COVID-19 & Telemedicine Technical Assistance

Telehealth provides an opportunity to make care more accessible, efficient, better coordinated, and closer to home (especially while business operations are disrupted). Understanding telehealth and the variety of tools available can help support patients better, improve overall care, and sustain finances.

• Telehealth is the use of electronic information and telecommunication to support and promote clinical health care. It allows long/short distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions.
• While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-clinical services, such as provider training, administrative meetings, and continuing medical education, in addition to clinical services.

Who can provide and receive telehealth services? 

• Provide

• • All provider types including Physicians, Nurse Practitioners, Physician Assistants, Midwives, Dentists, registered nurses, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals previously credentialed with Medicaid and Medicare managed care plans
  • The services provided must be appropriate for telehealth and should be written within the provider’s scope of practice.

• Receive
  • New or established patients that have not had a visit billed within the previous 7 days.

There are many ways to leverage telehealth technology to meet the needs of patients:

1. Live (synchronous) videoconferencing:  In these interactions, patients and providers or two providers interact in real time.

1. • Virtual Health Visit – provider to patient
   • Virtual Check-In – provider to patient
   • Remote physiological monitoring
2.  Store-and-forward (asynchronous) videoconferencing: Video, photographic images, and diagnostic tests are stored in a database and then sent on to a medical provider (usually a specialist), at a later date (e.g. Digital retinal exams sent to ophthalmologist for review).
3. Remote patient monitoring (RPM): Patients or providers (frequently nurses) will be able to enter key healthcare data and indicators, such as blood pressure, blood glucose levels, or weight, over an extended period.
4. Mobile health (mHealth): Refers to healthcare solutions or health delivery that is mobile-based or mobile-enhanced. These can include cell phones, tablets, personal digital assistants (PDAs), and mobile apps.

While telehealth can maintain or open access to patients, it is important to focus on communication when connecting telephonically or virtually. The following methods are suggested:

• Motivational Interviewing:
  OARS, Open-ended questions, Affirmations, Reflections and Summaries are skills that can be integrated into telehealth sessions to encourage and support feedback and obtain information from a patient. The interaction should become more of a flow of sharing instead of a question and answer response.
• Teach-back method
  A tool to use with patients to gauge if they have fully understood instructions, care plans, medications, or additional services they may need. This enables providers to fill in the gaps if information has not been understood or relayed proficiently.
• Patient-Centered Care
  Meeting the patient where they are while fully supporting their healthcare needs and behavior changes.
• Health Literacy
  Using plain language to explain a diagnosis, treatment plan, medication regimen, behavior change or referral for additional healthcare services.

Deciding on a Telehealth Solution

1. 1. Patient Portal – Your existing patient portal may have a telehealth option built into it. This allows you to leverage a tool your patients are already familiar with and integrate it into your Electronic Health Record (EHR) workflow.
   2. EHR-Integrated Application – Your EHR may support one or more third-party applications (e.g. Chiron, hale, OTTO).
   3. Standalone Solution – This may be a commercial application or software (e.g. Zoom, FaceTime, Updox.)

On March 2020, Centers for Medicare and Medicaid (CMS) broadened access to telehealth services in response to the Covid-19 public health emergency. The new guidance expands the services patients can receive and how which providers can receive reimbursement. The expansion includes the following provisions:

• Location: Allows patients to receive services at any location (originating site), and practitioners to provide services at any location (distance site) (Mar. 6, 2020).
• Technology: Permits the use of non-public facing remote communication technology, which may include personal mobile phones (Mar. 6, 2020).
  •  Facetime or Skype is acceptable; Facebook live is not.
• Purpose: Allows telehealth services to be provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19 (Mar. 6, 2020).
  • Patients may receive regular office visits, mental health counseling and other preventive health screenings via telehealth.
• HIPAA violations have been temporarily waived allowing for the use of non-HIPAA compliant software in good faith (such as personal mobile phones).
• New Patients: Allows telemedicine services to be available to new patients (rather than only established patients) (Mar. 6, 2020).

• It is recommended that practitioners document patient consent to telehealth encounters because certain procedure codes require consent be obtained prior to the delivery of the service.
  • Consent is required for:
    • G2010 – Store and Forward
    • G2012 – Virtual Check in
    • 99421 – 99423 – Online digital evaluation and management service
    • 99441 – 99443 – Telephone evaluation and management service

• Consent may be written or verbal. Make sure all telehealth visit documentation includes a statement such as the following:

“Patient consents to telemedicine visit conducted through an audio and video enabled device.”

Telehealth Service Codes:

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established 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;

• 99441 -5-10 minutes of medical discussion 
• 99442 -11-20 minutes of medical discussion 
• 99443 -21-30 minutes of medical discussion 

Appropriate Use of Modifiers for Telehealth: 

Providers may bill visits delivered via telehealth provision without regard to the diagnosis of the patient.

• Suspected Coronavirus:

• • Code relevant signs and symptoms

• Exposure to Coronavirus:

• • Z03.818 – Suspected exposure to other biological agents ruled out
  • Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases

• COVID-19 Diagnosis Codes:

• • B97.29 – Other coronavirus as the cause of diseases classified elsewhere; select for confirmed cases only (effective until 3/31/19)

• • U07.1 – COVID-19 (new code effective 4/1/20)

• • • Use additional code to identify pneumonia or other manifestations.
    • Excludes:

• • • • Coronavirus infection, unspecified site (B34.2)
      • Coronavirus as the cause of diseases classified to other chapters (B97.2-)
      • Severe acute respiratory syndrome [SARS], unspecified (J12.81)