CMS Audio-Only Telehealth: Understanding Coverage, Documentation, and Compliance Post-PHE

The landscape of telehealth services has undergone significant transformation, particularly in the wake of the COVID-19 Public Health Emergency (PHE). Among the most impactful changes has been the expanded recognition and reimbursement for audio-only telehealth services by the Centers for Medicare & Medicaid Services (CMS). While video-based telehealth often takes precedence, audio-only options play a crucial role in improving access for patients with limited broadband access, technological barriers, or those who prefer a simpler communication method.

This article delves into the current CMS policies regarding audio-only telehealth, outlining what services are covered, the essential documentation requirements, and the implications for healthcare providers.

Evolution of Audio-Only Telehealth Coverage

Prior to the PHE, Medicare's coverage for audio-only services was extremely limited, primarily restricted to specific types of behavioral health services. The PHE dramatically expanded this, allowing a wide range of services to be delivered via audio-only communication to ensure continuity of care during the pandemic. As the PHE ended, CMS worked to make many of these flexibilities permanent or extend them for a transitional period.

Key legislative actions, such as the Consolidated Appropriations Act, 2023, and subsequent CMS rulemaking, have shaped the current policies. These actions have focused on balancing patient access with program integrity, ensuring that audio-only services are medically necessary and appropriately documented.

Covered Audio-Only Services Under Medicare

CMS has clarified which services are eligible for audio-only reimbursement. It's crucial for providers to understand that not all services that can be delivered via two-way audio/video can also be delivered via audio-only. The primary focus for permanent audio-only coverage has been on certain behavioral health services and specific evaluation and management (E/M) services.

Behavioral Health Services

Many behavioral health services, including psychotherapy, medication management, and substance use disorder treatment, are now permanently covered when delivered via audio-only technology. This is a significant step towards addressing mental health access disparities, particularly in rural and underserved areas. These services can be furnished by a variety of professionals, including physicians, clinical psychologists, clinical social workers, and other qualified mental health professionals.

Evaluation and Management (E/M) Services

For E/M services, CMS has been more cautious. While some E/M services were temporarily covered via audio-only during the PHE, the permanent coverage is more restricted. Generally, established patient E/M visits are more likely to be covered via audio-only than new patient visits, and the medical necessity for using audio-only must be clearly documented. CMS has also specified certain codes that are eligible. For example, some virtual check-ins (G2012) and e-visits (G2061-G2063), which are specific short patient-initiated communications, can be audio-only.

Other Services

Certain other services, such as care management services (e.g., Chronic Care Management, Principal Care Management), may also have audio-only components or be eligible for audio-only delivery under specific circumstances. Providers should consult the latest CMS Physician Fee Schedule (PFS) and related guidance for the most up-to-date list of eligible CPT/HCPCS codes and modifiers.

Documentation Requirements for Audio-Only Telehealth

Rigorous documentation is paramount for audio-only telehealth services to ensure compliance and avoid claim denials. CMS expects providers to document specific elements that justify the use of audio-only technology and demonstrate the medical necessity of the service. Key documentation requirements include:

1. Medical Necessity: The clinical rationale for the audio-only visit must be clearly documented. This includes why the service was necessary and why it was appropriate to deliver it via audio-only rather than in-person or via two-way audio/video. For instance, if a patient lacks access to broadband internet or a device with video capabilities, this should be noted.
2. Patient Consent: Documentation that the patient consented to receive the service via audio-only telehealth is required. This consent should be informed, meaning the patient understands the limitations and benefits of this modality.
3. Real-Time, Interactive Communication: The service must involve real-time, interactive audio communication between the provider and the patient. Pre-recorded messages or asynchronous communication generally do not qualify for audio-only telehealth reimbursement.
4. Date, Time, and Duration: The exact date, start time, and end time of the audio-only encounter must be recorded. This is crucial for E/M services where time is a key component of code selection.
5. Location of Patient and Provider: The originating site (patient's location) and distant site (provider's location) at the time of service delivery should be documented.
6. Modifier 93: For audio-only services that are typically furnished via interactive audio/video technology, providers may need to append Modifier 93 (Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System) to the CPT code. This modifier indicates that the service was performed via audio-only and meets the requirements for such delivery. However, some codes are specifically designed for audio-only and may not require this modifier.
7. Clinical Content: All standard clinical documentation for the service provided, including chief complaint, history, assessment, plan, and any prescriptions or referrals, must be present.

Billing and Coding Considerations

Providers must use the appropriate CPT/HCPCS codes for the services rendered. For telehealth services, including audio-only, the place of service (POS) code 10 (Telehealth) should generally be used. As mentioned, Modifier 93 is critical for many audio-only services to indicate the modality. Providers should regularly consult the latest CMS guidance and the Medicare Learning Network (MLN) materials for updates on specific coding requirements, as these can change annually with the Physician Fee Schedule Final Rule.

Impact on Healthcare Businesses

Telehealth Platforms

For dedicated telehealth platforms, these policies represent both opportunities and compliance challenges. The expanded audio-only coverage allows for greater reach, particularly to underserved populations. However, platforms must ensure their technology securely supports audio-only interactions and that their documentation workflows are robust enough to capture all required elements, including the specific reason for audio-only delivery and patient consent. Training for clinicians on proper coding and documentation for audio-only visits is essential.

Medspas and Dental Practices

While direct procedural services typically offered by medspas and dental practices are not suitable for audio-only delivery, these practices may utilize audio-only for specific types of consultations or follow-up care. For example, a dental practice might conduct an audio-only follow-up for a post-operative check-in, or a medspa might use it for a medication management discussion related to a prescribed treatment. It is critical to ensure that the specific CPT codes used for these consultations are eligible for audio-only reimbursement under Medicare and that all documentation requirements are met.

Chiropractic Offices

Chiropractic services, which are primarily hands-on, are generally not conducive to audio-only telehealth. However, similar to dental and medspa practices, certain E/M components or patient education sessions might be conducted via audio-only. Providers must exercise extreme caution and ensure that any audio-only service billed is explicitly covered by CMS and medically necessary, with comprehensive documentation.

Mental Health and Substance Use Disorder Providers

This specialty benefits significantly from the permanent audio-only coverage for behavioral health services. It allows for continuity of care and removes barriers for many patients. However, these providers must still adhere to all documentation standards, including the medical necessity for audio-only, to prevent billing errors and potential audits.

Conclusion

CMS's policies on audio-only telehealth represent a significant advancement in healthcare access, particularly for behavioral health services. However, this expanded flexibility comes with stringent compliance requirements. Healthcare providers and organizations must remain vigilant in understanding the specific covered services, adhering to detailed documentation standards, and correctly applying billing codes and modifiers. Proactive training, robust compliance programs, and continuous monitoring of CMS updates are essential to leverage audio-only telehealth effectively and compliantly in the evolving regulatory landscape.

Source

• Centers for Medicare & Medicaid Services (CMS): Telehealth Services. https://www.cms.gov/medicare/medicare-general-information/telehealth
• CMS Medicare Learning Network (MLN): Telehealth Services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/telehealth-services-fact-sheet.pdf
• CMS Physician Fee Schedule (PFS) Final Rule: Relevant annual rules (e.g., CY 2023, CY 2024) for specific code coverage and policy details. https://www.federalregister.gov/documents/current-issues/medicare-and-medicaid-programs (Search for Physician Fee Schedule Final Rule)