MATRC Telehealth Resources for COVID-19

March 24, 2020

STARTING A TELEHEALTH PROGRAM

What is the Different Between Telemedicine, Telehealth and Remote Monitoring?

Telemedicine typically refers to the practice of medicine using technology to deliver care at a distance. A physician/clinician in one location uses a telecommunications infrastructure to deliver care to a patient at a distant site.  Telemedicine is a subset of telehealth.

Telehealth refers to a broader scope of remote health care services than telemedicine. Telemedicine refers specifically to remote clinical services, while telehealth can refer to remote non-clinical services (for example, clinician to clinician consults, patient education services, interprofessional care teams, etc)

Remote patient monitoring refers to using technology to gather patient data outside of traditional healthcare settings, for example, using digital scales, glucometers, pulse-ox, etc…to monitor a patient’s condition while they are at home.

 

I Don’t Know What I Don’t Know.  Where Do I Start? 

  • First check out this COVID-19 Telehealth Toolkit to get some ideas on how telehealth can be used in response to COVID-19, an understanding of some of the big picture policy issues, and for a list of additional resources.  
  • Next, if you are one of many clinicians and practices getting ready to ramp up with telehealth offerings in response to COVID-19, we offered a webinar where we walked through a checklist of the essentials you’ll need to have in mind (and get into place) to help you get started.  To access the recording of the webinar:  Click Here.
    • If you want to kill two birds with one stone and get trained while obtaining 1 credit/contact hour of CME/CE credits, this Foundations of Telehealth Course is also an option (there is a $95 fee associated with this course):  Click Here
  • Third, check out all the resources and information found on this page.  Got additional questions after taking a look?  Join us for our Virtual Office Hours.  We provide Virtual Office Hours related to “Telehealth Basics/Telemental Health” as as well as on “Telehealth Technology or Vendors”.  To see the full schedule:  Click Here
  • Finally, can’t make our Virtual Office Hours?  Request Technical Assistance online using this form:   Click Here   Hot Tip: Due to the overwhelming interest and need for telehealth during this pandemic, using the online form will generally get you a quicker response than calling and leaving voicemail messages.  It is much more difficult to return calls after hours and on weekends, but we can respond to your emails.  The more specific you are with your question or request (e.g., what type of provider you are, what type of setting you work in, what you specifically need), the better we will be at getting you timely and useful information.

 

Do You Have Any Specific Resources for TeleMental/Behavioral Health Providers Who Are Getting Started?

  • We have a great website called the Telebehavioral Health Center of Excellence with a large number of online resources just for you:  Click Here.    And make sure you take advantage of our Virtual Office Hours (see bullet three above).
  • If you are serious about telemental/behavioral health, you can get yourself Board Certified as a Telemental Health Provider (9 modules, $50 per module):  Click Here or Click Here

 

Do You Have Any Specific Resources for Providers Interested in Getting Started with Remote Patient Monitoring?

  • We have a great toolkit on our website dedicated to helping providers get started with Remote Patient Monitoring.  Click Here.    Make sure you download the actual RPM Toolkit (it’s an 8 page pdf document with lots of great information)

 

Do You Have Any Specific Resources Related to Telehealth Technology and HIPAA?

  • If you have a budget for this sort of thing and the luxury of taking your time, we would recommend you using our Vendor Selection Toolkit:  Click Here
  • Since most of you are frantically trying to get started yesterday, if you don’t currently have any technology that you could use for a telehealth visit, please know that as part of its response to the pandemic, a change was made regarding HIPAA. The HHS Office for Civil Rights is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype:  Click Here.   With that said, please check your State policies, as not every state has waived their HIPAA requirements.  Click Here, select the state of interest and then scroll down to the lower half of the page to see the original guidance documents and any new guidance related to COVID-19.
  • For a quick introduction to HIPAA Compliance and Telehealth, check out our very brief (under a minute) video (the middle one at the top of the page):  Click Here
  • If you don’t have a budget for telehealth technology, the following are vendors who are offering either free or significantly reduced prices as a response to COVID-19.  Please note that MATRC is not in a position to either endorse or recommend any of the vendors on this list. We strongly encourage you to do your due diligence when making a vendor selection. There may be other vendors also making available platforms for free or at a significantly reduced price in response to COVID-19. These are the ones that have been brought to our attention:

 

Do You Have Any Specific Resources on How to Provide a Telehealth Visit?

  • This article “Why the Telemedicine Physical is Better than You Think” gives some great perspective as well as very practical ideas:  Click Here
  • Telemedicine: Conducting an Effective Physical Exam Online Course ($100, includes CME/CE):  Click Here
  • Free Telehealth Etiquette Video Series:  Click Here
  • Free (registration required) Telehealth Coordinator Online Training:  Click Here
  • Telehealth Workflow Samples (from the California TRC)
  • Depending on the type of provider you are and the type of service you offer, there are some specific clinical guidelines and best practices for telehealth that have been developed.  There are too many documents to list here.  Please contact us using our online Technical Assistance Form and let us know your specific interest area(s): Click Here
  • If you are an FQHC, the Weitzman Institute is offering a series of Project ECHO sessions on Preparing for COVID-19.  One of the sessions is entitled “Develop and Define Your Telehealth Strategy”  Click Here for a listing of upcoming sessions and access to recordings of past sessions.
  • If you are a physician, the AMA has developed a “Quick Guide to Telemedicine in Practice” that has a section on Practice Implementation:  Click Here

 

What About Consent? 

  • Some states require you to get consent for telehealth visits and others do not.  Some states require very specific components in the consent process.  To see if yours does, Click Here
    • Using the filter boxes:
      • Select your state of interest
      • Select “All Categories” (this is the default)
      • Select “Consent” as your topic
      • Click on “Apply” and soon you will see if/where there are consent requirements within your state’s policies.  Sometimes it is only required as part of Medicaid reimbursement, other times it is part of state law, and other times it is embedded in health professions regulations for specific types of providers.
  • We think it’s a good practice to get consent, whether it is required or not.   For a Sample Consent Form in English: CLICK HERE and in Spanish: CLICK HERE (credit goes to California TRC).   Adapt this form to your clinical use case and your state’s policy requirements (you may not need every element).   Unless your state explicitly requires the consent form to be signed (most places do not), it may be done verbally, with a note in the patient record.  Make sure you have a written process and protocol developed that is considered standard operating procedure.   Once that is in place, you just need to note in the medical record that your consent process was used and that the patient gave consent. 

 

How Do I Document a Telehealth Visit?  

For documentation of a telehealth visit, you should include  everything you usually need to document for the CPT or E&M code being billed, PLUS…

    • Patient’s location (enough detail to satisfy a Medicare audit, i.e., covered rural site).
      • With all the exceptions being made during this pandemic with the waiver, this is not as important during the state of emergency, but in general you should do this so you might as well make it a practice!
      • If the patient’s home is the location of service, and the address is already somewhere in the medical record, then you just need to include in your note that the visit took place at the patient’s home.  You don’t need to capture the address again.
      • It is always good practice to verify the patient’s location at the start of every virtual visit.  Do not assume they are at home!  Remember that if the patient experiences an emergency/crisis when they are in the middle of a visit with you, if you don’t have easy access to their physical location address (a PO Box will not work), it will be impossible to contact first responders and have them deployed to the patient’s location.
    • Provider’s location (this would be the usual place of practice – for most, it would be the office location, but if home is a routine or the only office location, then the provider’s home location should be registered as a site of service and used)
    • That the encounter was conducted via telehealth
    • Start and stop time
    • That the patient consented (unless otherwise documented).  Please refer to your State’s laws/licensing board regulations and guidance documents regarding specific requirements.  See section on consent above for how to do this.
    • Any other providers involved, including telepresenters
    • Optional:  A reason for using telehealth (medical or otherwise), and any criteria used to evaluate whether the case was appropriate for telehealth.

 

TELEHEALTH POLICY AND COVID-19

 

What Telehealth Related Federal Medicare, Licensure and Other Policy Changes Have Taken Place As a Result of the Pandemic?   

For a summary of the most up to date information on changes at the federal level, Click Here!

What Telehealth Related State Medicaid, Licensure and Other Policy Changes Have Taken Place As a Result of the Pandemic?  

For a summary of the most up to date information on changes at the state level, Click Here.

 

TELEHEALTH REIMBURSEMENT AND COVID-19: BILLING, CODING AND DOCUMENTATION

How Do I Bill and Code for Telehealth Services? 

Click Here to access a really good guidance document on billing and coding for telehealth.  In general, you would use the same CPT or E&M codes as for an in-person encounter, but to indicate that the service was provided via telehealth, each payer type has their own schema pertaining to a specific modifier or POS code (sometimes even both).    In addition, this guidance document also discusses how to bill and code for several types of services that CMS does not consider “telehealth”.   These include: Remote Communication Technology, Virtual Check-In, Remote Evaluation of Pre-Recorded Patient Information and Interprofessional Internet Consultation.

 

Help Me Understand Medicare Reimbursement for Telehealth:

  • Fee for Service Medicare and Telehealth Reimbursement

     

    • Prior to the COVID-19 pandemic, there were a large number of restrictions placed on Fee-for-Service Medicare reimbursement for telehealth services.   These restrictions included:
      • The originating site (location of the patient).  Providers could only get reimbursed for telehealth services if the patients receiving those services were located at specific types of facilities (e.g., hospitals,  FQHCs, physician and practitioner offices) AND those facilities were located in specific geographic locations.  There were a few exceptions to this rule,  including treatment for Substance Use Disorder, Telestroke and Dialysis for End-State Renal Disease)
      • The distant site practitioner (type of provider providing the telehealth service).    Only a specific subset of provider types were eligible to serve as distant site providers (e.g., Physicians, NPs, PAs).  FQHCs and RHCs were specifically excluded from being able to serve as distant site practitioners.
      • Types of service.  Only a limited set of HCPCS/CPT Codes were eligible for telehealth reimbursement.
    • To understand Fee for Service Medicare Telehealth Services prior to the pandemic: Click Here.
    • To see a compilation of telehealth reimbursement questions that were submitted to CMS for clarification and their responses: Click Here  (also included in this document are links to additional CMS guidance documents that may be of use/interest)
  • Accountable Care Organization (ACO) and Medicare Telehealth Reimbursement
    • CMS has developed this Telehealth Factsheet just for you!   Click Here
  • Medicare Advantage (MA) Plans and Medicare Telehealth Reimbursement
    • CMS released final rules for changes to MA plans regarding telehealth in April 2019.  To see a summary of those changes: Click Here
  • In response to the COVID-19 pandemic, a waiver was granted removing all of the originating site restrictions.  This allows the patient to be located anywhere at the time of service, including their home.  There were NO changes related to the distant site practitioner or the types of services restrictions.  See Medicare guidance regarding billing and coding related to the waiver:  Click Here (helpful hint – scroll down to the bottom half of the page for specific billing codes and  to the very bottom of the page for a helpful summary comparison chart).
  • What if I am an FQHC or RHC?  In response to the pandemic, providing telehealth services as a distant site provider is considered “in scope” for an FQHC according to this guidance from BPHC:  Click Here  However, this is disconnected from the Medicare reimbursement mechanisms. For Medicare billing and reimbursement purposes, FQHCs and RHCs are still limited by the existing distant site practitioner restrictions.  There is language in the current bill being negotiated in Congress to lift the FQHC and RHC distant site practitioner restrictions, and presumably it will be retroactive to the start of the emergency declaration, but there is no guarantee at this point until the bill passes.

 

Help Me Understand Medicaid Reimbursement for Telehealth:  

Each State Medicaid program makes decisions on the types of restrictions they will place on originating sites, distant site practitioners and types of services.  Some have very few restrictions, while others have many. 

MATRC maintains guidance documents related to Medicaid and other policies for each state in the MATRC coverage area.  We have made an effort to keep our website updated as we find out about waivers and other policy changes in response to the pandemic.   Click Here, select the state of interest and then scroll down to the lower half of the page to see the original guidance documents and any new guidance related to COVID-19.  Alternatively, go up to the top menu bar and select the state of interest under “Our Region”.

 

Help Me Understand Private Payer Reimbursement for Telehealth:   

Most of the states in the MATRC region (DC, DE, KY, MD, NJ, VA) have passed “parity legislation”,  meaning that if a service being provided and billed for is considered a covered service in a face to face situation, a commercial carrier may not deny coverage solely because the service was provided via telehealth.

A few states in the MATRC region do not have parity legislation (NC, PA, WV).   For these states, it is up to the carrier to set its own policies regarding coverage.  In this case, you  would need to contact each commercial payer to ascertain their coverage policy.  In response to the pandemic, several health plans that serve our region have announced that they will make telehealth more widely available or are offering telehealth services for free for a certain period of time.  These are the ones that have come to our attention to date:

Not all commercial carriers have the same schema regarding modifiers or POS codes.  If guidance about billing codes is not provided in the above links and/or if your plan is not listed above, you will unfortunately need to contact each plan to find out which modifer or POS codes that they want you to use to indicate a telehealth visit.

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