Providing Telehealth Services Under Medicare During the COVID-19 Pandemic

Updated November 18, 2022

In response to the spread of COVID-19, the Centers for Medicare & Medicaid Services (CMS) now allows audiologists and speech-language pathologists (SLPs) to provide select telehealth services to Medicare Part B (outpatient) beneficiaries for the duration of the federally-declared public health emergency (PHE). 

CMS announced the telehealth expansion in an April 30, 2020, press release and its COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers [PDF]. The original expansion included a limited set of eligible audiology and speech-language pathology telehealth services. CMS subsequently expanded the list of Current Procedural Terminology (CPT) codes on March 30, 2021, resulting in a more comprehensive list of eligible telehealth services provided by audiologists and SLPs. Medicare Part C (Medicare Advantage plans) may also reimburse for telehealth services provided by audiologists and SLPs during the public health emergency. Check with the plan directly for coding and billing guidelines.

ASHA and its members participated in extensive advocacy with Medicare to achieve this temporary expansion. ASHA will continue advocating for permanent coverage of telehealth services under Medicare. ASHA members are encouraged to contact your member of Congress and ask them to permanently authorize telehealth services for audiologists and SLPs by cosponsoring H.R. 2168/S. 3193, the Expanded Telehealth Access Act.

Note: ASHA uses the term telepractice. Any reference to telepractice includes telehealth, which is Medicare’s term for the health care services delivered via interactive audio and video telecommunications technology with real-time capability.

On this page:

• Federal Public Health Emergency
• What to Know Before You Get Started
• Institutional Billing
• Covered Audiology and Speech-Language Pathology Services
  • Audiology CPT Codes
  • Speech-Language Pathology CPT Codes
• Coding and Billing Guidelines
• Providing Noncovered Audiology and Speech-Language Pathology Services
• Resources

Federal Public Health Emergency (PHE)

(Updated 10/13/2022)

The U.S. Department of Health and Human Services (HHS) must extend the federal PHE related to COVID-19 every 90 days to maintain certain health care flexibilities and waivers, including temporary coverage of audiology and speech-language pathology services provided via telehealth. The PHE has been in place since January 27, 2020, and has been renewed several times during the course of the pandemic. The latest HHS extension for the PHE is effective October 13, 2022, through January 11, 2023.

In a letter to the state Governors, the Administration has indicated they will give at least a 60-day notice before the PHE ends. In addition, the Consolidated Appropriations Act of 2022 (P.L. 117-103) provides a 151-day extension to some flexibilities, once the federal PHE ends. With this PHE renewal and the additional 151-day extension, ASHA expects certain flexibilities will continue at least into the second quarter of 2023, such as continued access to audiology and speech-language pathology telehealth services for Medicare beneficiaries. Please continue to monitor ASHA's 2022 federal PHE update page for the latest information.

See also: What to expect at the end of the PHE: Maintaining compliance with state, federal, and payer laws and requirements

What to Know Before You Get Started

Clinical, Ethical, and Legal Considerations

ASHA guidelines state that the use of telehealth must be equivalent to the quality of in-person services and must adhere to the ASHA Code of Ethics, audiology or speech-language pathology scope of practice, state and federal laws, and ASHA policy.

Clinicians must also consider their own skill/experience and the patient’s needs and capabilities before beginning telehealth services. To ensure compliance, you should do the following: 

• Check whether your state allows telehealth by audiologists or SLPs on ASHA’s state-by-state pages.
• Follow best practice and legal requirements for telehealth, including using Health Insurance Portability and Accountability Act (HIPAA)-compliant technology. Learn more through ASHA’s Practice Portal on telepractice, the Center for Connected Health Policy, and the American Telemedicine Association.

Private Pay Arrangements

Medicare’s temporary expansion of telehealth services means that audiologists and SLPs may no longer enter into a private pay arrangement with Medicare beneficiaries for those services that are now included on Medicare’s telehealth list. For codes that are not authorized telehealth services, audiologists and SLPs can continue to accept private payment from Medicare beneficiaries.

Enrolled Medicare Providers

If you delivered covered telehealth services to a Medicare beneficiary under a private pay arrangement at any time since the CPT code(s) became eligible for telehealth coverage, you will need to reimburse the patient if you intend to now bill Medicare for those services. Medicare will process the claim and inform the beneficiary of their copayment obligation. For example, if you provided a telehealth service in January, February, or March 2021, you could now reimburse the patient and submit a claim to Medicare if the service was effective January 1, 2021.  See the tables below for a list of approved audiology and speech-language pathology services and the date each code became eligible for telehealth coverage. 

Not Enrolled in Medicare

If you delivered covered telehealth services to a Medicare beneficiary under a private pay arrangement at any time since the CPT code(s) became eligible for telehealth coverage, you should return those funds. Unenrolled providers may not submit claims to Medicare for reimbursement and may not enter into private pay agreements with Medicare beneficiaries for covered services. See the tables below for a list of approved audiology and speech-language pathology services and the date each code became eligible for telehealth coverage.

If you want to deliver covered telehealth services to Medicare beneficiaries during the public health emergency or beyond, you must enroll as a Medicare provider. Federal law requires mandatory enrollment and claims submission for Medicare covered services.

CMS currently allows certain flexibilities to expedite temporary provider enrollment [PDF] into the Medicare program during the public health emergency.

Equipment and Security Requirements

CMS has waived certain equipment and HIPAA requirements during the public health emergency. Clinicians can now use nonpublic facing platforms that allow two-way, real-time interactive communication but aren’t HIPAA-compliant. Examples of acceptable platforms listed by CMS include Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype.

Examples of public facing platforms that aren’t acceptable include Facebook Live, TikTok, or Twitch. Telephones with no video function are temporarily approved for a limited set of telehealth services, and may also be used for other communication technology-based services.

Approved Patients and Locations

Although Medicare only allows established patients to receive telehealth services, CMS has said it will not conduct audits to ensure that a prior relationship existed during the public health emergency. This means that clinicians may provide telehealth services to both new and established patients. Clinicians should consider state practice acts or other local laws and regulations before beginning services with new patients. Clinicians may be required to evaluate new patients before providing clinical recommendations or treatment.

CMS also removed limitations on where Medicare patients must be located to be eligible for telehealth services. Patients outside of rural areas and patients in their homes can now receive telehealth services during the PHE. Clinicians may also provide services from their own home.

Patient Consent

During the PHE, the patient must consent to receive services via telehealth at least once annually. You or your administrative staff can obtain verbal consent and notify the patient of applicable co-pay and deductible costs at the same time you provide the service. Be sure to document that you received the verbal or written consent.

Institutional Billing

On May 28, 2020, CMS announced that institutional settings may now provide Medicare outpatient therapy services via telehealth and report them on institutional claims, such as the UB-04, with the -95 modifier. However, this applies only to services that can be billed separately from the institutional bundle, are paid under the Medicare Physician Fee Schedule (MPFS), and are included as an authorized service on the Medicare telehealth list.

CMS provides guidance for specific settings including applicable type of bill (TOB) codes and services, as follows.

• Hospital: Report hospital outpatient therapy services on TOB 12X or 13X. 
• Skilled Nursing Facility (SNF): Report PT, OT, and speech-language pathology services on TOB 22X or 23X only when the patient is not on a Part A stay.
• Critical Access Hospital (CAH): Report PT, OT, and speech-language pathology services on TOB 85X.
• Comprehensive Outpatient Rehabilitation Facility (CORF): Report ambulatory outpatient PT, OT, and speech-language pathology services on TOB 75X.
• Outpatient Rehabilitation Facility (ORF): Report ambulatory outpatient PT, OT, and speech-language pathology services on TOB 74X. 
• Home Health Agency (HHA): Report PT, OT, and speech-language pathology services on TOB 34X to patients in their homes only if those patients are not under a home health plan of care. 

For additional details, see Medicare Allows Institutional Billing for Some Outpatient Telehealth Services During the COVID-19 Pandemic.

Facilities providing services via telecommunications technology as part of the bundled institutional payment, including audiology services paid under the hospital outpatient prospective payment system (OPPS), should follow additional CMS guidance, as outlined below.

Home Health Agencies

Medicare is precluded by federal law from covering telehealth services under the Part A home health benefit. In its home health fact sheet [PDF], CMS states that only in-person services can be reported via the home health claim even when the home health plan of care is developed or updated to include the use of telecommunication technology. As noted above, home health agencies may provide telehealth services to Medicare beneficiaries in their homes, but only when the patient is not under an established Medicare Part A home health plan of care. 

Skilled Nursing Facilities (SNFs)

SNFs have options for providing services via telecommunications technology to their residents. Medicare officials have stated that services provided via audiovisual equipment—such as a smartphone or platforms like FaceTime or Skype—in the same building as the patient or through the patient’s window are allowed but are considered in-person services and not telehealth services. Documentation and billing should follow the same guidelines as services provided in person.

Services provided remotely from an offsite location are considered telehealth services and policies depend on whether the patient is on a Medicare Part A or Part B stay.

• Part A: SNFs can count telehealth treatment minutes in the Minimum Data Set (MDS). Note that evaluation minutes can't be counted on the MDS, whether provided in person or via telehealth. Telehealth coding restrictions do not apply because CPT codes aren't used for Part A billing. See also: Telehealth Now Allowed for Part A Services.
• Part B: As noted above, Part B services can be reported on the UB-04. However, only select services can be provided via telehealth, as outlined later on this page.

Hospital Outpatient Departments (HOPDs)

HOPDs can choose to register patients' homes as temporary extension sites or bill services as telehealth.

Telehealth

As noted above, hospitals may report certain therapy telehealth services separate from the institutional bundle. However, this option means hospitals are limited to those services that are listed on Medicare's approved outpatient telehealth services list, as outlined later on this page.

Temporary Extension Site

According to an April 30, 2020, CMS press release and related guidance for HOPDs [PDF], “hospitals may bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is at home...” when the hospital has registered the patient’s home as a temporary expansion location with the CMS Regional Office. Audiologists and SLPs should work with their hospital to ensure each patient’s home is registered with the regional office and that services are provided remotely only when clinically appropriate for the patient.

According to CMS, if the patient is a registered outpatient of the hospital and is in a temporary expansion location of the outpatient department (including the patient’s home), the service can be provided via audiovisual equipment. In cases where both audio and visual are not available, the service can be furnished exclusively with audio. These services can be provided by the hospital’s clinical staff and should be billed as if they were provided in the hospital.

An advantage of this option is that telehealth restrictions don't apply and the hospital can bill for all covered evaluation and treatment services. However, there is an administrative burden associated with registering patients' homes as a temporary extension sites.

Covered Audiology and Speech-Language Pathology Services

Medicare’s telehealth services list outlines approved Medicare Part B services by Current Procedural Terminology (CPT) code. Clinicians should not use CPT codes on the approved list to submit claims for other telehealth services not included on this list. 

Clinicians must follow Medicare requirements for covered services, whether provided in person or via telehealth. For example, audiology services require a physician referral, and speech-language pathology services should include physician certification of the plan of care. Chapter 15 of the Medicare Benefit Policy Manual [PDF] outlines coverage and documentation requirements for Medicare Part B services.

Codes not included on this list may be provided via telehealth to Medicare beneficiaries under a private pay arrangement, with the patient's consent.

Audiology CPT Codes

(updated 11/18/22)

It's important for audiologists to know how telehealth coverage will change and what options you have to continue Medicare telehealth services once the federally-declared PHE and 151-day extension are over.

During the PHE

The following codes represent audiology services covered under the Medicare telehealth benefit during the PHE and the 151-day extension following the end of the PHE. CMS will also include ongoing coverage of several CPT codes on this list through the end of 2023, even if the PHE and extension expire earlier. These codes are designated in the table as "available through 12/31/2023".

Keep in mind that audiologists can't charge Medicare beneficiaries for these specific services and must bill Medicare directly. If a service isn't on the temporarily authorized telehealth services list, you can enter into a private pay arrangement with the Medicare beneficiary for that specific service (vestibular testing, for example).

After the PHE

Once the federally-declared PHE and 151-day extension end, Medicare will no longer reimburse audiologists for any telehealth services, even those designated to remain on the temporary telehealth list through December 31, 2023. You can enter into private pay arrangements with Medicare beneficiaries to continue providing telehealth services, if the patient agrees.

See also: What to Expect at the End of the PHE

Speech-Language Pathology CPT Codes

(updated 11/18/22)

It's important for SLPs to know how telehealth coverage will change and what options you have to continue Medicare telehealth services once the federally-declared PHE and 151-day extension are over.

During the PHE

The following codes represent speech-language pathology services covered under the Medicare telehealth benefit during the PHE and the 151-day extension following the end of the PHE. There are also a limited number of codes available for billing through December 31, 2023, even if the PHE and 151-day extension expire earlier, but only under limited circumstances (see below for additional information).

As noted in the table, CMS also allows select speech-language pathology services to be conducted via audio-only in those cases where the patient does not have access to audiovisual equipment. These services may still be reported to Medicare as telehealth services using the appropriate CPT codes and telehealth modifier during the PHE. 

Keep in mind that SLPs can't charge Medicare beneficiaries for these specific services and must bill Medicare directly. If a service isn't on the temporarily authorized telehealth services list, you can enter into a private pay arrangement with the Medicare beneficiary for that specific service.

After the PHE

Once the federally-declared PHE and 151-day extension end, Medicare will no longer reimburse SLPs directly for any telehealth services. SLPs will have two options for reimbursement for Medicare telehealth services.

• You can enter into private pay arrangements with Medicare beneficiaries to continue providing telehealth services, if the patients agree.
• You can also provide select telehealth services “incident to” a physician, meaning these services would be provided under the direct supervision of a physician and billed under the physician’s NPI. This option is available through December 31, 2023.
  • Direct supervision means the physician is in the office suite (but not necessarily in the same room) or available through real time audio-visual communication technology.
  • The services SLPs may provide "incident to" a physician are desigated on the list above as "available through 12/31/2023".
  • See ASHA's website for additional information regarding "incident to" billing.

See also: What to Expect at the End of the PHE

Coding and Billing Guidelines

Audiologists and SLPs providing telehealth services should report the same CPT codes and follow the same coding guidelines as they would for in-person services, including same-day billing rules and time requirements. For example, a brief check-in via telecommunication technology should not be reported with an evaluation or treatment CPT code (such as 92507 or 92601) and is not considered a Medicare telehealth service.

Medicare telehealth services are reimbursed at the same rate as in-person services paid under the Medicare Physician Fee Schedule for Part B services.

Place of Service (POS) and Modifiers

Medicare instructs Part B providers who perform telehealth services to report the POS code that reflects the location where in-person services would have been provided. Providers should also append the modifier -95 (synchronous telemedicine service) to each CPT code provided via telehealth. Modifier -95 indicates telehealth services provided in an outpatient nonfacility setting. Providers in outpatient settings should not use POS 02 (telehealth provided in a location other than the patient's home) because this will result in payment at the facility rate. There is also new POS code 10, effective January 1, 2022, that reflects telehealth services provided in the patient's home. Although Medicare recognizes POS 10, clinicians providing outpatient services into the patient's home should continue billing for services provided via telehealth as outlined above.

For example, a clinician who provides telehealth services from their own home, but would normally have seen their patients in their private practice, would use POS 11 (office) and include modifier -95 for each CPT code reported.

SLPs should also append the -GN modifier to all CPT codes to indicate services provided under a speech-language pathology plan of care.

Communication Technology-Based Services Versus Telehealth Services

Communication technology-based services (CTBS) are not considered telehealth services under Medicare’s definition. According to Medicare, telehealth services represent services that would normally occur in person. On the other hand, CTBS codes represent brief communication services conducted over different types of technology to help avoid unnecessary office visits and slow the spread of COVID-19. They are virtual, by definition, and do not replace full evaluation and treatment services covered under the Medicare benefit and described by existing CPT codes for telehealth/in-person services. CTBS codes are limited in scope and reflect brief, virtual services such as e-visits or virtual check-ins that require clinical decision-making.

Medicare now allows SLPs to report CTBS codes both during and after the end of the PHE.

Providing Noncovered Audiology and Speech-Language Pathology Services

Medicare’s temporary coverage of telehealth services means that audiologists and SLPs may no longer enter into a private pay arrangement with Medicare beneficiaries for those services that are now included on Medicare’s telehealth list. Clinicians may continue to accept private payments from Medicare beneficiaries for services not included on the telehealth list. However, if Medicare adds more services to the approved telehealth list, enrolled Medicare providers must reimburse their patients for those services and submit claims to Medicare for payment. Unenrolled providers must also reimburse their patients, but may not submit claims to Medicare for reimbursement and may not enter into private pay agreements with Medicare beneficiaries for covered services.

Informed Consent

Because telehealth services not included on the telehealth list are statutorily excluded from Medicare coverage, clinicians aren’t required to provide an Advance Beneficiary Notice (ABN) [PDF] of financial liability to the Medicare beneficiary. However, an ABN may be given as part of the informed consent necessary for engaging any patient in a private contact to make direct payment for non-covered telehealth services. ASHA also recommends that clinicians clearly inform the Medicare beneficiary, in writing, that Medicare covers audiology and speech-language pathology services provided in-person and have them voluntarily confirm their desire to receive services via telehealth.

Establishing Rates

The Medicare fee schedule does not directly apply to services statutorily excluded from Medicare coverage. ASHA recommends following the Medicare Physician Fee Schedule (MPFS) rates for private pay contracts with Medicare beneficiaries for telehealth services. Medicare reimburses providers at the same rate for both in-person and telehealth services, when covered. ASHA recommends following that precedent. Some adjustments to MPFS rates can be made to accommodate the financial needs of the patient under a written policy that applies to all patients, regardless of form of insurance.

Legal and Regulatory Foundation

Although CMS has temporarily waived certain telehealth laws, allowing audiologists and SLPs to provide some telehealth services during the public health emergency, Section 1834(m) of the Social Security Act (SSA) precisely defines telehealth as a service provided by a physician or practitioner under the Medicare benefit. The SSA currently classifies audiologists and SLPs as suppliers. This means standing Medicare law doesn’t recognize audiologists and SLPs for reimbursement for telehealth services. This statutory exclusion eliminates such services from Medicare service delivery requirements and shifts financial liability for paying for the services to beneficiaries at the discretion of the patient. As a result, audiologists and SLPs may provide non-covered telehealth services to Medicare beneficiaries and enter into private pay contracts to receive reimbursement, if the patient agrees. This interpretation is supported by a series of direct communications with CMS staff, engagement with external experts familiar with Medicare law, and in consultation with other professional associations.

Section 50.3.2 of Chapter 30 of the Medicare Claims Processing Manual [PDF] also makes it clear that when services are statutorily excluded from coverage, Medicare policy does not apply, there is no Medicare reimbursement, and the use of an ABN is voluntary.

It is important to note that the statutory exclusion of certain telehealth services creates this unique exemption from coverage. Audiologist and SLPs cannot opt out of Medicare and must comply with all regulatory requirements when they provide covered services to Medicare beneficiaries, including temporarily covered telehealth services. 

Resources

Contact reimbursement@asha.org for additional information. Check this webpage and ASHA’s COVID-19 Updates page frequently for the latest developments related to Medicare, Medicaid, and commercial insurance coverage of telehealth services during the COVID-19 pandemic.

CMS also publishes extensive resources, including frequently asked questions [PDF], to help providers during the public health emergency.