Unwinding of the Public Health Emergency (PHE)

Audio-Only Telehealth Post-PHE — Medicare, Medicaid, and Private Payers

By South Central Telehealth Resource Center •

During the height of the COVID-19 pandemic, the Public Health Emergency (PHE) allowed individuals with Medicare to have a broader access to a variety of telehealth services to include audio-only visits. This blog will explore how audio-only telehealth visits looked during the PHE and what to expect post-PHE focusing primarily on evaluation and management (E/M) visits.

What is Audio-Only telehealth?

“Audio-only” telehealth takes us back to where telemedicine started – delivering care over the telephone. Decades later, we describe this telephonic care, aka audio-only telemedicine, as a service where patients can receive medical care over audio devices such as landline phones, cell phones, and smartphones in the absence of video. Audio-only telehealth is particularly important for individuals who may have difficulty accessing the technology for a video feed. These individuals may lack the technological understanding, financial resources, access to broadband, or even cellular coverage required to support video communication. Additionally, they may be unfamiliar with how to initiate or engage in virtual visits. 

Audio-only visits between a patient and provider usually last up to 15 minutes. The intended use is to discuss medicines, test results, and other brief medical subjects. (Policy and Advocacy – What You Need to Know About Audio-Only Telehealth, 2021)

The impact on audio-only telehealth – during the PHE

During the PHE, a waiver authority under the Coronavirus Preparedness and Response to Supplemental Appropriations Act, 2020, allowed telehealth services to be provided through telecommunications systems to allow health care providers to provide care remotely, regardless of their geographic region, even from their own homes. Under this act, all Medicare beneficiaries were able to receive services via telehealth. Centers for Medicare and Medicaid Services (CMS) also utilized section 1135 waivers to create further flexibilities that allowed the use of audio-only telephone E/M services for behavioral health counseling and educational services. During the PHE, Medicare reimbursement for telephone E/M matched the payment rate for office/outpatient visits conducted with established patients, i.e., payment parity. Practitioners could bill for specific behavioral health services and E/M services provided through audio-only methods. The scope of providers eligible to bill for telehealth services from remote locations was broadened during the PHE. This expansion encompassed practitioners like physical therapists, occupational therapists, and speech-language pathologists, allowing them to receive compensation for their rendered services.

According to a recent report from the Center for Connected Health Policy, the inclusion of audio-only reimbursement within Medicaid has been a consistent trend over the past two years, during the PHE. In numerous states, this approach has already been integrated into Medicaid’s permanent reimbursement policy. This is frequently indicated by the use of the 93 modifier to indicate the utilization of the audio-only mode. As an example, the state of Georgia recently made this change with an update to their telemedicine guidance.  Likewise, Nevada Medicaid issued an announcement that allows audio-only to be used for telehealth visits outside of the COVID-19 PHE for certain telephone E/M codes. (Center for Connected Health Policy, 2023)

Impact on audio-only telehealth – after the PHE

Although the PHE officially ended on May 11, 2023, the Consolidated Appropriations Act, 2023 (CAA, 2023), provided an extension for some flexibilities through December 31, 2024, to include audio-only telephone E/M, behavioral health, and educational services. The expanded list of providers can bill for services through December 31, 2024. However, Congress did not mandate payment parity for audio-only reimbursement consistent with in-person care. After December 31, 2024, CMS does not intend to cover audio-only services except for mental health. 

Audio only became permanent for behavioral health with CAA of 2021 and was included in the 2022 Medicare Physician Fee Schedule. Certain rules govern when such allowances are permitted.  For instance, while CMS opened the door to permanently allowing audio-only reimbursement for mental health services, it is only in situations where the distant site provider:  1) has the technical capability at the time of service to use an interactive telecommunications system that includes video; 2) the patient is incapable or fails to give consent for the use of video technology for the service; and 3) the patient is located at his/her home at the time of the service.  Therefore, the considerations of this blog post primarily apply to E/M services via audio-only.

Note: The Physician Fee Schedule 2024 proposes to extend allowing audio-only to be used for periodic assessments by Opioid Treatment Programs to the extent audio-only is permitted by SAMHSA and the DEA, and only if video is not available.

Are there HIPAA considerations?

Yes, definitely. Just as with virtual visits, providers should inform patients about potential privacy risks associated with audio-only visits. This includes situations where calls are conducted in public spaces or when speakerphones are used. (See this article pertaining to “…the End of HIPAA Enforcement Discretion” from the NCTRC. Additionally, read more about HIPAA and VoIP.)

Additionally, HHS Office for Civil Rights (OCR) developed guidance to help entities understand how they can use audio-only telehealth in compliance with HIPAA Rules. For more information, visit: https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/hipaa-audio-telehealth/index.html

Implications of Population:

Recently, RAND, a nonprofit research organization, posted a study describing some of the implications of audio-only telehealth for rural populations. The lead author of the study indicated that most likely, safety net clinics [FQHCs] will continue to deliver audio-only visits in high volume because of their role in improving access to health services. 

According to researchers, FQHCs continued use of audio-only telehealth may be a result of the clinics and their patients not having access to the technology (devices, broadband, etc.) needed for video telehealth. In addition, since California’s Medicaid program (Medi-Cal) granted permanent payment parity for audio-only visits, there are no financial incentives for the clinics to limit audio-only visits. (RAND study https://www.rand.org/news/press/2023/04/11.html)

Audio-only or TCM billing?

Unlike transitional care management (TCM) or post-procedure follow-up calls, the audio-only telehealth call serves as a comprehensive E/M visit for established patients. Medicare has approved E/M Physician/Qualified Health Professional Services for audio-only through 2024. E/M timed codes include 99441-99443. 

While these audio-only services are often exclusively associated with telephone CPT codes, 99441-99443, many payors allow other services to be performed via a real time, audio-only connection. In fact, several payors do not allow the traditional telephone codes, and instead only allow specific services to be performed via a real time audiovisual or audio-only connection.  We often see this with commercial and Medicaid payors.  For example, United Healthcare does not allow telephone phone codes but does have a published “audio-only” code list that contain behavioral health codes, preventative screening services, nutritional counseling, and numerous other services.  Arkansas Medicaid is another great example of this, as they also do not allow telephone codes to be utilized, but do allow real time, interactive, audio-only communication if it meets the requirements for a service that would otherwise be covered.  It is critical that Medicaid and commercial audio-only code sets and telephone code allowability are reviewed prior to performing audio-only services.  Medicare’s inclusion of telephone codes is currently considered a temporary measure, as their allowance was extended until the conclusion of 2024 through the Consolidated Appropriations Act.  Medicare does allow numerous other services via an interactive audio-only connection such as behavioral health, nutritional/diabetic counseling, preventative screenings, and speech therapy.  TRC Tip: Make sure to consult your state’s payment policies to identify which services can be delivered through audio-only connections and to understand the correct billing procedures. 

CPT codes 98966-98968, however, describe telephone assessment and management services provided by a qualified non-physician health care professional, and are not considered telehealth services.

When documenting, it is good practice to include a statement that the visit took place utilizing audio- only technology and the length of the call. The second component (length of call) is only required if you are billing the time-based telephone codes.  Medicare, and most other payors, allow certain codes to be performed via audio-only that are not time-based.  For example, payors allow numerous behavioral health codes via audio-only communication, which are not time-based, and therefore time doesn’t need to be documented.  

In the proposed Physician Fee Schedule for 2024, CMS intends to continue to assign an active payment status to CPT codes 98966-98968 to align with telehealth-related flexibilities that were extended via the Consolidated Appropriations Act of 2023, specifically section 4113€, which permits the provision of telehealth services through audio-only telecommunications through the end of 2024.

It’s worth noting that some private insurers have already stopped reimbursing coverage for audio-only telehealth visits. However, this can change by payer and by state so, each payer should be consulted individually. Many regional Telehealth Resource Centers (TRC) and the Center for Connected Health Policy provide additional information for billing and reimbursement guidance. We encourage you to reach out to your region’s TRC for assistance as needed.

References:

(ii) Uscher-Pines, L. & Schulson, L. (2021). Rethinking the impact of audio-only visits on health equity. Health Affairs, https://www.healthaffairs.org/do/10.1377/forefront.20211215.549778/full/

Useful Resources: 

Author Acknowledgements

Wendy Ross is the Director of Programs for the Institute for Digital Health & Innovation and serves as the Co-Director for the South-Central Telehealth Resource Center (SCTRC). 

Melony Stokes, DNP, RN is the Senior Director for Implementation for the South Central Telehealth Resource Center and a Clinical Educator at the Institute for Digital Health & Innovation at the University of Arkansas Medical Sciences.

Contributors

Thank you also to input from fellow National Consortium of Telehealth Resource Center colleagues and to billing and reimbursement advisors: Amy Jones, University of Arkansas for Medical Sciences and Hayley Prosser, RuralMed Revenue Cycle Management.

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