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Telehealth Services & Billing [CMS 1135 Waiver Guide]

Telehealth Services & Billing [CMS 1135 Waiver Guide]

CMS 1135 Guide to Understanding Telehealth/Telemedicine Services & Billing

Not so very long ago the only way to see a doctor and get a medical opinion was to schedule a visit and then travel to visit your local healthcare clinic.  While that is still an option the COVID-19 pandemic the expansion of telehealth services and billing with 1135 waiver has catapulted a growing technology niche into a preferred first step.  Welcome to the future of healthcare and the advent of telehealth and telemedicine, where patient’s places of residence become the location for healthcare services to be furnished remotely.

Via an internet-connected device like an iPad or a smartphone, a patient can now have a long-distance consultation directly with a doctor, nurse practitioner, clinical psychologist or licensed clinical social worker eliminating the need for an in person visit.  The immediate benefit to this new alternative, which was promoted in the CARES Act, is the diminished physical interaction that is the leading cause of COVID-19 transmission.  However, there are many longer-term benefits and applications as well.  The services that can be provided are not just limited to outpatient evaluation or office visits but also general care and health maintenance, observation, psychotherapy, behavior and health analysis, interventions and even end of life consultations.

So what is the difference between telehealth and telemedicine?  Alternatively, are they just interchangeable words for the same topic?  Actually, the differences are profound.

What qualifies as telehealth?

According to the healthit.gov website, “The Health Resources Service Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.  Technologies include videoconferencing, the internet, store-and-forward imaging (think X-Rays and MRIs), streaming media, and terrestrial and wireless communications.  Telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine.  Telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.”

During the pandemic, telehealth is proving itself to be especially critical.  However, prior to the COVID-19 outbreak, telehealth was beginning to blossom for underserved communities.  “Telehealth connects rural providers and their patients to services at a distant site.  This capability enables patients to receive care in their communities and avoid long travel times.  Given the shortage of some medical specialties in rural America, telehealth will play an important role in ensuring patients in rural communities can access the care they need.  For example, imagine a rural primary care provider (PCP) needs to refer a patient to a Stroke Specialist in an area where no such specialists practice.  With telehealth, the PCP may be able to leverage telecommunications technologies to connect the patient with a specialist at a remote site instead of asking the patient to travel to another community to obtain care.”

What qualifies as telemedicine?

According to the healthit.gov website “Telemedicine refers specifically to remote clinical services.  Telemedicine refers specifically to interactive health communications with clinicians on both “ends” of the exchange.  For example, telemedicine allows you to video conference grand rounds, transmit X-Rays between radiologists and help a remote practitioner present a patient to a specialist for a consultation.”

What is CMS 1135 Waiver?

Prior to the COVID-19 pandemic, medical telehealth visits were fairly restricted and limited.  While that is still the case, according to the cms.gov website, as of March 6, 2020, “the Centers for Medicare and Medicaid Services (CMS) have broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility.  CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.  The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19 – are aware of the easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of the virus.”  That means that at least for the time being, this innovative approach to the delivery of some healthcare will have the opportunity to be tested in the real world.

Does Medicare pay for telehealth visits?

Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence.  This will increase access to telehealth for Medicare patients so they can get care from their physicians and other clinicians while staying safely at home.  Prior to this waiver Medicare could only pay for telehealth on a limited basis:  when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for this service.  Even before the waiver authority, CMS made several related changes to improve access to virtual care.  In 2019, Medicare started making payment for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner.  Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal.”

“Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings.  This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk.”

How do I bill for telehealth 2020?

According to the cms.gov website, for Medicare telehealth visits “Medicare patients may use telecommunication technology for office, hospital visits and other services that generally occur in-person.  The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  Distant site practitioners who can furnish and get payment for covered healthcare services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians and nutrition professionals.  These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.  Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.”

Telemedicine Reimbursement 2020

Virtual Check-Ins

For virtual check-ins, “established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.  Medicare pays for these virtual check-ins for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office.  These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available).  The patient must verbally consent to receive virtual check-in services.  The Medicare coinsurance and deductible would generally apply to these services.  Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code 2012).  The practitioner may respond to the patient’s concern by telephone, audio/video, secure text-messaging, email or use a patient portal.  Standard Part B cost sharing applies to both.  In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).”


For E-Visits, “in all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals.  These services can only be reported when the billing practice has an established relationship with the patient.  For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period.  The services may be billed using CPT codes 99421-99423 and PCPCS codes G2061-G2063, as applicable.  The patient must verbally consent to receive virtual check-in services.  The Medicare coinsurance and deductible would apply to these services.

Does Medicare Part B Pay for E-Visits?

Medicare Part B also pays for E-Visits or patient-initiated online evaluation and management conducted via a patient portal.  Practitioners who may independently bill Medicare for evaluation and management visits can bill the following codes:

99421:  Online digital evaluation and management service for an established patient, for up to 7 days, cumulative time during the 7 days: 5-10 minutes
99422:  Online digital evaluation and management service for an established patient, for up to 7 days, cumulative time during the 7 days: 11-20 minutes
99423:  Online digital evaluation and management service for an established patient, for up to 7 days, cumulative time during the 7 days: 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

G2061:  Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time dur the 7 days: 5-10 minutes
G2062:  Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time dur the 7 days: 11-20 minutes
G2063:  Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time dur the 7 days: 21 or more minutes

For a comprehensive list of covered telehealth CPT codes, you can reference this link from the American Medical Association.

What telehealth equipment is required for virtual check-ins and E-visits? (THE HARTFORD SOLUTION)

Short patient-initiated communications with a healthcare practitioner conducted electronically to deliver in-home services present a unique set of technology challenges.  Office, hospital, and other visits furnished via telehealth require a secure app, a device for communicating and an internet connection.  When patients encounter technology issues, frustration sets in and some become less likely to adopt this new, better approach to point-of-care, at home healthcare.  The following are some of the issues to consider when delivering qualified Medicare telehealth services:

For Patients

At-home patients need to supply their own device, tech support and internet connectivity.  For some this will be no problem but for others this is a challenge that will require an extra layer of engagement.  For patients who do not have access to the proper equipment, or may have equipment that does not meet the technical specs a third party provider will be needed to meet the telemedicine requirements.  This third party provider should also be able to provide 24/7/365 remote tech support as well as an option for reliable internet access.

For Doctors and Practitioners

Medicare telehealth will expand efficiency and margins for healthcare providers as adoption increases.  The benefits include no additional staff requirements, the same physician fee schedule, brief patient communications or virtual check-ins and less personal contact during the pandemic.


Equipment – The right telehealth equipment is crucial for successful virtual check-ins and E-visits.  Size matters, at least when it comes to screens.  Given the typical age of Medicare and Medicaid populations, a larger screen in a device such as an iPad is preferable to the smaller screen of the typical smartphone.  A smaller screen presents more difficulty in navigating telemedicine apps.  Moving to a tablet can greatly increase usability and patient satisfaction.  We stock a huge inventory of iPads from the 7.9” Mini to the 12.9” iPad Pro.  We also carry a large selection of Android tablets.

Cellular Service – To ensure no connectivity issues, we will provide cellular tablets using Verizon 4G LTE or better.

Customization – Prior to deployment, HTR will customize the tablets to the specifications of the Medicare telehealth provider.  The tablet will be set up to ensure easy patient use.  We will create a profile that has only what is needed for telemedicine purposes to make sure that telehealth billing is smooth and hassle-free.  We will also set restrictions on the devices to prevent patients from disabling any required apps or using the tablet for anything other than telemedicine.

Mobile Device Manager – Through the use of a mobile device manager, HTR can remotely manage the deployed tablets.  We set up alerts to notify us of any attempts to make changes to the tablets, connectivity alerts or excessive network usage.  We can also track the location and health of each device.

Sanitation – Prior to any device leaving our facility, they will be sanitized using disinfectant cleaners designed to kill bacteria and viruses.  All returning tablets will also be sanitized during the check-in process and prior to being made available for redeployment.

Post Deployment – Once tablets have been deployed, our services include 24/7/365 technical support, remote installation of additional apps or setting customization, remote asset tracking, remote device reset for lost or stolen items and overnight replacement via FedEx for malfunctioning units.

To learn more about our unique Telehealth and Telemedicine rental solutions please call us at 888-520-5667.  With offices, inventory and technicians in Chicago, Los Angeles, New York City and Washington DC, we are ready and available to help you move your practice to the next level.