Telemedicine What you need to know “now”!

Nancy Lohuis, M.D.

GOALS Why use

telemedicine in a pandemic?

What are the types of telemedicine?

What are the billing and coding

requirements for each type?

How do I get started with video/audio

sessions? What is the change in office workflow?

What about controlled substance

prescribing with telemedicine?

EMERGENCY WAIVER 1135 • Declared by the Secretary of HHS on Jan 31, 2020 and remains

in effect until the end of the Public Health Emergency has been declared.

• List of allowable telemedicine codes available at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

• List of qualified providers does not change with the waiver and is basically anyone who bills Medicare.

• Waived the originating site and the distant site telehealth requirements Wid th tit HIPAA li i d tldii

WHY USE TELEMEDICINE IN A PANDEMIC? 1. PREVENT SPREAD OF DISEASE. 2. Keep at-risk or mildly symptomatic patients with infectious

diseases or stable patients with CONFIRMED diagnoses at home while they receive evaluation and medical care, thus limiting their interactions with other patients in waiting rooms or other communal settings, and thus decreasing the risk of person-to-person transmission.

3. CONSERVE PPE EQUIPMENT to keep healthcare providers safe

4. Allow providers/staff who are symptom-free, but who need to remain in quarantine to continue to provide patient care

Example: RESPIRATORY SYMPTOMS TO PRESERVE PPE EQUIPMENT

AND PREVENT TRANSMISSION:

PATIENT CALLS WITH RESPIRATORY SYMPTOMS

ARRANGE TELEMEDICINE VISIT

DETERMINE NEED FOR TESTING/FACE TO FACE VISIT

CONSIDER DRIVE UP TESTING FOR PATIENT

ASSIGN ONE STAFF to take samples in parking lot

TYPES OF TELEMEDICINE WITHOUT REAL TIME VIDEO

VIRTUAL VISITS (Medicare Patients Only) Telephone only for short 5-10 min issue

REMOTE MONITORING (BP, BS, O2 Sat, Weight)

STORE AND FORWARD (Rashes, skin lesions, Apple watch EKG)

TELEPHONE ONLY: DOCUMENT TIME SPENT. Allowed by COMMERCIAL PAYORS and Medicaid/Medicare.

Types of telemedicine WITH REAL TIME VIDEO

TELEHEALTH VIA AUDIO/VIDEO PLATFORM: ZOOM For Healthcare, Doxy Me, Doximity, Skype, Cisco WebEx, Team Meetings etc. NOT TIK TOK, FACETIME LIVE. Medicare, Medicaid, Humana, BCBS, Anthem, Aetna, PEIA, United Health Care, Tricare, Anthem, Cigna., CHAMP VA. ***Paid with PARITY with regular office visits.

E-VISITS: VIDEO AND AUDIO REALTIME VIA EHR PORTAL: Rules same as before COVID 19: Medicare, Medicaid, Aetna, Humana, Champ VA, Cigna, Tricare. ***Reimbursement is much less than Telehealth visits.

RHC/FQHC: TYPES OF TELEMEDICINE

DEFINE INITIATING VS DISTANT SITE DESIGNATION (Coding and reimbursement is different)

RHCs/FQHCs can be DISTANT SITES during the COVID 19 Waiver (Home, Office etc)

TELEPHONE ONLY (G2025) $92

AUDIO/VIDEO (G2025) $92 RHC AND (G0466-G0470) with E and M code and Modifier for FQHCs

E VISITS (G0071) $24.73

REQUIREMENT FOR ALL TELEMEDICINE • Patient must INITIATE VISIT once they have been made aware

of the availability of this service. • Receptionist must obtain VERBAL CONSENT and document in

chart due to some potential cost sharing. • Consent is necessary only once a year. Scan to chart. • COPAY and DEDUCTIBLE CAN BE REDUCED OR WAIVED

with COVID related DUE TO EMERGENCY 1135 WAIVER (optional)

• PROVIDER MUST PROVIDE THE SERVICE. Reception and i t ff d l k b t PROVIDER t h

MarKETING: FaCEBOOK, WEBSITE, FLYERS, EHR PORTAL

VERBAL CONSENT Date: ______________________ Patient: ______________________ DOB: _________________ Patient has verbally requested and consented to participation in telemedicine visit. There may be copay, deductible and cost sharing depending on coverage. This consent is active for period of one year. STAFF PERSON: ______________________ Signature of Staff: ______________________

VIRTUAL CHECK-IN (TELEPHONE) MEDICARE

MEDICARE PATIENTS ONLY

Established Patients Only with face-to-face visit in clinic within the last year RELAXED DURING EMERG WAIVER 1135 No visit within 7 days and can’t have visit for the same reason in the 24 hours following the Virtual Check-in.

Platform: Telephone only or Video/Audio or “Store and Forward” evaluation of pictures, videos, data or images, secure text message or portal.

*** Only 5-10 min conversation. REIMBURSEMENT: $15 and 0.25RVU

HOW TO GET PAID: VIRTUAL VISITS: Telephone, 5-10min

• G2012: telephone call $15/0.25 RVU

• G2010: evaluation of uploaded image from last 7 day and interpreted within 24 hours $15/0.25 RVU

• G0071: RHC/FQHCs: National avg of G2010 and

REmoTE MONITORING/STORE and FORWARD

Remote Monitoring: • Can SUPPLY the device: 99454 • Can CALIBRATE/EDUCATE re using the

device: 99453, 99473 • Can MONITOR the device: 99421-99423

9visa Portal), 99457, 99458 (other methods), • Can DEVELOP A PLAN OF ACTION using

the device: 99474, 99091

Store and Forward • Patient takes picture or video and stores and

forwards to you via portal or other secure digital G2010 Medicare. $12.73.

TELEPHONE ONLY COMMERCIAL and MEDICARE • Established Patients OR NEW PATIENTS with face-to-face visit

in clinic within the last year. (waived during COVID-19) • Telephone evaluation and management service provided by a

physician to patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

• PLATFORM: Telephone only • Based on TIME SPENT.

RHC d FQHC DOING TELEPHONE ONLY VISITS ill b

HOW TO GET PAID

COMMERCIAL PAYORS/MEDICARE TELEPHONE ONLY: PROVIDER TO PATIENT

• 99441: 5-10min $14.44 avg /$44(Apr 30) RVU: 0.25 wRVU

• 99442: 11-20min $28.15 avg/$74 (Apr 30) RVU: 0.50 wRVU

99443: 21 30min $41 14 avg/$110(Apr

HOW TO GET PAID TELEPHONE ONLY: outliers

MEDICAID, UHC, HUMANA

Do not honor 99441 to 99443 and want E and M codes instead.

Check on the Modifiers

RHC/FQHC use G2025

TELEHEALTH:

VIDEO/AUDIO REAL-TIME

RULES BEFORE COVID 19 • Originating Site/Patient must be in

DESIGNATED RURAL HEALTH AREA. • Must be established patient within the

last 3 years. • Patient travels to ORIGINATING SITE

(Hospital or Clinic) where there is video and audio connection to DISTANT SITE (Provider at another center).

• Platform used must be HIPAA compliant and secure.

TELEHEALTH DURING COVID 19 UNDER EMERGENCY WAIVER 1135 • DESIGNATED RURAL HEALTH AREA: RELAXED: TO

INCLUDE ANY PATIENT/PROVIDER/HOSPITAL IN THE USA • Must be established patient within the last 3 years: RELAXED:

CMS WILL NOT AUDIT TO DETERMINE IF EST PT. • Patient travels to ORIGINATING SITE (Hospital or Clinic) where

there is video and audio connection to DISTANT SITE (Provider at another center). RELAXED: CMS ALLOWS PROVIDER TO BE ORIGINATING SITE and PATIENT TO BE DISTANT SITE and CONNECT FROM ANYWHERE INCLUDING HOME

• Platform used must be HIPAA compliant and secure. RELAXED: ANY VIDEO/AUDIO REALTIME CAN BE USED

VIDEO/AUDIO HOW TO GET PAID: TELEHEALTH VIDEO/AUDIO REAL-TIME BILL E&M regular office visit • MEDICARE/MEDICAID: Bill

regular office visit except with POS-11 for Medicare Mod 95 and POS-2 for Medicaid Mod GT. If waived Copay/deductible use CS modifier in cases where visit results in COVID testing or RX.

• MEDICARE RHC, FQHCs: Jan 27-June 30,2020 Paid at RHC AIR or FQHC PPS. After June 30 use

WHY ATTEMPT VIDEO/AUDIO INSTEAD OF TELEPHONE ONLY? TIME SPENT VIRTUAL VISIT

G2010-G2012 AVG CMS reimbursement

TELEHEALTH VIDEO/AUDIO AVG CMS reimbursement

E-VISIT AVG CMS Reimbursement

TELEPHONE ONLY 99441-99443 AVG CMS reimbursement

5-10 min

$15/0.25 wRVU

99211 5min $23.46 99212 10min $46.19 G025 $92 RHC/FQHC

99421 $14.50 G2061 G0071 $24.73 RHC/RQHC

$14.4/$44 (April 30) 0.25 wRVU G025 $92 RHC/FQHC

11-20 min

N/A 99213 15min $76.15 G025 $92 RHC/FQHC

99422 $31 G2062 G0071 $24.73 RHC/RQHC

$28.15/$74 (Apr 30) 0.50 wRVU G025 $92 (RHC/FQHC)

21-30 min

N/A 99214 25min $110.43 G025 $92 RHC/FQHC

99423 $50 G2063 G0071 $24.73 RHC/RQHC

$41.14/$110(April 30) 0.75 wRVU G025 $92 (RHC/FQHC)

RESIDENT W/O INSURANCE? MEDICAID WILL

TESTING: for COVID 19: U0001 and U0002 without approval with utilization management UM vendor. MEDICATIONS:

• Albuterol 90mcg inhaler • Guaifenesin • Dextromethorphan • Mucinex DM • Acetominophen

For both use: Member ID of “24000000099” and for Medication use “DX: for symptoms related to a possible COVID-19 infection”.

E-VISITS: EXPANS

E PORTAL

VIDEO/AUDIO PLATFORM VIA EHR PATIENT PORTAL

Patient can request an E-VISIT VIA PORTAL. Visit must be completed within 7 days of request. Any services provided via phone or portal during that 7 day time are included.

This option was present BEFORE COVID 19. Reimbursement is markedly LESS THAN the TELEHEALTH option.

HOW TO GET

PAID: E-VISITS

PORTAL

MD/DO, NP, PA, Midwife 99421 5-10m AVG Payment $14.50 99422 11-20m AVG Payment $31 99423 >20m AVG Payment $50 Licensed Psychologists, SW G2061 5-10m G2062 11-20m G2063 >20m

TELEMEDICINE WORKFLOW

EHR WORKFLOW: RECEPTIONIST • Patient initiates request after receptionist makes

them aware of option. Should be offered if patient is HIGH RISK, has SYMPTOMS on screening or if they do not feel comfortable coming in for face to face visit.

• Receptionist obtains VERBAL CONSENT and books Telehealth visit. Asks patient to do their own vitals on day of visit and have them ready for nurse.

• PATIENT can also initiate E Visit from EHR PORTAL.

• Receptionist determines if patient has computer, laptop, tablet, smartphone and internet capable of doing TELEHEALTH.

What about Controlled substances?

Controlled Substances Under EMERGENCY Declaration: Practitioner may issue controlled substance to patient when they have not conducted in person evaluation of patient so long as the following are met: 1. RX is for legitimate medical reason and

prescribed by practitioner in usual course of his/her profession

2. Telemedicine must be through audio/visual real-time 2-way communication platform.

3. Practitioner must act in accordance with applicable Federal and State Law.

*** NOTE: If a practitioner has evaluated patient face to face in the past for this reason, even when no emergency, it is lawful to renew RX for controlled via any form of telemedicine so long as it complies with state law. (FOR WV: In office FACE TO FACE to assess pain in last 90 days)

Example: TELEHEALTH VIDEO-AUDIO PLATFORM

ZOOM MEETINGS with ZOOM For HEALTHCARE HIPAA Compliant ZOOM

SET UP ZOOM ACCOUNT FOR EACH PROVIDER SET UP

SHARE the User-Name (PCHONLINE.ORG email) and Password with the Receptionists and Nursing staff so they can book ZOOM sessions.

SHARE

SEND EMAIL TO THE PATIENT ON BEHALF OF THE PROVIDER inviting patient to the ZOOM SESSION and include LINK.

SEND

How to get patients on board with ZOOM

1. Do they have any device or if a family member has a smart phone?

2. Do they feel comfortable in downloading the ZOOM APP? Do they have a family member who could?

3. Use the link to a You Tube instructional video: https://www.youtube.com/watch?v=GEQLjLYhuJQ&feature=youtu.be

4. Have them download the APP or Software the day before the visit.

EHR TELEHEALTH WORKFLOW RECEPTIONIST 1. checks in TELEHEALTH PATIENTS in the morning. 2. Changes STATUS TO NURSE. NURSE 1. Changes STATUS TO NURSE IF Receptionist has not. 2. NURSE calls patient and asks if they received their email with link

to ZOOM session. 3. NURSE determines if the patient has ZOOM APP/software

installed (this is only a problem the first time).

TELEHEALTH WORKFLOW NURSE cont’d 4. While ZOOM APP is downloading, OPEN document, do CC, Vitals (if patient has them), Meaningful Use (Yes we have to do this!), Meds Reconciliation and ROS. (DO NOT NEED VIDEO FEED FOR NURSING PART) 5. CHANGE STATUS TO PROVIDER. 6. TELL PATIENT TO TRY LINK AND MAKE SURE IT WORKS. IF IT DOES, they can close the window and go back to it when provider is ready. NURSE TO CALL PATIENT when provider is ready to start. Patient will then activate link again and join ZOOM.

TELEHEALTH WORKFLOW PROVIDER PROVIDER 1. “START” THE ZOOM MEETING from the ZOOM website bookmarked on the providers

computer. 2. UNCLICK the VIDEO button so patient can see you. 3. “Manage Participants” button allows the PROVIDER to manipulate the Patient’s Video

and audio. 4. Use a second computer open EHR and document the visit. Do the visit just as you

normally but tailor the EXAM section. You can order tests, office procedures etc. 5. CHANGE STATUS to MA if there are office procedures. CHANGE STATUS TO PRE-

DEPART so that receptionist or MA will Depart the patient, BOOK NEXT APT, SEND VISIT SUMMARY and a copy of the COVID 19 CDC instructions.

HOW TO BOOK A ZOOM AND SENT EMAIL TO PATIENT Please see the handout sent to office managers for instructions:

• Once you have created an account, click on meetings in blue on the left.

• Give the meeting a title.

• Fill in time and date.

• Schedule for amount of time you wish to use.

• UNSELECT the MEETING PASSWORD. We don’t want patients to have to enter a password every time.

• CLICK SAVE

• Add to your calendar.

• ON the right side: look for COPY THE INVITATION.

• INVITATION POPS UP and select COPY THE INVITATION AGAIN.

• GO TO EMAIL AND PREPARE EMAIL FOR PATIENT USING THE CANNED TEXT or something similar below. SEND.

SET UP ZOOM MEETING

SET UP A ZOOM MEETING

What is in the EMAIL?

WHAT IS IN THE EMAIL Dear PATIENT, Please join me on a TELEHEALTH call via ZOOM session March 20 at 8:00 AM. Use any laptop or computer with microphone and camera, tablet, iPad or simply your smart phone. What ever you use, it must be connected to the internet. Locate this email and click on the link in BLUE below. Follow the instructions. The first time there may be some installation issues, but the next time should be super easy. Remember, this is new to all of us. So, if it doesn’t work, we will simply call you on the telephone for your visit. Our goal is to improve your care while keeping you safe during this pandemic. As always, Nancy Lohuis, M.D. *** Reminder. This is not a secure email and should never be used to send any health or patient information. Please call our office or use the patient portal.

What is in the EMAIL

SUMMARY • Telemedicine has quickly become an expected and likely permanent

part of every practice’s expected offerings. • It is important to understand the ramifications for workflow, resource

and financials. • Billing and coding is a ever changing landscape. Designate someone

in your coding department to monitor and respond to these changes. • Market, market, market: tell patients what and why you are doing

telemedicine and what they need to do to make it happen. • Lobby government agencies to get what you need to provide this

service: better broadband, T1 fiber, better reimbursement.

Useful Links • Medicaid Telemedicine:

https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html

• Medicare HIPAA Telemedicine Guidelines: https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html

• AMA Telemedicine guide including the Playbook: https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice

annoyed, someone moved my Cheese?