonials from APTA members on how they have balanced in-person and telehealth visits.
Check with individual payers to verify what is and is not permitted and what will be reimbursed. Confirm with each payer whether the originating site can be a private home or office, if services must be real-time or can be asynchronous, and any other limitations to your use of telehealth. Before reporting CPT codes you traditionally use for clinical visits, check with your payer. A payer also may require an addendum attached to the bill that identifies the service as being provided via telehealth, along with an explanation of the charges, so be prepared to outline your reasoning for using telehealth. Also be aware if your state has parity laws that require insurers to pay the same amount for telehealth services as they would for an in-person visit.
Note: Under CMS guidance issued to Medicare Advantage organizations (.pdf), CMS is affording MAOs the flexibility to expand coverage of telehealth services.
APTA developed a template letter for you to use in advocating to your payers--private, Medicare Advantage, and Medicaid (both fee for service and MCOs) for coverage of telehealth furnished by PTs and PTAs to ensure that patients continue to have access to the rehabilitative care they need amid the COVID-19 pandemic. Instructions are included at the top of the page.
States have the option to determine whether or not to cover telehealth services; what types of telehealth services to cover; where in the state such services can be covered; how services are provided and covered; which types of providers may be reimbursed for telehealth services (as long as they are "recognized" and qualified according to the state's Medicaid statute or regulation); and how much to reimburse for telehealth services, as long as payment does not exceed federal upper limits.
Medicaid guidelines require all providers to practice within the scope of their state practice act. Some states' legislation requires providers using telehealth technology across state lines to have a valid state license in the state where the patient is located, and these requirements are binding under current Medicaid rules.
Before you bill for telehealth services under Medicare, always check the regulations and policies of your state Medicaid fee-for-service (FFS) program and Medicaid managed care organizations to confirm whether or not the FFS program and/or MCOs reimburse for telemedicine services.
The Center for Connected Healthcare Policy identified the following in a 2019 summary of state telehealth policies, including telerehabilitation:
- 9 states (Arkansas, Connecticut, Delaware, Idaho, Kentucky, Minnesota, Missouri, New York and Oregon) explicitly reimburse for telerehab services.
- 11 states (Iowa, Maine, Montana, Nebraska, New Mexico, North Dakota, Rhode Island, Tennessee, Utah, Vermont and Washington) contain open language in state regulation or reimbursement policies that may allow for Medicaid to reimburse for telerehab services.
Medicaid policies on the originating site setting (private home or office) and real-time vs. asynchronous services also differ among states, so check your state's policy as well as each payer's policy.
The Center for Connected Healthcare Policy has a good resource that identifies where the law stands with telehealth in the states (.pdf).
There are not specific CPT codes for telehealth services furnished by physical therapists. Some therapists use codes in the 97000 series that best describe the services being provided and then use the place-of-service code "02" to indicate that the services were provided remotely. Because the CPT codes are direct contact codes it is important to verify that the payer allows you to use these codes when services are provided via telehealth, or if you must use a specific modifier. We also encourage you to check with each payer about using place-of-service code "02" when billing for telehealth services to specify the entity where service(s) were rendered.
In addition to the links to resources above, we will continue to develop education related to delivery of services via telehealth. For one thing, APTA staff will prerecord a webinar in early April with members of the Health Policy and Administration Section's Tech SIG. The webinar, Digital Telehealth Practice - Connect for Best Practice, Compliance, and Healthcare, will then be followed by a live online Q&A session later in the month.
These resources should answer most of your questions on billing and coding, practice considerations, legislation and regulation, and other issues related to telehealth. If you still have a question that wasn't addressed, send it to email@example.com. We will update our resources accordingly to ensure we're providing the information the profession needs.