COVID-19 Telehealth Timeline: Connecticut and Federal Government

Keeping track of the flurry of rules and changes related to telehealth during this COVID-19 public health emergency has been challenging.  I offer the timeline below as a resource with links to all the underlying sources.  I will update this timeline as changes come about.

March 6:          The president issued waivers under Section 1135 of the Social Security Administration Act and CARES Act relating to telehealth.  Medicare will pay for telehealth visits when a patient participates from home for certain evaluation and management services, behavioral health sessions and preventative health screenings.  Must include video component.  Effective March 6.

March 11:         DSS Provider Bulletin 2020-09, 2020-10 temporarily expanded portions of telehealth coverage for the procedure codes detailed on page 9 of the 2020-09 at the same rate as in-person services.  General requirements: (1) written informed consent including notification of right to opt out at any time; (2) for minors, parent must be present to the same extent required for an in-person visit; (3) DSS will recoup payments for services that do not meet all guidelines; (4) provider must ensure appropriate, secure and private location for telehealth services; (5) must have a process to verify provider and patient identity; (6) cannot bill for sole purpose of obtaining a prescription where the provider previously determined the need; (7) documentation must be maintained; (8) if the visit cannot be completed, it must not be billed.  Effective March 13.

March 13-15[1]:    DSS issued “Responses to Frequently Asked Questions (FAQs) About CMAP’s Response to COVID-19.”  The first several questions relate to Provider Bulletins 2020-09 and 2020-10.  While the requirements detailed in 2020-09 included written informed consent, DSS walked that back in these FAQs permitting verbal consent so long as such consent is documented in the medical record.

March 19:         DSS Provider Bulletin 2020-14 further expanded telehealth coverage for certain children’s behavioral health, Autism spectrum disorder treatment, case management and family therapy services (codes detailed in the bulletin) and permitted telehealth via telephone for established patients only for the procedure codes in the 2020-09 bulletin and 2020-10.  This bulletin also permits opioid treatment programs to use video telehealth to meet face-to-face requirement when the patient is present with an RN who initiates the visit and video interaction with the provider.

                        DSS directs that all medical telephone visits be billed using codes 99442 (11-20 minutes of medical discussion) or 99443 (21-30 minutes of medical discussion).  For behavioral health visits, providers must use either code 98967 (11-20 minutes of behavioral health discussion) and 98968 (21-30 minutes of behavioral health discussion).  Effective March 18.

March 19:        The Governor issued Executive Order 7G, which temporarily amended the Connecticut telehealth statute to permit audio-only (telephone) telehealth delivery by Medicaid enrolled providers to Medicaid recipients and by in-network providers for commercial insurers fully covering telehealth services but only when there is an existing patient-provider relationship.

March 17:         The federal Department of Health and Human Services announced that the agency enforcing HIPAA would exercise enforcement discretion and will not impose penalties for noncompliance with HIPAA rules in connection with the good faith provision of telehealth services during the COVID-19 pandemic.  The Office for Civil Rights followed this announcement three days later with FAQs.

March 23:        CT DPH Commissioner suspends licensure, certification and registration requirements for certain healthcare providers for 60 days, which opens the door for out-of-state providers to offer telehealth services in Connecticut. 

March 24:        DSS Provider Bulletin 2020-23 expanded telehealth services (video only) to cover certain physical therapy, occupational therapy and speech and language pathology services for established patients.  All eligible CPT codes are detailed in the bulletin.

                        DSS Provider Bulletin 2020-24 expanded telehealth services for PT, OT and SP services to established patients rendered at rehabilitation clinics (no mention of telephone).  All CPT codes are detailed in the bulletin.  Effective March 20.

March 26:        DSS Provider Bulletin 2020-25  expanded telehealth services to cover specified

group therapy services and autism spectrum disorder (ASD) services.  Procedure codes are detailed in the bulletin. These services cannot be provided via telephone.  Effective March 23.

March 30:        The Centers for Medicare and Medicaid issued an interim final rule permitting the use of telephone services for new and established patients for codes 99441-99443 and 98966-98968 (with a place of service of 11 for office).  While the codes are specifically for “established patients,” CMS announced enforcement discretion and will not review whether the patient was established or not during this pandemic to allow for these services to be provided to new patients.

March 31:         DSS Provider Bulletin 2020-26 expanded telehealth services to school based child health services (note that this is different than school based health centers, which are excluded from telehealth coverage in 2020-09).  No mention of telephone.  Effective March 16.

March 31:         The Drug Enforcement Agency (DEA), which is responsible for enforcing the Ryan Haight Act, sent letter to registered providers which clarified that both new and existing patients could receive buprenorphine prescriptions via telephone.  Also relevant are SAMHSA FAQs.

April 1:             DSS Provider Bulletin 2020-28 expanded telehealth services for certain home health and hospice services for established patients.  Home health therapy must be via video, but medication administration services can be via telephone.  Effective March 27.

April 16:           DSS Provider Bulletin 2020-38  expanded the telehealth services available via telephone for certain services provided by free-standing school based health centers, family planning clinics and local health departments.  See bulletin for procedure codes.  Effective March 18.

April 22:           Executive Order 7DD removed the “established patient” requirement from in-network providers for commercial insurers to allow for telephone visits for new patients.  The “established patient” requirement remained for Medicaid-enrolled providers providing services to Medicaid recipients.  The order also added several providers to the definition of “telehealth provider” including dentists.

April 24:          Executive Order 7FF removed the “established patient” requirement for Medicaid-enrolled providers providing services to Medicaid recipients to allow for telephone visit for new patients.

April 30:          CMS issued a new interim final rule to expand the list of providers eligible to provide telehealth services (e.g., physical therapists, occupational therapists) and  expanded telehealth via telephone beyond the six codes provided in the March interim final rule and increased the reimbursement for CPT codes 99441-99443.  The additional codes eligible for telephone service can be found here.

May 11: DSS issued Provider Bulletin 2020-44, which ended the use of codes 98967 and 98968 for behavioral health telephone services with a retroactive effective date of May 7.  The bulletin provided a list of other procedure codes that must be used for telephone-only behavioral health services.  Notably, the newly identified codes require a higher time minimum than codes 98967 and 98968. DSS also issued Provider Bulletin 2020-45 that same day.  Although the bulletin seems to reaffirm the use of codes 98967 and 98968, a closer read of 2020-44 reveals that 2020-44 supersedes 2020-45 with respect to behavioral health billing.  Provider Bulletin 2020-45 appears to align billing for telephone visits with CMS rules with respect to codes 99442 and 99443.  It also makes clear that supervision of residents cannot be performed via telephone.

May 18: DSS walked back the retroactive effect of the May 11th change by issuing a notice to providers and in a response to question 25 in its FAQs. DSS clarified that providers do not need to modify or resubmit claims for the period of May 7th through May 12th.

[1]               The exact date of the initial version of DSS’s FAQs is not clear as DSS replaces the earlier version with each update.  It is clear, however, that the first several questions related to Provider Bulletins 2020-09 and 2020-10 pre-dated Provider Bulletin 2020-14.