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COVID-19: Unmasking Telemedicine.
Nathan Hare, MD, Priya Bansal, MD, Sakina S. Bajowala, MD, Stuart L. Abramson,MD, PhD, AE-C, Sheva Chervinskiy, D.O, Robert Corriel, David W. Hauswirth, MD,Sujani Kakumanu, MD, Reena Mehta, MD, Quratulain Rashid, MD, Michael R. Rupp,Jennifer Shih, Giselle S. Mosnaim, MD, MS
PII: S2213-2198(20)30673-5
DOI: https://doi.org/10.1016/j.jaip.2020.06.038
Reference: JAIP 2958
To appear in: The Journal of Allergy and Clinical Immunology: In Practice
Received Date: 16 June 2020
Accepted Date: 17 June 2020
Please cite this article as: Hare N, Bansal P, Bajowala SS, Abramson SL, Chervinskiy S, CorrielR, Hauswirth DW, Kakumanu S, Mehta R, Rashid Q, Rupp MR, Shih J, Mosnaim GS, COVID-19:Unmasking Telemedicine., The Journal of Allergy and Clinical Immunology: In Practice (2020), doi:https://doi.org/10.1016/j.jaip.2020.06.038.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the additionof a cover page and metadata, and formatting for readability, but it is not yet the definitive version ofrecord. This version will undergo additional copyediting, typesetting and review before it is publishedin its final form, but we are providing this version to give early visibility of the article. Please note that,during the production process, errors may be discovered which could affect the content, and all legaldisclaimers that apply to the journal pertain.
© 2020 Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology
1
Title: COVID-19: Unmasking Telemedicine. 1
2
This workgroup report was approved by the American Academy of Allergy, Asthma and 3
Immunology. 4
5
Authors: Nathan Hare, MD1*; Priya Bansal, MD2*; Sakina S. Bajowala, MD3; Stuart L. 6
Abramson, MD, PhD, AE-C4; Sheva Chervinskiy, D.O.5; Robert Corriel6; David W. Hauswirth, 7
MD7; Sujani Kakumanu, MD8; Reena Mehta MD9; Quratulain Rashid MD10; Michael R. Rupp11; 8
Jennifer Shih12; Giselle S. Mosnaim, MD, MS13 9
10
Author Affiliations: 11
1*UPMC Susquehanna Health Allergy, Williamsport, PA; 12
Email: [email protected] 13
2*Asthma and Allergy Wellness Center, Saint Charles, IL; Email: [email protected] 14
3Kaneland Allergy & Asthma Center, North Aurora, IL and Advocate Sherman Hospital, Elgin, IL; 15
Email: [email protected] 16
4Shannon Clinic/Shannon Medical Center, San Angelo, TX; 17
Email: [email protected]. 18
5University of Arkansas For Medical Sciences, Little Rock, AR; Email: [email protected] 19
6Partner ProHealth Care, LLP (Optum); Email: [email protected] 20
7Ohio ENT and Allergy Physicians, Columbus, OH and Nationwide Children’s Hospital, 21
Columbus, OH; Email: [email protected] 22
8University of Wisconsin School of Medicine and Public Health and William S. Middleton 23
Veterans Memorial Hospital, Madison, WI; 24
Email: [email protected] 25
9Uptown Allergy & Asthma, New Orleans, LA; 26
2
Email: [email protected] 27
10Division of Allergy Immunology, Beth Israel Deaconess Medical Center, Harvard Medical 28
School, Boston, MA; 29
Email: [email protected] 30
11Medical Director and President of The Allergy & Asthma Clinic of Southern New Mexico, NM; 31
Email: [email protected] 32
12Assistant Professor of Pediatrics and Medicine Emory University, Atlanta, GA; 33
Email: [email protected] 34
13Division of Pulmonary, Allergy and Critical Care, Department of Medicine, NorthShore 35
University HealthSystem, Evanston, IL; 36
Email: [email protected] 37
38
*Nathan Hare and Priya Bansal are co-primary authors. 39
40
Corresponding Author: Giselle Mosnaim, MD, MS; 1001 University Place; Evanston, IL 41
60201; Email: [email protected] 42
Funding: None 43
Running Title: Telemedicine During COVID-19: Work Group Report 44
Abstract word count: 170 45
Text word count: 5965 46
E-supplement word count: 2579 47
48
Author conflicts of interest: 49
Nathan Hare has no conflict of interest. 50
3
Priya Bansal has served on the advisory boards for: Genentech, Regeneron, Kaleo, 51
AstraZeneca, ALK, Shire, Takeda, Pharming, CSL Behring, Teva. Speaker for: AstraZeneca, 52
Regeneron, ALK, Takeda, Shire, CSL Behring, Takeda and Pharming. She has served as an 53
independent consultant for ALK, AstraZeneca, and Exhale. 54
Sakina Bajowala has no conflict of interest. 55
Stuart Abramson has no conflict of interest. 56
Sheva Chervinskiy has no conflict of interest. 57
Robert Corriel has no conflict of interest. 58
David Hausewirth has no conflict of interest. 59
Sujani Kakumanu has no conflict of interest. 60
Reena Mehta has no conflict of interest. 61
Quratulain Rashid has no conflict of interest. 62
Michael Rupp has no conflict of interest. 63
Jennifer Shih has no conflict of interest. 64
Giselle Mosnaim has received research grant support from AstraZeneca and GlaxoSmithKline; 65
currently receives research grant support from Propeller Health; owned stock in Electrocore; 66
and has served as a consultant and/or member of a scientific advisory board for 67
GlaxoSmithKline, Sanofi-Regeneron, Teva, Novartis, Astra Zeneca, Boehinger Ingelheim, and 68
Propeller Health. 69
70
Author contributions: 71
Wrote or contributed to the writing of the manuscript: All authors. 72
73
4
Abstract 74
Telemedicine adoption has rapidly accelerated since the onset of the COVID-19 pandemic.1 75
Telemedicine provides increased access to medical care and helps to mitigate risk by 76
conserving personal protective equipment and providing for social/physical distancing in order to 77
continue to treat patients with a variety of allergic and immunologic conditions. During this time, 78
many allergy and immunology clinicians have needed to adopt telemedicine expeditiously in 79
their practices while studying the complex and variable issues surrounding its regulation and 80
reimbursement. Some concerns have been temporarily alleviated since March 2020 to aid with 81
patient care in the setting of COVID-19. Other changes are ongoing at the time of this 82
publication. Members of the Telemedicine Work Group in the American Academy of Allergy, 83
Asthma & Immunology (AAAAI) completed a telemedicine literature review of online and Pub 84
Med resources through May 9, 2020 to detail Pre-COVID-19 telemedicine knowledge and 85
outline up to date telemedicine material. This work group report was developed to provide 86
guidance to allergy/immunology clinicians as they navigate the swiftly evolving telemedicine 87
landscape. 88
89
5
Introduction 90
The COVID-19 pandemic led to an unprecedented change in clinical operations, motivating 91
physicians and healthcare systems worldwide to rapidly implement telemedicine programs to 92
reduce or replace in-person visits.1 Telemedicine has allowed for increased workforce 93
sustainability, limitation of clinician direct exposure to patients, overall reduction of personal 94
protective equipment (PPE) use, and may reduce clinician burnout. It has also facilitated staffing 95
of both large and small facilities that are overwhelmed with pandemic-related patient overload.2 96
In addition, telemedicine has been used for surge control or “forward triage” - the triaging of 97
patients before they arrive in the emergency department (ED). Direct-to-consumer (DTC) visits 98
have allowed patients to be efficiently screened while protecting patients, clinicians, and the 99
community from exposure.3 100
This rapid need for telemedicine visits has generated the demand to effectively educate 101
allergists/immunologists on how to optimize utilization. Prior to the pandemic, telemedicine was 102
often reserved for patients with decreased access to care. It is quickly becoming the preferred 103
mode of delivering care for both follow-up and new clinic patients.3, 4 Recognizing telemedicine 104
as a growing field for the practicing allergist/immunologist, the American Academy of Allergy, 105
Asthma and Immunology (AAAAI) Health Informatics, Technology and Education (HITE) 106
Committee established a Telemedicine Work Group (TWG) to review multiple aspects of 107
telemedicine including utility, adoption procedures, billing, security, electronic medical record 108
(EMR) integration, education, and state specific issues. 109
110
Traditional Rationale for Telemedicine: Convenience of Care, Increased Access, and Cost 111
Savings 112
6
Telemedicine has been shown to decrease costs of travel for patients in both time and money. 113
By making it more convenient for them to obtain care, telemedicine has increased access for 114
patients who might not otherwise be able to receive care or be seen at a given practice.5, 6 115
Prior to the COVID-19 pandemic, patients who may have benefited from telemedicine included 116
poor, elderly or disabled patients, or those who simply lived too far away to travel for an in-117
person visit.5 Telemedicine is well-suited to large rural states or medically underserved urban 118
areas. A 2019 study found that telemedicine in the Veteran’s Health Administration (VHA) has 119
likely improved access to care for veterans who live in rural areas.7 120
This convenience is also applicable in emergency and hospital settings where specialists may 121
not be on site. Virtual consultations can limit the need for transportation of ED patients to other 122
facilities for care and hospital transfers.8, 9 As early as 2007, estimates predicted that 123
teleconsultations could obviate the need for up to 850,000 transfers and save US$537 million 124
dollars per year.8 125
A 2016 retrospective study done in the VHA looking at data from 1997-2008 found that, for the 126
clinics studied, the mean no-show rate for doctor appointments was 18.8%. The average cost 127
of a no-show visit in the VHA in 2008 was US$196.10 Telemedicine may help improve patient 128
compliance and decrease the associated financial cost to practices and clinicians of no-show 129
visits by reducing barriers to care.11 Cost-benefit analysis data for the use of telemedicine is 130
minimal at this time. However, recent studies conducted in tele-dermatology and telemedicine 131
in the pre-hospital care setting have recently shown promising results.12, 13 132
133
Rationale for Telemedicine during the COVID-19 Pandemic 134
Despite the exponential growth of telemedicine in the past five years in the United States, the 135
adoption of these services by the allergist/immunologist community was minimal prior to the 136
7
pandemic .14 Several factors contribute to the rationale for growth of telemedicine during the 137
COVID-19 pandemic. First, the public health emergency (PHE) has led to the development of 138
guidelines for quarantine as well as for social and physical distancing .15 The Centers for 139
Disease Control (CDC) and Department of Health and Human Services (HHS) has statutory 140
authority to promulgate regulations that protect individuals from communicable diseases, 141
including quarantinable communicable diseases as specified in an Executive Order of the 142
President.16 A study conducted in late March 2020 by the inspector general of the HHS 143
indicated hospitals in the US were desperately short of PPE 17 putting health care workers at 144
increased infectious risk. Telemedicine visits have the potential to decrease unnecessary use 145
of PPE and reserve available PPE for hospital use. In addition, it is imperative to continue to 146
treat non-emergent patients outside the hospital in order to prevent deterioration in their health, 147
as well as to accommodate for the increased demand to care for the sickest coronavirus 148
patients in EDs and intensive care units. Therefore, utilizing telemedicine is ideal for ongoing 149
safe treatment of patients, while continuing to promulgate responsible social and physical 150
distancing in accordance with quarantine regulations in the hopes of slowing the spread of 151
COVID-19. 152
153
Steps Involved in Starting a Telemedicine Program 154
The first step in setting up a telemedicine program is determining the types of patients that will 155
be seen. Assuming that federal, state, malpractice, and insurance guidelines are taken into 156
account, these may include initial consultations, established visits, and patients at a distance. It 157
is important to know the limitations of telemedicine, as there are certain visits that can be 158
challenging to perform through telemedicine. Procedures and procedure-related visits, such as 159
allergy skin tests, immunotherapy and/or biologic injections, food and/or drug challenges, in 160
general are difficult to accomplish except in the case of a facilitated visit where a trained 161
8
clinician is present at the patient’s site who is adequately trained and is able to accept 162
responsibility for treating the patient if a systemic allergic reaction occurs. 163
The next step is to decide whether the telemedicine visits will be through a synchronous or 164
asynchronous approach. Asynchronous telemedicine is communication with a patient separated 165
by distance and time. Synchronous telemedicine is where the clinician and patient are 166
connected at the same time in a live interactive audiovisual exchange. 167
Synchronous telemedicine is further classified into direct-to-consumer (DTC) visits or facilitated 168
visits (FV). A direct-to-consumer (DTC) visit occurs between the patient and clinician at a non- 169
medical facility, such as the home, where communication is directly through the patient’s 170
smartphone or computer. A facilitated visit (FV) requires a facilitator to operate equipment and 171
guide the patient through the video visit. 172
The equipment needed at the origination (patient) site depends on whether the appointment is a 173
facilitated visit (FV), a DTC visit, or a telephone visit. Please refer to the online supplement for 174
Specific Technology Guidelines. For a FV, there should be a specific room in which the patient 175
can be seen (often a regular examination room). Most origination sites have a “telemedicine 176
cart”, which contains the hardware, software and other equipment needed for a telemedicine 177
visit. For a DTC visit, the only equipment required at the patient’s site is what is necessary for 178
video conferencing. This can include a smartphone or a computer with internet, audio and video 179
capability. The DTC visit should be conducted through a HIPAA compliant platform. However, 180
during the COVID-19 pandemic, the HHS Office for Civil Rights has temporarily decided to 181
“exercise enforcement discretion and waive penalties for HIPAA violations against health care 182
providers that serve patients in good faith through everyday communications technologies such 183
9
as FaceTime or Skype” (Facetime: Apple Inc., Cupertino, CA; Skype: Skype Technologies, 184
Palo Alto, CA).18 There is no video requirement for a telephone visit, only audio. 185
The third step is determining where the clinician will conduct the visit. For telemedicine visits, 186
the distant site is the location of the clinician while they are providing care. The location of the 187
patient at the time they are receiving care is termed the originating site. During COVID-19, 188
restrictions have been lifted on where the patient and the clinician can be located for a 189
telemedicine visit to help eliminate barriers to care.18 Requirements at the distant site include 190
access to a reliable internet connection and adequate privacy to protect patient private health 191
information. Attention should be given by the clinician to lighting, sound, and their surroundings. 192
The clinician should be aware that everything in their environment can be seen and heard by 193
the patient. Positioning the clinician’s camera to maximize eye contact can provide needed 194
nonverbal communication within the digital platform. If additional family members are present 195
with the patient, establishing their role and connection with the patient is recommended. 196
Once the platform and equipment are in place, the next step is to organize the scheduling of 197
patients. Guidelines for patients best suited for telemedicine should be established. Pre-clinic 198
huddles can be effective forums for identifying patients suitable for telemedicine visits. Initially, 199
consider scheduling the same amount of time for a telemedicine visit as an in-person visit to 200
allow a buffer for technology issues that may come up. Documentation in the EMR can be done 201
at the same time as talking to the patient. The scheduling of telemedicine visits among in-202
person visits depends on practice efficiency, notification system, and workflow. This can be 203
adjusted as needed. 204
One important aspect to developing a successful telemedicine program is adequate training. 205
Clinicians (and facilitators in the case of FV visits) should familiarize themselves with the 206
software and any telemedicine equipment being used ahead of time. It is important to review 207
protocols for coping with software failures and have an easily accessible list of technical support 208
10
numbers on hand in case there are hardware or software issues. For example, during the 209
COVID-19 pandemic, one may have their primary platform on their HIPAA-secure EMR 210
software. If that fails, one may have a backup, encrypted independent platform. If the first two 211
encrypted options fail, traditional phone modalities may be used (See Tables IA and IB for 212
examples of encrypted and non-encrypted telemedicine platforms, respectively). Flexibility and 213
versatility in dealing with technology failures in real time is paramount. 214
Providing checklists or a toolkit for patients that include educational handouts on the patient’s 215
expectations, an introduction to the consent process, how to contact information technology if 216
they encounter difficulties during the visit, and how the patient can prepare to ensure a stable 217
digital connection during the visit is essential. Online tools including podcasts and webinars can 218
offer clinicians multiple medical education modalities.11 Please see Table II (Online Resources 219
for Telemedicine). 220
Clinic schedulers and other staff should contact patients prior to the visit to discuss preparation 221
for their telemedicine visit. Included in this discussion should be a review of the devices 222
(computer with camera, smartphone, phones, digital tablets) that can be used for the remote 223
telemedicine encounter. In addition, test calls with the device are recommended to ensure the 224
patient will be able to reliably connect to the clinician for their telemedicine visit. Depending on 225
the platform and the healthcare system involved, consent, required by most states, may be 226
obtained by the clinic staff or clinician and documented prior to the visit. Even if obtaining a 227
patient consent for telemedicine visits is not required in a particular state, it is an advisable best 228
practice to implement in telemedicine.19 229
A telemedicine visit starts when the patient logs into the telemedicine site. Some EMRs have an 230
integrated telemedicine application, thereby eliminating the need for a separate telemedicine 231
application. However, this is not a requirement; the telemedicine and EMR applications do not 232
have to be linked. Once a connection with the patient has been established and consent 233
11
obtained, the encounter can start. It may be helpful to have the patient’s chart in the EMR open, 234
either on the same screen or on a separate screen, to refer to and facilitate documentation 235
during the visit. The clinician may want to discuss what to do if the call drops or internet access 236
is disrupted with the patient at the start. Documenting information from the patient as to their 237
current location and phone number is recommended as it can be used to contact emergency 238
medical services (EMS) services if an emergency occurs during the telemedicine visit or if the 239
connection with the patient is lost. 240
The clinician should then conduct the history as they would for an in-person visit. After the 241
history has been obtained, a physical examination is performed. The depth of the physical exam 242
depends on the location of the patient. If the patient is at a medical facility, the physical 243
examination can be performed with the use of peripheral equipment (e.g. electronic stethoscope 244
and otoscope) and the facilitator. If it is a DTC visit, a physical exam can still be performed, with 245
the clinician guiding the patient to maneuver certain aspects for visualization. As expected, the 246
telemedicine exam is not as comprehensive as compared to an in-person exam. However, it is 247
not as limited as one might expect. With a little creativity, the clinician can still obtain a fair 248
amount of useful data from the telemedicine exam. (See Table III for example telemedicine 249
physical exam pearls). After the physical exam and medical decision making, an assessment 250
and plan are formulated. It is necessary to write orders, give prescriptions, and provide 251
instructions to the patient to conclude the visit. Please see Table IV for an overview of the Steps 252
for Conducting a Telemedicine Visit. 253
254
Integration with EMRs 255
The utility of EMR integration can depend upon the type of telemedicine that is employed. For 256
remote monitoring telemedicine, there have been studies using patient-facing technologies to 257
collect patient-generated health data that then flow into EMRs (such as peak flow or frequency 258
12
of MDI use).20, 21 However, these processes currently remain cumbersome and are not widely 259
implemented. For video conferencing telemedicine visits, the medical history, orders, and visit 260
notes associated with each video visit are integrated within the electronic health record (EMR), 261
thus improving work flows and clinician/patient satisfaction.22, 23 The patient-facing interface can 262
be via the vendor’s mobile application or EMR patient portal. EMR telemedicine vendors offer 263
additional features including integration with referral management, scheduling and visit 264
reminders, patient intake, and patient communications. Please refer to the E-supplement for 265
additional information on Integration with EMRs. 266
267
Evidence for Benefit of Use of Telemedicine in Allergy/Immunology Clinical Practice 268
In a recent meta-analysis, combined tele-case management and teleconsultation were effective 269
telemedicine interventions to improve asthma control and quality of life in adults.24 Telemedicine 270
was also used to provide asthma education in medically underserved areas. Scheduled 271
facilitated telemedicine visits with certified asthma educators over a period of one year reduced 272
the number of unscheduled visits for asthma.25 In addition, telemedicine was shown to be non-273
inferior to in-person evaluation for asthma care. This is particularly important in medically 274
underserved areas where access to asthma specialists may not be readily available. Remote 275
Presence Solution (RPS) equipped with a digital stethoscope, otoscope, and high-resolution 276
camera was used to perform the visits in this study, with either a registered nurse or respiratory 277
therapist serving as telefacilitator.26 A pilot study of 50 patients published in 2018 utilizing 278
telemedicine to evaluate penicillin allergy demonstrated high patient satisfaction and potential 279
savings of over US$30,000 dollars due to increased access to specialty allergy/immunology 280
care and improved antibiotic stewardship.27 As with any benefit comes an evaluation of risk. 281
Patient safety and the lack of inferiority of the quality of care with telemedicine versus standard 282
care are ongoing areas of research.28 283
13
Billing and Reimbursement 284
The relationship between telemedicine reimbursement rules and access to care is complex. 285
Concerns about potential overuse and quality of care have caused many payers to place 286
considerable restrictions on fee-for-service telemedicine coverage. Inconsistency among payers 287
and states in coverage for telemedicine services may shift costs from payers to clinicians and 288
patients, preventing adoption. The opportunity cost of non-reimbursed or under-reimbursed care 289
has been a major barrier to telemedicine implementation and prior to COVID-19 prevented 290
many physicians and health systems from offering potentially valuable telemedicine services to 291
their patients. Studies show that when reimbursement is limited, patients are under-served by 292
telemedicine services.29 293
Coverage 294
Although parity in coverage (both in-person and telemedicine services are covered for the same 295
indication) and payment (e.g., meaning that reimbursement for telemedicine services 296
approximates that of the equivalent in-person E/M service) has never been universally 297
mandated, payment parity is the coveted norm. Existing data suggest that enactment of parity 298
increases adoption of telemedicine. Almost 90% of both users and non-users (of telemedicine) 299
said they would use telemedicine if they were to be reimbursed.29 In fact, a 77.5% increase in 300
telemedicine adoption was noted after implementation of parity in Michigan.30 301
Because telemedicine coverage and reimbursement are not federally regulated, there is 302
considerable variability in rules, depending on the state and insurer. No two payers or states are 303
alike in how they define or cover telemedicine services. Although the COVID-19 PHE has 304
certainly brought increased coverage for telemedicine services, nationwide standardization of 305
coverage and payment policies is still lacking. The Center for Medicare and Medicaid Services 306
(CMS) has historically placed strict limits on criteria for telemedicine reimbursement, requiring 307
14
patients receiving telemedicine services to reside in a rural area and travel to a designated 308
health center to receive facilitated care via a synchronous live video link.31 However, these strict 309
limits on telemedicine services may have contributed to thwarting innovation and adoption of 310
new technologies, thereby limiting access to care. Even before the COVID-19 pandemic, CMS 311
had pivoted to enhanced coverage of telemedicine. 312
Medicaid has generally had broader telemedicine coverage than Medicare, but rules vary from 313
state to state. Currently, all 50 states and Washington DC provide reimbursement for some form 314
of live video in Medicaid fee-for-service plans. Fourteen states reimburse for store and forward 315
delivered services (not including teleradiology). Twenty-two states reimburse for remote patient 316
monitoring (RPM).32 317
Coverage for telemedicine by commercial insurers is dependent on both state regulations and 318
insurer-specific policies. Currently, 40 states and Washington DC have laws that govern private 319
payer telemedicine reimbursement policies.33 Some laws require reimbursement be equal to in-320
person coverage. However, most only require parity in covered services, not reimbursement 321
amount. Depending on how the law is written, it may provide payers with the ability to limit the 322
amount of that coverage. Unfortunately, inconsistent coverage and reimbursement policies 323
among the various insurers can lead to confusion, incorrect coding and billing, and denied 324
claims.34 325
Some patients prefer to pay a convenience fee to access non-covered telemedicine services 326
rather than come into the office for an in-person visit or forgo care. Costs vary significantly but 327
tend to be lower than the routine charges for an in-person evaluation.35 328
Coding Prior to COVID-19 Expanded Guidelines 329
15
Correct coding of telemedicine services is essential to obtaining reimbursement for care. In 330
most cases, coding for telemedicine services was done using the corresponding codes for an in-331
person E/M visit (using either time or history and medical decision-making to justify the level), 332
but with commercial insurers requiring the -95 modifier (synchronous telemedicine service 333
rendered via a real-time interactive audio and video telecommunications system) appended. 334
Some insurers also accepted modifier GT in lieu of 95. Medicare did not require a modifier for 335
E/M services provided via telemedicine. Place of service was to be designated as “02” to signify 336
telemedicine for all payers. While Medicare only covered telemedicine services for established 337
patients, some private payers permitted telemedicine visits for new patients, but not with the 338
standard new patient CPT codes. Instead, they required billing with code 99499 (Unlisted 339
evaluation and management code) with place of service “02”. This may have been associated 340
with lower reimbursement than an in-person new patient visit. Due to this variability, it had 341
always been best to check with each individual payer to determine how best to code 342
telemedicine visits. For further information about CMS coverage of telemedicine services pre-343
COVID-19, see Table V. 344
It is important to know if the site qualifies for billing a facility fee. If providing consultation 345
services, it is important to be familiar with the rules if the referring physician and the consulting 346
physician are participating in the telemedicine visit at the same time. In this scenario, the 347
consulting physician would bill the E/M CPT for the visit, and the referring physician would bill a 348
facility fee (CPT Q3014) if the visit is conducted at the referring physician’s office. 349
Documentation is key for billing and coding whether billing based on time or based on exam. 350
For visits that are billed based on time, it is ideal to note start and stop times for the 351
telemedicine visit and document risk/complexity of visit. If billing based on time, 50% of the time 352
must be spent on counseling and/or coordination of care. See Table VI for coding and billing 353
telemedicine visits by time. For visits that are based on exam, documentation requirements for 354
16
the systems that were examined is the same as for an in-person visit. Please see Table III for 355
telemedicine physical exam coding guidance. 356
Coding Changes during COVID-19 Expanded Guidelines 357
The COVID-19 PHE has rapidly ushered in expanded coverage/reimbursement for telemedicine 358
services by both CMS and commercial payers.18 One of the major changes from Medicare 359
includes the lifting of geographic restrictions on patient location, making telemedicine services 360
available to Medicare beneficiaries residing outside of underserved rural areas. Beginning 361
March 6, 2020, Medicare permitted patients to receive telemedicine services regardless of 362
location and without the need to leave their homes to visit an originating site, such as a clinic 363
that might be used for a FV. This means that, for the first time, Medicare patients can receive 364
telemedicine services from the comfort and safety of their own homes. CMS issued guidance to 365
use modifier -95 to designate an E/M service as telemedicine, and change the place of service 366
for all care to the location in which the service would have ordinarily been provided instead of 367
“02”, thus enabling payments to achieve parity with in-person rates instead of being reimbursed 368
at the lower facility rates. Although CMS itself is not waiving the cost-sharing for beneficiaries 369
during the COVID-19 PHE, the Office of the Inspector General (OIG) policy statement informed 370
practitioners that they will not be sanctioned for choosing to reduce or waive a patient’s cost-371
share obligations.36 During the COVID-19 pandemic, Medicare has continued to allow 372
telemedicine visits to be billed either by E/M (with history, physical exam, and medical decision 373
making, as per a normal in-person office visit) or by time (If billing based on time, 50% of the 374
time must be spent on counseling and/or coordination of care, as per a normal in-person office 375
visit). Please see Table III for telemedicine physical exam coding guidance and Table VI for 376
coding and billing telemedicine visits by time. Finally, Medicare temporarily has permitted new 377
patient codes to be billed for telemedicine visits and allowed telephone visits to be reimbursed 378
at face-to-face rates, enabling virtual care for those patients without access to video technology. 379
17
After weeks of rapidly changing guidance from commercial payers, many have now followed 380
CMS’s lead, and adopted many of the same telemedicine coverage expansions. This has 381
interestingly resulted in telemedicine billing/coding guidance that is significantly more uniform 382
than pre-COVID-19. Many commercial payers are now covering new patient visits via 383
telemedicine. Additionally, many have issued guidance to bill using the place of service “11” 384
instead of “02”, along with modifier -95 or -GT. In many (but not all) cases, this will result in 385
payments that achieve parity with in-person rates. See Table VII for Pre- and During-COVID-19 386
changes based upon insurance. Some states without coverage and payment parity laws have 387
issued executive orders temporarily mandating coverage (and in some cases, payment) parity 388
for telemedicine services provided for state residents.37 It remains to be seen if the increased 389
adoption of telemedicine resulting from these changes will be maintained post-COVID-19 or if 390
coverage and parity policies return to baseline. See Table VIII for examples of telemedicine 391
coding and billing. 392
Educating Clinicians on Telemedicine Adoption 393
Past data has shown that health care systems average a time period of 23 months to implement 394
digital healthcare solutions.38 With the mounting pressure to preserve clinical operations 395
remotely during the COVID-19 pandemic, many health care systems were faced with 396
implementing telemedicine within a few weeks. Systems that had already identified superusers 397
and who had utilized telemedicine to address medical care access issues were quick to expand 398
their telemedicine services. For any health care system, key factors of successful 399
implementation include stakeholder engagement, end user buy-in, effective educational delivery 400
programs and soliciting feedback.38 Preparing clinicians for implementing telemedicine involves 401
understanding of how telemedicine affects various aspects of the traditional clinic workflow, 402
which will look different for a large health care system vs academic setting vs 403
allergy/immunology private practice.39 (See Table V). 404
18
In addition to these components of education, clinicians will require access to information 405
regarding the most suitable telemedicine platform for their current needs. They expect to be 406
able to access this information quickly as it rapidly changes during and after the post COVID-19 407
pandemic. Platforms will differ on the breadth of data security and privacy that is offered and will 408
vary in their ability to be integrated within the EMR available to the clinician for documentation 409
and billing. 410
Federal Changes with COVID-19 411
Federal regulators announced another set of regulatory changes and waivers, particularly 412
relating to telemedicine, in response to the growing pandemic crisis throughout the United 413
States. These changes are described in the E-Supplement. 414
415
Malpractice and Cyber Liability Insurance 416
Clinicians should check with their own malpractice insurance carriers about coverage for 417
telemedicine visits. While confirming, it is recommended to check into new and follow up patient 418
coverage and coverage for practicing telemedicine across state lines if that is 419
needed. Clinicians should obtain written confirmation of the policy. This should be assessed 420
now and after the COVID-19 pandemic as regulations may change. 421
While inquiring into malpractice insurance, clinicians may also want to look into cyber liability 422
insurance coverage.40 This is critical to managing violations in patient data. Breaches may 423
come in the form of data being hijacked, inappropriately distributed or uncovered, or held for 424
ransom. Inadvertent data infringement, such as a lost tablet or laptop with unencrypted data 425
visible, may also occur. Both small and large practices have fallen victim to cyber theft.41 426
With telemedicine, HIPAA and security is something to keep in mind as protected health 427
information is exchanged regularly42 and arguably more often since the COVID-19 pandemic. 428
19
During the pandemic, many states have added protections under their “Good Samaritan” laws, 429
and the Federal Government, through the CARES Act: Section 3215. CARES Act – 430
Congress.gov43 has added limited protections for hospitals and clinicians during this health care 431
emergency. 432
433
State Specific Issues / Providing care across state lines 434
The practice of medicine has become progressively more complex in the last decade as 435
increasing regulation and payer restrictions/policies have encroached on the physician-patient 436
relationship. Nowhere is this clearer than at the cutting-edge application of technology and 437
healthcare delivery. Telemedicine is no different. Prior to COVID 19, only about 37 states had 438
signed on to the consortium making licensing for telemedicine visits across state lines easier to 439
obtain. Within each state there might have been multiple hurdles to overcome, boards to interact 440
with, specific technology requirements, and payer specific requirements as well. This process 441
has been accelerated with the COVID-19 pandemic, and many regulatory and payer issues 442
have been waived or modified to allow a rapid response to changing practice logistics, such as 443
eliminating licensing requirements for out of state telemedicine visits until the COVID-19 444
pandemic emergency has diminished. 445
Upon the rescinding of federal and state emergency orders related to COVID-19, these 446
requirements may revert back to their prior complexity or continue to exist in a partially modified 447
form. It is therefore advisable that all of these bodies be consulted prior to beginning/continuing 448
the practice of telemedicine in order to ensure proper care, fair reimbursement, avoidance of 449
unforeseen medicolegal issues, and to provide the best care for our patients. It is also advisable 450
that clinicians regularly check laws, legislative agendas, best practice recommendations, and 451
payer policies to ensure the practice continues to be compliant. This section will provide 452
20
information for approaching this process and cover regulatory issues at the state level, but not 453
reimbursement or technology requirements. 454
Efforts are being made by the Interstate Medical Licensure Compact Commission,44 (a branch 455
of the Federation of State Medical Boards that joins 29 states, the District of Columbia and the 456
Territory of Guam), to continue expansion to other states as they assist physicians with their 457
telemedicine licensing needs.This is an excellent resource for ongoing formation regarding 458
licensure. Upon expiration of current emergency orders removing barriers to telemedicine 459
licensure and requirements, the lack of license portability will continue to be a barrier. There is 460
an expedited process for licensing board-certified physicians with no background issues. But 461
physicians practicing in multiple states must adhere to a variety of state-specific medical 462
practice regulations, and there are annual license renewal fees for each state license. There is 463
no national licensure at present. The exception to this is patients and clinicians working with the 464
Veterans Administration (VA) system, where rules were in place effectively bypassing state 465
licensure laws.45 Please see the specific licensing issues in the E-supplement. 466
HIPAA Concerns 467
It is important to maintain Health Insurance Portability and Accountability Act of 1996 (HIPAA) 468
compliance in a telemedicine visit in the same manner as an in-person clinic visit. 469
HIPAA Compliance in Telemedicine 470
Medical professionals often mistakenly believe that communicating electronic protected health 471
information (ePHI) is acceptable when the communication is directly between physician and 472
patient. Often, little regard is given to the method of communication that is used for 473
communicating ePHI. Medical professionals who wish to comply with the HIPAA guidelines on 474
telemedicine must adhere to rigorous standards for such communications to be deemed 475
21
compliant. HIPAA requires ePHI data be encrypted when they are transferred.5 HIPAA also 476
directs that a telemedicine vendor must monitor data that are stored during transfer. 477
Lack of privacy and security standards play an important role in the legal challenges facing 478
telemedicine, and may have considerable implications for the acceptance of telemedicine 479
services.46 Any transmissions via video or internet protocol should be encrypted to ensure 480
security.47 Internet protocol encryption in other settings, such as private networks, is also highly 481
recommended. Any medical records, faxes, or communications associated with telemedicine 482
visits should also be held to the same HIPAA privacy and security standards that apply in a 483
standard in-person clinical office environment.48 484
Third Party Data Storage 485
HIPAA dictates that a telemedicine vendor must monitor data, such as ePHI, stored during 486
transfer. Therefore, telemedicine vendors have been required to provide customers with a 487
Business Associate Agreement (BAA). A BAA must include methods used by the third party to 488
ensure the protection of the data and provisions for regular auditing of the data’s security. Video 489
conferencing platforms such as Facetime, Google Hangouts (Google, Mountain View, CA), and 490
Skype do not have a BAA and thus previously did not fully comply with HIPAA. Some small 491
practices use these platforms for telemedicine. However, some insurers will not pay for 492
telemedicine care that uses the non-BAA platforms, and some large organizations will not allow 493
their doctors to use these platforms.49 In addition, copies of communications sent by SMS, 494
Skype, or email remain on the service clinicians´ servers and contain individually identifiable 495
healthcare information that is not encrypted. This ePHI is also not considered HIPAA 496
compliant.50 497
Technologies for HIPAA Compliance 498
22
There are a variety of vendors that provide telemedicine technology (Table IA). Because each 499
technology changes frequently, it is important to visit each vendor’s website for information 500
about current offerings. It is important to check with each company to determine HIPAA 501
compliance and encryption and to verify it with an IT security expert.51 Other technologies to 502
consider utilizing include Intrusion detection systems (IDS), web application protection, and log 503
management. 504
Patient Privacy Concerns 505
Patients have every right to be concerned about privacy and question how their information will 506
be handled during a telemedicine visit. Clinicians should be prepared to educate patients about 507
the steps taken for HIPAA compliance and ways to ensure the privacy of other confidential 508
information. It is important to let patients know technology is designed for this purpose and that 509
clinicians take this obligation under HIPAA very seriously.4 510
COVID-19 HIPAA-Specific Information 511
The emergency declaration by the President of the United States on March 15, 2020 removed 512
some of the HIPAA and state-related barriers that required recording all telemedicine visits and 513
that those copies be maintained in an archive as part of the medical record. For the time being, 514
CMS has also noted that accidental HIPAA violations that occur in the course of caring for 515
patients via this method will not be prosecuted, as long as the clinician was acting in the best 516
interest of the patient. Many state governors have released similar letters providing similar 517
policies for Medicaid in their respective states. With the declaration, the originating site can be 518
the patient’s home, nursing homes, hospital outpatient departments, and other settings and 519
across state lines.11 520
23
To immediately allow clinicians to start telemedicine services, HHS Office for Civil Rights (OCR) 521
will exercise enforcement discretion and waive penalties for HIPAA violations against healthcare 522
clinicians who serve patients in good faith through everyday communications technologies such 523
Zoom (Zoom Video Communications, Inc., San Jose, CA), Skype, and FaceTime, among 524
others.52 Telemedicine visits are also more flexible in that the video solution has an exception 525
for HIPAA security rules requiring BAA for technology. This change now also supports platforms 526
such as Facetime, Google Hangouts, and Skype which do not offer a BAA. Nevertheless, best 527
practice is to work toward the use of a HIPAA-compliant video solution as soon as available. 528
This emergency declaration regarding telemedicine requirements is to extend through the 529
COVID-19 PHE. At this point it remains unclear how long these changes will remain in effect or 530
what form they will take once the COVID-19 emergency ends. To dispel any confusion, 531
clinicians need to remember that HIPAA regulations are still in place at this time; it is the 532
enforcement of these regulations that has been temporarily relaxed. 533
Conclusion 534
Telemedicine has been shown to increase access to and decrease the cost of medical care.5, 8, 535
10, 47, 53 Many of the types of patients that we care for in the field of Allergy and Immunology can 536
be helped using telemedicine. Past examples include the use of telemedicine for asthma and 537
antibiotic allergy and stewardship.24-27 We and our patients are therefore uniquely positioned to 538
take advantage of and benefit from telemedicine. 539
540
Until recently, however, there was not widespread adoption of telemedicine. Therefore, a work 541
group from the Health, Information, Technology and Education (HITE) Committee of the 542
American Academy of Allergy, Asthma, and Immunology was formed to investigate the 543
baseline use and needs of the allergy and immunology community with regards to 544
telemedicine. Since that time, the COVID-19 pandemic has led to an unprecedented 545
24
heightened need for telemedicine from private practices to academic centers throughout the 546
country.2, 3, 54 There is now an opportunity to integrate telemedicine into the Medical Education 547
curriculum and experience telemedicine at all levels. It remains to be seen if the changes in 548
technology, regulation and reimbursement of telemedicine will be maintained long term. 549
550
HITE is planning to longitudinally follow the adoption of telemedicine by allergy/immunology 551
clinicians in the context of COVID-19 and afterwards. Our goal is to continue the development 552
of tools to assist allergy/immunology clinicians with adoption of telemedicine and to help push 553
the boundaries of telemedicine use by the allergy and immunology community. 554
555
25
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700
Table VI. Coding and Billing Telehealth Visits by Time
A. Telemedicine Visits (audio and video, synchronous)
New Patient
CPT Code
Total Face-to-Face
Time
Outpatient Consultation
CPT Code
Total Face-to-Face
Time
Established Patient
CPT Code
Total Face-to-Face
Time
99201 10 minutes 99241 15 minutes 99211 5 minutes
99202 20 minutes 99242 30 minutes 99212 10 minutes
99203 30 minutes 99243 40 minutes 99213 15 minutes
99204 45 minutes 99244 60 minutes 99214 25 minutes
99205 60 minutes 99245 80 minutes 99215 40 minutes
B. Telephone Visits (audio only)
CPT Code Total Visit Time
99441 5-10 minutes
99442 11-20 minutes
99443 21-30 minutes
Table VIII: Examples of Telemedicine Coding and Bil ling
Example 1: New Patient
Telemedicine Visit Type
Online Synchronous Video
Patient Visit Type New
Chief Complaint Multiple Food Allergies, Requesting Second Opinion Regarding Dietary Management, Review of Emergency Action Plan
Diagnosis Multiple Food Allergies
Treatment /Management
Plan for Multiple Food Allergies developed with discussion of Dietary Management and Review of Emergency Action Plan
Visit Duration 35 minutes, >50% spent in counseling / coordination of care
Example 1 Billing Options Pre and During COVID-19
Option 1 Option 2
Insurance Private Medicare
Billing Choices Unlisted E/M code(New Patient E/M during PHE expanded access)
Time History & Medical Decision Making
CPT Code 99499 (99203 during PHE expanded access)
99203 (during PHE expanded access ONLY, otherwise not permitted)
Modifier 95 or GT (depending on payer)
None required (95 during PHE expanded access)
Place of Service Code 02 (11 during PHE expanded access)
02 (11 during PHE expanded access)
Originating Site (Patient’s Physical Location) Bills
N/A CPT Q3014 (Originating Site not required during PHE expanded access)
Example 2: Established Patient
Telemedicine Visit Type Online Synchronous Video
Patient Visit Type Established
Chief Complaint New Onset Pruritic Rash
Diagnosis Atopic Dermatitis
Treatment / Management
Emollients & triamcinolone 0.1% ointment
Visit Duration 15 minutes, >50% spent in counseling / coordination of care
Example 2 Billing Options
Option 1 Option 2
Insurance Private Medicare
Billing Choices Time History & Medical Decision Making
Time History & Medical Decision Making
CPT Code 99213 99213
Modifier 95 or GT (depending on payer)
None required (95 during PHE expanded access)
Place of Service 02 (11 during PHE expanded access)
02 (11 during PHE expanded access)
Originating Site (Patient’s Physical Location) Bills
N/A CPT Q3014 (Originating Site not required during PHE expanded access)
Table IA: Examples of Encrypted Telemedicine Platforms During the COVID-19 Pandemic
Charm Telehealth1 https://www.charmhealth.com/telehealth
Doximity2 https://www.doximity.com
Doxy.me3 https://doxy.me/
Jotform4 https://jotform.com
Kareo5 https://www.kareo.com/
Mend6 https://www.mendfamily.com/
Poly (formerly Polycom)7 https://www.poly.com/us/en/solutions/industry/healthcare
Secure Telehealth8 https://securetelehealth.com
Teladoc9 https://www.teladoc.com/
Vidyo10 https://www.vidyo.com/
Vsee11 https://vsee.com/
Zoom - Health Care verison12 https://zoom.us/healthcare
1. charmhealth.com [Internet]. ChARM TeleHealth. 2020 [cited 2020 May 9. Available
from: https://www.charmhealth.com/telehealth/.
2. doximity.com [Internet]. doximity. 2020 [cited 2020 May 9. Available from:
https://www.doximity.com/about/faq.
3. doxy.me [Internet]. Doxy.me. 2020 [cited 2020 May 9. Available from: https://doxy.me/.
4. jotform.com [Internet]. JotForm. 2020 [cited 2020 May 9. Available from:
https://www.jotform.com.
5. kareo.com [Internet]. Kareo. 2020 [cited 2020 May 9. Available from:
https://www.kareo.com.
6. mendfamily.com [Internet]. Mend. 2020 [cited 2020 May 9. Available from:
https://www.mendfamily.com.
7. poly.com [Internet]. Poly. 2020 [cited 2020 May 9. Available from:
https://www.poly.com/us/en/solutions/industry/healthcare.
8. securetelehealth.com [Internet]. Secure Telehealth. 2020 [cited 2020 May 9. Available
from: https://securetelehealth.com.
9. teladoc.com [Internet]. Teladoc. 2020 [cited 2020 May 9. Available from:
https://www.teladoc.com.
10. Vidyo.com [Internet]. Vidyo. 2020 [cited 2020 May 9. Available from:
https://www.vidyo.com.
11. vsee.com [Internet]. VSee. 2020 [cited 2020 May 9. Available from: https://vsee.com.
12. zoom.us [Internet]. Zoom for Healthcare. 2020 [cited 2020 May 9. Available from:
https://zoom.us/healthcare.
Table IB: Examples of Non-Encrypted Telemedicine Platforms During the COVID-19 Pandemic
Apple FaceTime1 https://apps.apple.com/us/app/facetime/id1110145091
Google Hangouts2 https://hangouts.google.com/
Skype3 https://www.skype.com/en/
Zoom4 - Free and regular paid versions
https://zoom.us/
1. apps.apple.com [Internet]. FaceTime. 2020 [cited 2020 May 9. Available from:
https://apps.apple.com/us/app/facetime/id1110145091.
2. hangouts.google.com [Internet]. Google Hangouts. 2020 [cited 2020 May 9. Available
from: https://hangouts.google.com.
3. skype.com [Internet]. Skype. 2020 [cited 2020 May 9. Available from:
https://www.skype.com/en/.
4. zoom.us [Internet]. Zoom. 2020 [cited 2020 May 9. Available from: https://zoom.us/.
Table II: Online Resources for Telemedicine
AMA1 https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook
ATA2 http://hub.americantelemed.org/thesource/resources/telemedicine-forms
AAAAI3-5 Detailed Toolkit COVID-19 Billing Platforms
https://www.aaaai.org/practice-resources/running-your-practice/practice-management-resources/telemedicine https://education.aaaai.org/resources-for-a-i-clinicians/telemedicine-billing_covid-19 https://education.aaaai.org/resources-for-a-i-clinicians/telehealthplatforms_covid-19
AAP6 https://www.aap.org/en-us/Documents/coding_factsheet_telemedicine.pdf
CMS7 https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
ACAAI8 https://college.acaai.org/practice-management/telehealth-toolkit
1. American Medical Association. Telehealth Implementation Playbook [Internet]. 2020
[cited 2020 May 9. Available from: https://www.ama-assn.org/amaone/ama-digital-health-
implementation-playbook.
2. American Telemedicine Association. Telemedicine Forms [Internet]. 2020 [cited 2020
May 9. Available from: http://hub.americantelemed.org/thesource/resources/telemedicine-
forms.
3. American Academy of Allergy Asthma & Immunology. Telemedicine [Internet]. 2020
[cited 2020 May 9. Available from: https://www.aaaai.org/practice-resources/running-your-
practice/practice-management-resources/telemedicine.
4. American Academy of Allergy Asthma & Immunology. Utilize Telemedicine: How Does
Billing Work? [Internet]. 2020 [cited 2020 May 9. Available from:
https://education.aaaai.org/resources-for-a-i-clinicians/telemedicine-billing_covid-19.
5. American Academy of Allergy Asthma & Immunology. Telehealth Platforms to Consider
[Internet]. 2020 [cited 2020 May 9. Available from: https://education.aaaai.org/resources-for-a-
i-clinicians/telehealthplatforms_covid-19.
6. American Academy of Pediatrics. Coding for Telemedicine Services [Internet]. 2020 Apr
13 [cited 2020 May 9. Available from: https://www.aap.org/en-
us/Documents/coding_factsheet_telemedicine.pdf.
7. Centers for Medicare and Medicaid Services. Medicare Telemedicine Health Care
Provider Fact Sheet [Internet]. 2020 Mar 17 [cited 2020 May 9. Available from:
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-
fact-sheet.
8. college.acaai.org [Internet]. American College of Allergy, Asthma & Immunology. 2020
[cited 2020 May 9. Available from: https://college.acaai.org/practice-management/telehealth-
toolkit.
Table III: Example Telemedicine Physical Exam with E/M Billing Guidance Example Physical Exam: VS: T 98.5 F Wt. 180 pounds BP 126/75 HR 65 Constitutional: appears healthy, alert, cooperative, oriented, and in no acute distress Head: Normocephalic and atraumatic. Eyes: conjunctivae/corneas clear, without redness or drainage. Nose: External nose normal, no drainage Pulmonary/Chest: no tachypnea, no retractions, no cyanosis Neurological: Grossly normal without focal findings based on what could be seen. Skin: Skin color normal. No rashes or lesions visible. Psychiatric: Normal mood and affect. Behavior is normal. Additional Exam Items Possible With: Patient assistance Extra equipment at home (e.g., Peak Flow Meter) Smart phone applications with modifications and/or digital telemedicine equipment Wearables (e.g., ECG) Tips for Obtaining Vital Signs Temperature: Patients can take it themselves Blood Pressure: Patients can check it if they have the equipment Heart Rate: Patients can count it if taught how to do so or use a smart watch Respirations: Patients or the clinician can count it Oxygen Saturation: Patients can check it if they have a pulse oximeter at home Weight: Patients can weigh themselves Tips for Examining Other Organ Systems Ear exam: Can be performed with a smart phone app and otoscope attachment, or digital telemedicine otoscope Sinus tenderness : Patients can be taught self-palpation Oropharynx: Use the patient’s flashlight Lymph node exam: Patients can be taught self-palpation Heart and / or lung exam: Can be performed with a digital telemedicine stethoscope Abdominal exam: Patients can be taught self-palpation Extremities: Can observe if any clubbing, cyanosis, or edema E/M Billing Guidance: All other things being equal and if documentation requirements for history and medical decision making are met and maximized: 95 Guidelines: This would be a Detailed Exam (7 organ systems) The exam would meet criteria to bill a Level 3 New Patient or a Level 4 Established Patient 97 Guidelines: This would be an Expanded Problem focused exam (6 bullet points) The exam would meet criteria to bill a Level 2 New Patient or a Level 3 Established Patient
Table IV: Steps for Conducting a Telemedicine Visit
Area of the Allergy Encounter
Component Requiring Education
Pre-Visit Determine what visits are best suited for telemedicine
Ensure that the patient has telemedicine platform access
Ensure that the patient and clinician have pre-visit planning and test calls to establishing secure remote and if needed, video connections
During the Visit Obtain and Document Consent
Ensure Effective Video Communication
Conduct Physical Exams
Optimize Privacy and Data Security
Complete Orders, Prescriptions, and Patient Instructions
Post-Visit Bill and Code
Correspond with PCP
Table V: CMS 2019 Coverage Additions Pre-COVID-191
Brief communication technology-based service (e.g. virtual check-in):
CMS and some private payers will reimburse for a brief 5-10-minute patient-initiated check-in via phone or other telecommunications modality that is meant to determine if an in-person visit is necessary
Remote evaluation of pre-recorded patient information:
CMS and some private payers will reimburse for physician review of video or images submitted by an established patient
Interprofessional internet consultation:
CPT codes 99452, 99451, 99446, 99447, 99448, and 99449
E-visit codes:
Non-face-to-face digital evaluation codes (CPT 99421-99423) are billed once weekly based on the cumulative amount of time spent reviewing, researching, and responding to patients via a secure health portal. Place of service “11” is appropriate, as an e-visit had not been formally recognized by CMS as a telehealth service.
(HCPCS G2010). (HCPCS G2012)
1. Centers for Medicare and Medicaid Services. Medicare Program; Revisions to Payment
Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare
Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting
Interoperability Program; Quality Payment Program-Extreme and Uncontrollable Circumstance
Policy for the 2019 MIPS Payment Year; Provisions From the Medicare Shared Savings Program-
Accountable Care Organizations-Pathways to Success; and Expanding the Use of Telehealth
Services for the Treatment of Opioid Use Disorder Under the Substance Use-Disorder
Prevention That Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and
Communities Act [Internet]. 2018 Nov 23 [cited 2020 May 9. Available from:
https://www.federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-
revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions.
Table VII: Pre and During COVID-19 Changes Based upon Insurance
Historical Rules (pre-COVID) vs. COVID-19 Public Health Emergency
(COVID-19 PHE) Medicare
Medicaid (Illinois as example)
Each state different
Aetna
BCBS (Illinois as example) Each plan different
Cigna Humana UHC
Virtual Check-in
Pre-COVID G2012 POS 11
G2012 POS 11
G2012 POS 11 - G2012
POS 11 G2012 POS 11
G2012 POS 11
COVID-19 PHE G2012 POS 11
G2012 POS 11
G2012 POS 11 - G2012
POS 11 G2012 POS 11
G2012 POS 11
Remote Evaluation of Video/Image
Pre-COVID G2010 G2010 - - - - G2010
COVID-19 PHE G2010 G2010 G2010 - G2010* G2010 G2010
Telephone Visit
Pre-COVID - 99441-3 99441-3 98966-8
99441-3 98966-8 - 99441-3* -
COVID-19 PHE 99441-3; 98966-8
Will be paid at face-to-face rates
99441-3 99441-3 98966-8
99441-3 98966-8
99441-3 OR Usual face-to-face E/M
modifier -95 POS 11
98966-8*
99441-3 OR Usual face-to-face
E/M modifier -95
POS 11
99441-3; 98966-8 OR
99201-5; 99211-5 ($)
modifier -95 POS 11, 20, 22,
23
E-Visit (Digital Health Evaluation)
Pre-COVID 99421-3 - - - - 99421-3* -
COVID-19 PHE 99421-3 98970-2
99421-3 98970-2
99421-3 98970-2
99421-3 98970-2 99421-3
99421-3 98970-2 99421-3
New Patient Telemedicine
Pre-COVID - - - - - - 99499 POS 02
COVID-19 PHE usual E/M
modifier -95 POS 11
usual E/M modifier -GT
POS 02
99201-5 modifier -
95/GT POS 02
99201-5 modifier -95/GT
POS 11
usual E/M modifier -95/GT
POS 11
usual E/M modifier -95
POS 11
99201-5 modifier -95
POS 11, 20, 22, 23
Established Patient Telemedicine
Pre-COVID usual E/M (patient location restrictions)
no modifier POS 02
99211-5 modifier -GT
POS 02
99211-5 modifier -
95/GT POS 02
99213-5 modifier -95/GT
POS 02
usual E/M modifier -95/GT
POS 02
99211-5 modifier -95
POS 02
99211-5 modifier -95
POS 02
COVID-19 PHE usual E/M
modifier -95 POS 11
usual E/M modifier -GT
POS 02
99211-5 modifier -
95/GT
99213-5 modifier -95/GT
POS 11
usual E/M modifier -95/GT
POS 11
usual E/M modifier -95
POS 11
99211-5 modifier -95
POS 11, 20, 22,
Table VII: Pre and During COVID-19 Changes Based upon Insurance
POS 02 23
Payment Parity during PHE
COVID-19 PHE Yes. Telephone visits will also be reimbursed at face to face rates Yes Yes Yes Yes Yes Per current policy
Waived cost-sharing for telehealth during PHE?
COVID-19 PHE Waived by CMS for care resulting in COVID testing when billed with modifier -CS # Yes
Yes, if in-network
(3/31 - 6/4/20)
Yes, if in-network (3/19/20 - 6/30/20)
Yes, if COVID-related (Yes, through 7/31/20)* % Yes Yes, if in-network
Date range for COVID-19 PHE telehealth expansion (subject to modification)
3/9/20 - PHE end 3/9/20 - PHE end 3/31/20 - 8/4/20
3/19/20 - 12/31/20 3/2/20 - 7/31/20 2/4/20 - PHE end
(2/4/20 - 12/31/20)* 3/18/20 - 9/30/20
* Medicare Advantage Only % Individual and Family Plans
$ Commercial Only
# Providers may waive cost-share at their discretion
