Congress recently passed legislation effectively extending Medicare’s payment for virtual PT/OT, so this is a good time for an overall update on these rules.
Medicare payment for virtual PT/OT has been somewhat of a moving target. As a first step, it is important to understand the terms CMS uses which are:
- “Telehealth” or “virtual visits” are terms that generally refer to all types of remote patient interactions
- “Telemedicine” is generally used to refer to telehealth that is similar to an in-clinic visit (using in clinic codes) over an audiovisual connection
- “E-Visit” refers to audiovisual assessment and management not intended for typical PT/OT treatments
Prior to the Covid Public Health Emergency (PHE), Medicare did not pay for any virtual PT/OT. After some initial machinations, CMS announced that it would pay for PT/OT telemedicine at in clinic rates retroactive to March 1, 2020 and would also pay for e-visits.
We will first address telemedicine PT/OT. For context, it is important to understand that CMS’s discretion to pay for telemedicine is subject to statutory restrictions so CMS can only do what legislation allows it to do. There are two related but separate requirements for Medicare to pay for telemedicine PT/OT. First, the PT/OT codes must be on CMS’s list of permitted telemedicine codes. Second, physical and occupational therapists must be permitted telemedicine providers.
The first requirement is controlled by CMS which has announced that (a) all initial evals, re-evals, 97110, 97112, 97116, 97535, 97750, 97755, 97760 and 97761 via telemedicine will be allowed though 2023 and (b) 97150, 97530 and 97542 will be allowed through the end of the PHE. (All of these codes are paid at in clinic rates.)
The second requirement is not controlled by CMS because a statute lists permitted telemedicine providers. A Congressional-authorized PHE waiver temporarily added physical and occupational therapists to the list of permitted telemedicine providers through end of the PHE (currently 4/16/2022 but likely to be extended). Legislation enacted in March 2022 extended this period until 151 days after the end of the PHE.
So, if the PHE ends on 4/16/22, Medicare will pay for telemedicine provided by PTs and OTs through 9/14/22 using the codes listed above (but note that 97150, 97530 and 97542 cannot be used after the end of the PHE).
If and when physical and occupational therapists are no longer qualified telemedicine providers (following 151 days from the end of the PHE), PT/OT telemedicine claims can be submitted under a supervising physician or NPP (PA or NP) using the incident to rules as long as the PT/OT codes are authorized because physicians and NPPs are regularly authorized telemedicine providers. Note that Medicare’s incident to rules require the supervising physician or NPP to be in the same office suite as the physical or occupational therapist when the patient is treated and for the patient to be under the care of a physician or NPP in the same group. However, until at least the end of 2022, a PHE exception allows the same office suite requirement to be replaced by a real time audiovisual connection.
Medicare claims for telemedicine should include place of service code 10 if the patient is at his or her home and the 95 modifier. PT claims should include the GP modifier and OT claims should include the GO modifier.
If a patient does not need a treatment visit or a treatment visit is not covered, an “E-Visit” may be an alternative. Medicare will pay PTs and OTs for virtual evaluation and management services. The codes are for online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days:
- 98970: 5-10 minutes (replaced G2061)-National payment rate for 2022=$11.77
- 98971: 11-20 minutes (replaced G2062)- National payment rate for 2022=$20.76
- 98972: 21 or more minutes (replaced G2063)- National payment rate for 2022=$32.18
PTs and OTs can only charge patients for one of these codes during a consecutive 7-day period. For example, if a PT has two e-visits with Mr. Jones during a 7-day period that together take 18 minutes, Mr. Jones can only be charged for one unit of 98971 and the PT will be paid a total of about $21.
You cannot bill an e-visit if you saw the patient in a face-to-face visit fewer than 7 days before the e-visit or if you see the patient in a face-to-face visit fewer than 7 days after the e-visit.
PTs and OTs can also use telephone assessment and management codes. These codes are for telephone assessment/management services provided to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment/management service or procedure within the next 24 hours or soonest available appointment. The alternative codes and Medicare pricing are:
- 98966: 5-10 minutes of medical discussion- National payment rate for 2022=$13.15
- 98967: 11-20 minutes of medical discussion- National payment rate for 2022=$24.22
- 98968: 21-30 minutes of medical discussion- National payment rate for 2022=$34.26
Remote Therapeutic Monitoring
Starting in 2022, PTs and OTs can use remote therapeutic monitoring (RTM) codes.
The key point regarding RTM is that it requires use of a “medical device” as defined by the U.S Food and Drug Administration. An example of a PT-related device is the Aria Home PT monitoring device.
PTs and OTs can use the following RTM codes:
- 98975-RTM; initial set-up and patient education on use of equipment; can only be charged once per episode of care; Medicare national payment amount for 2022=$19.38
- 98977-RTM; device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days; may be charged once every 30 days; Medicare national payment amount for 2022=$55.72
- 98980-RTM treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes; Medicare national payment amount for 2022=$50.18
- 98981-RTM treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure); Medicare national payment amount for 2022=$40.84
- 98980 and 98981 can be charged to a patient only once per calendar month