2020 Ophthalmic Telemedicine and the CMS 1135 Waiver

Diagnosis and Management in Retina Disease


A massive effort has been undertaken by the Centers for Medicare and Medicaid Services (CMS) to tackle the pandemic coronavirus (COVID-19) by the issuance of waivers and changes to national telehealth regulations and guidelines for Medicare, the principal one being the 1135 waiver. The objective is to lessen restrictions on the practice of medicine as well as to facilitate the use of telehealth medicine rather than face-to-face encounters.

Telehealth describes health care delivery using various techniques that include the following:

  • Audio-video information that is transmitted in real time (synchronous)
  • Stored and then forwarded audio and/or video information (asynchronous)
  • Social medial techniques such as Facetime, cell phone images (synchronous and asynchronous)

Current Procedural Terminology (CPT) uses the term “telemedicine” — a term that is narrower in its scope of providing medical care — rather than “telehealth.” However, both terms are used interchangeably to express the performing of the diagnosis and management of medical problems remotely using these varied modalities. This article concentrates on the original Medicare program coverage for performance of the standard remote telehealth services incorporating the waivers that Medicare has issued that is synchronous by definition.

Take Note:

  • Bold font is used in this article to highlight the most important points in the 1135 waiver. Many are changes from the original rules and may eventually revert back to them.
  • Loosening of the original requirements is changing constantly now. Be sure to keep abreast of your MAC’s and CMS’s updates.
  • Sign up for your MAC’s news alerts and assign one person to check the emails daily and report changes.

Standard Medicare Synchronous Telehealth Visits and the 1135 Waiver

Many requirements have been waived temporarily. Synchronous equals real-time communication, whereas asynchronous does not have to be in real time. The original telehealth policy mandates synchronous visits and has other rigorous regulations regarding how it is to be conducted.1

Medicare Telehealth Visits

The following original regulations still apply:

  • Telecommunication technology may be used for office visits, hospital visits, and other services that generally occur in person.
  • The provider must use an interactive audio-video telecommunication system that permits real-time communication between the distant site and the patient.
  • Distant-site practitioners can furnish and get payment for covered telehealth services (subject to state law); this includes all physicians under the Medicare Fee-for-Service program (MDs, DOs, ODs), nurse practitioners, and physician assistants. The provider must be enrolled in the Medicare program, have an NPI number to bill Medicare, and be licensed.
  • Applicable CPT codes that you will most often use include:
    • 99201-99215: Office or other outpatient visits; Note: Eye codes are not included!
    • G0425-G0427: Telehealth consultations, emergency department or initial inpatient
    • G0406-G0408: Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs;
  • As a result of the new Interim Final Rule issued by CMS on March 30, 2020, the choice of code is based on the premise for 2021 office visits that specifies codes selected be based on Medical Decision Making (MDM) or Time. However, the MDM is based on the 1997 rules for MDM as specified in the original 1997 Guidelines and are found in the 2020 CPT.

G codes, which are special Medicare codes, may be used for new or established patients under the 1135 waiver.

Medicare Telehealth Visit: Revised Guidelines per 1135 Waiver

  • CMS has stated that, “It is imperative during this public health emergency that patients avoid travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness. Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.”
  • This will be effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency.
  • HHS will not conduct audits to ensure that the patient have a prior established relationship with a given practitioner. Note: This is not a statement that all audits have been suspended.
  • The 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.
  • Physicians licensed in one state can provide services to Medicare beneficiaries in another state. State licensure laws still apply.
  • Original regulations mandated that patients must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility, or hospital for the visit. Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.
  • Healthcare providers may reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
  • HIPPA regulations are waived.
  • These changes apply to new and established patients.

Applicable CPT Codes

There is a very long list of Medicare covered telehealth services in the MLN Matters booklet;2 however, the ones that primarily pertain to ophthalmic practitioners are listed in Table 1.3

Table 1: Codes for Telehealth Services Pertinent to Ophthalmology
Telehealth consultations, emergency department or initial inpatient HCPCS codes G0425-G0427
Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS codes G0400-G0408
Office or other outpatient visits CPT codes 99201-99215
Subsequent hospital care services, with limitation of 1 telehealth visit every 3 days CPT codes 99231-99233
Subsequent nursing facility care services, with limitation of 1 telehealth visit every 30 days CPT codes 99307-99310
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour CPT code 99354
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes CPT code 99355
Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service) CPT code 99356

Billing and Payment for Original Telehealth Originating Sites and Distant Site Instructions

Billing, coding, and payment instructions are in constant flux:

  • Providers in Alaska and Hawaii should append telehealth modifier GQ if the services were performed “via an asynchronous telecommunications system” (for example, 99201 GQ).
  • After January 1, 2017, use Place of Service (POS) 02: Telehealth.
  • After January 1, 2018, distant-site practitioners billing telehealth services from Critical Access Hospitals (CAH) under the CAH Optional Payment Method should submit institutional claims using the GT modifier. However, it no longer has to be used.
  • Physicians billing for their services that are not rendered in a CAH would bill the Medicare Administrative Contractor (MAC) under the Medicare Physicians Fee Schedule.

Keep abreast of CMS and MAC instructions and contact them for help.

Case Studies

Anterior Segment Issues: Modalities that involve imaging (ie, photographs and videos) of the eyelids/eyelashes and external examination elements (sclera, cornea, iris, pupil, anterior chamber depth) lend themselves to visual diagnosis using various telehealth modalities (cell phones, photographs, EMR video uploading to the cloud with instantaneous transmittal [new from Modernizing Medicine] and artificial intelligence imaging). Although these modalities are more generally utilized in anterior-segment management, the following scenarios may be diagnosed, or even perhaps managed, by the use of various telehealth visual modalities.

  • Intravitreal injections (CPT code 67028 are the second most frequent ophthalmic surgery performed, numbering 3,512,147 performed in 2018, the last year available for Medicare’s Bess statistics): Postoperative problems can occur at the injection site or anterior portion of the eye, including endophthalmitis, subconjunctival hemorrhage, and Betadine-induced conjunctivitis. Remote visualization of the area will help making a diagnosis and providing subsequent treatment.
  • Ophthalmologists/optometrists owning visual documenting and transmitting equipment: A patient presents to a comprehensive ophthalmologist or optometrist with symptoms of retinal detachment. The optometrist, for example, has sophisticated equipment due to the fact that the nearest ophthalmologist is located several hours away. He contacts a retina specialist and transmits the images while the patient is in the office. The consulting retina specialist determines that this is emergent and recommends the patient find transportation to her office.

Basic Steps in Chart Documentation

Last, but not least, it is imperative to open a chart for any new patient that you communicate with via telehealth and document the following for all patients, established and new. The codes apply to both sets of patients under the 1135 waiver. Here are the elements that are necessary:

  • Documentation of verbal informed consent
  • Date and time of contacts as well as start and stop times (when)
  • Demographic data of patient (who)
  • Reason for contact, including symptoms, and that contact is not related to an office visit in the past seven days (why)
  • Method by which teledata were received (phone call, photo, medical records) (how)
  • Presumptive or active diagnosis and dispensation of the patient, proscribed treatment, and follow-up (what)


The coronavirus pandemic is a most trying time for the world. Physicians are among those at the highest risk. A myriad of codes have been made available for retina specialists’ use, and many regulations have been modified.4,5 This may be confusing now, but it is beneficial to patients and providers alike, and when this episode is over, many physicians will incorporate telehealth into their practice management.


  1. Asbell RL. Telehealth coding — Medicare regulations for ophthalmology. Accessed April 6, 2020.
  2. Mtelehealth, LLC. CMS Medicare Learning Network telehealth services booklet 2019. Accessed April 6, 2020.
  3. Asbell RL. 2020 telemedicine retina screening codes: 92227 92228. Accessed April 6, 2020.
  4. American Society of Retina Specialists. COVID-19: updates and resources. Accessed April 6, 2020.
  5. American Academy of Ophthalmology. Telemedicine for ophthalmology information statement – 2018. Accessed April 6, 2020.