Telehealth Guide For Dermatologists During COVID-19

Telehealth Guide During COVID-19

As guidance from the Centers for Medicare and Medicaid Services (CMS) continues to change, we’d like to take this opportunity to make sure you have the best possible information consolidated in one telehealth guide. In this telehealth guide, we’ll cover the full range of changes that have been made so far, both the original modifications on March 30, 2020 and the sweeping updates released April 30, 2020.

For all of these changes, the effective date of service is on or after March 1, 2020. As the public health emergency associated with COVID-19 is ongoing, there is no end date for these changes, as of yet.

For our telehealth guide purpose, telehealth and telemedicine may be used interchangeably. However, telehealth is generally considered a collection of tools and/or services. In contrast, telemedicine includes audio/video as part of a real-time E/M visit where the provider and patient interact and communicate. For your purposes, it is important to note that:

• The approved list of telemedicine codes can be found on the CMS site linked here.
• Modifier 95 is defined as “synchronous telemedicine service rendered via real-time interactive audio and visual telecommunications systems.” Modifier 95 must be added to all telehealth services with a place of service code 11 (Office).
• Medicare guidance refers to “telemedicine services” as the umbrella of services including “telehealth visits,” “virtual check-ins,” and “e-visits.”
• Effective March 17, 2020, the Office for Civil Rights (OCR) will not impose penalties for practitioners in noncompliance with HIPAA rules in connection with the good faith provision of telehealth during the COVID-19 emergency, regardless of the patient’s diagnosis.
• Finally, please note that separate state action will be required in certain areas. As a result, physicians and non-physician practitioners should assess their state-specific privacy (and other related) laws prior to moving forward.

As a result, our telehealth guide will cover a wide range of considerations and billing notes, and hopefully address any questions you may have regarding CMS guidelines on telehealth.

 Questions as you get started

While you have likely begun utilizing telehealth to a greater extent these past weeks, the following considerations may still help you better determine where you might be able to utilize telehealth better to protect your team and serve your patients:

 Platform selection

 CMS will pay for telehealth visits and consults (provided they fall within given guidelines) that use telecommunications technology with audio and video capabilities and are used for two-way real-time interactive communication between providers and patients. It is worth keeping the following in mind as you consider platforms:

1. Compatibility with your EHR vendor. Many EHR platforms include telehealth applications, which may make expanding your telehealth options easier for both team members and patients. If you look at options outside your current platform, a key consideration may be how easy it is for that telehealth platform to communicate with your other key systems.
2. HIPAA-compliance waivers. Because of the unique situation in which we find ourselves, CMS is temporarily waiving enforcement when it comes to using HIPAA-compliant platforms, instead of asking physicians to use their best judgment and follow state privacy laws as applicable. As a result, Apple FaceTime, Facebook Messenger video chat, Google Hangouts/Meet video, Skype, and Zoom may all be options for some providers. A few key considerations

• • Physicians are encouraged to notify patients that these third-party applications may introduce privacy risks;
  • Physicians should enable all available encryption and privacy modes when using such applications; and
  • Physicians should ensure they do not share personal contact information with patients (using a business account, for instance, instead of a personal account).
  • A final caveat: Public-facing video communication platforms such as Facebook Live, Twitch, and TikTok should not be used.

3. HIPAA secure platforms. While CMS is temporarily waiving the usual HIPAA compliance, there are numerous HIPAA secure platforms available in the marketplace, such as me(free version and a paid version with upgraded features), Google G Suite Hangouts Meet, Hopdoc, ModMed, OrthoLive, PreciseCare, Rezilient, Updox, VSee, Zoom for Healthcare, and others.
4. Equipment needs. Finally, when perusing platforms, keep your equipment needs in mind. Your equipment choices should align to the codes you are billing for.

Operational considerations

Similarly, there are numerous operational considerations to keep in mind when embracing telehealth and the new CMS guidelines:

• Informed consent. Because you are not seeing patients in your physical practice, you may wish to contact your medical malpractice carrier for specific telehealth informed consent forms which can be signed electronically, such as this example. (For Medicare, verbal consent is enough; for other payors, check their requirements.)
• Documentation templates. You likely have documentation templates in place for your normal practice, but may not have telehealth specific templates. Having templates in place can help make documentation easier in the future, as well as help your practice keep detailed records. These are some example telehealth documentation templates that may prove helpful to you, for instance.
• Scheduling. Depending on how your office is currently operating, you may want to consider right-size scheduling, following similar patterns as you might for in-office visits. One particular consideration might be how you differentiate telehealth visits from in-office visits, as well as on different appointment visits: telehealth, telephone, e-visit, virtual check-in, for instance. Similarly, keep in mind any scheduling or appointment reports or counts you may need or want later. Keep in mind how your team will interact with your scheduling, or how they might “room” the patients and providers. Finally, consider how scheduling appointments may impact billing.
• Patient flow. Similarly, consider patient perspective, and how you will physically interact with patients as you schedule telehealth appointments. Where will you conduct telehealth visits—in an exam room? In an office? From your home? Who will prepare the patient for their appointment?
• Tech troubleshooting. Not only might you have occasional technical issues that need troubleshooting, but it is nearly inevitable that some patients will have technical issues. Who on your team will be responsible for troubleshooting those problems? Some teams may decide to proactively assign a tech-savvy team member to assist patients with telehealth appointments.
• Payments. Payment collections can be a delicate matter right now. For instance, Medicare allows coinsurance and deductibles to be waived, just as some payers have eliminated cost-sharing requirements for telehealth visits. (This chart may offer some guidance.) For patients who have patient responsibility amounts, a prudent choice may be allowing online payments or sending the bill for services after the telehealth visit.

Billing considerations

 Finally, billing considerations may also be part of your telehealth decision-making matrix. In particular, there are four kinds of services that can be performed remotely during the current public health emergency, with the type of modality used (audio and visual, phone, or patient portal) the driving determiner as to what kind of visit it is.

The following telehealth guide for billing considerations chart may help:

	Telehealth visits/telemedicine	E-visits	Telephone only	Virtual check-ins
Description of service	Real-time interactive visit (video chat)	Patient-initiated online digital evaluation and management service for an established patient for up to 7 days cumulative in a period of 7 days	Patient-initiated telephone E/M service not originating from a related E/M service provided in the previous 7 days nor leading to an E/M service with the next 24 hours (or soonest appointment available)	Brief connection between visits where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available)
Modality	Audio and video	Digital (online patient portal)	Phone	Phone, secure text, portal

When it comes to reimbursement, telemedicine visits typically pay best, followed by e-visits, telephone visits, and virtual check-ins. When determining which services you may wish to offer, you may want to consider not just reimbursements, but also your resources, technology, continuity of care, and cost.

As you answer those questions for your dermatology practice, the following points will also help guide how you implement and bill telehealth services.

Billing clarifications

There are a few places where billing clarifications may be helpful as you embrace telehealth.

Place of Service (POS)

 When it comes to billing for telehealth services, there are three new major points:

1. Effective March 1, 2020, and through the public health emergency, use the place of service where care would have normally been offered had the patient been seen face-to-face (such as POS 11 for in-office or POS 22 for in-clinic visits) rather than POS 02 for all CMS telehealth and telephone services.
2. Append modifier 95 (synchronous telemedicine service rendered via real-time interactive audio and visual telecommunications system) for all telemedicine visits on Medicare claims. (A quick caveat: No modifier 95 on e-visits, virtual check-ins, and telephone calls as these services are telehealth, but not telemedicine.) Doing so allows Medicare to pay these claims at the higher non-facility fee schedule rate as applicable. (While you can continue to use POS 02 for all telehealth services, this will result in decreased reimbursement. As always, other payers may have different guidelines; this payor summary chart may be a good starting point.)
3. Finally, you may wish to file corrected claims for telehealth services that have already been billed if doing so will allow you to update the place of service. Similarly, you may wish to wait on non-Medicare payers to see if they will update their guidelines.

Lastly, if as a provider you are furnishing telehealth services from your own home, list your address in the Box 32 service location on the claim. For your place of service, you would still use where you would typically see the patient (POS 11 or POS 22, for instance), though the address on the claim would be your home address, rather than the clinic address.

MDM or time for outpatient/office E/M code?

 Another change is that the appropriate E/M code for telehealth visits may now be determined either by Medical Decision Making (MDM; based on the existing guidelines, rather than the 2021 guidelines recently released) or the total amount of time. For surgeons and other practitioners who sometimes must choose a lower level E/M code because they have not met the examination component, this means higher reimbursements. Whichever you use—MDM or time—to choose your E/M code, you may want to be sure you have good documentation.

 Modifiers

 There are a couple of modifiers to keep in mind when coding:

• 95 (synchronous telemedicine services rendered via a real-time interactive audio and video telecommunications system). Of particular importance is that Medicare now temporarily requires all telehealth visits that would generally be face-to-face visits include the modifier 95.
• Other modifiers may be applicable, as well, depending on your practice’s unique circumstances; see this payor summary chart for information on whether your payors may require the GT modifier, for instance.

 Physician supervision

 Another clarification to keep in mind, as well, is that CMS has temporarily expanded the direct physician supervision definition to include virtual supervision during the current public health emergency. The provision does require, however, that the supervising physician uses real-time audio and video while supervising.

Originating site

Similarly, rural and site limitations have been removed during the coronavirus pandemic, such that home is temporarily an approved site. Telehealth services can be provided regardless of the type of facility or where the enrollee is located geographically. While you may need to seek additional coding clarifications, physicians can generally refer to place of service (POS) codes for guidance.

 Telephone only services

 Previously Medicare did not necessarily pay telephone only services, but telephone only E/M visits are now approved for both established and new patients. Physicians and non-physician practitioners (NPPs) that bill under their own NPI should use codes 99441-99443 while “qualified non-physician health care professionals” should use codes 98966-98968. CMS also requires therapists to use the appropriate therapy modifier (GO, GP, GN) for their services. One caveat: Codes 99201-99215 still require real-time audio and visual for Medicare, though some private payers may allow billing 99201-99215 for telephone-only service.

Virtual check-in

 Consider the following guidelines for virtual check-in telehealth:

• Use code G2010 for remote evaluation of recorded video and/or images and code G2012 for brief communication (5-10 minutes of medical discussion); both codes require they not originate from a related E/M service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.
• Can currently be a new or established patient (via the guidance surrounding this current public health emergency).
• Can by any chronic patient who needs to be assessed as to whether an office visit is necessary.
• Can be billed by therapists, etc, if needed, though that may require the use of a modifier for their services (GO, GP, or GN).
• Can be any real-time audio (such as a telephone call) or “2-way audio interactions that are enhanced with video or other kinds of data transmission.”
• Are not restricted by patients’ geographic locations.
• Should be initiated by the patient; verbal consent to bill (and requisite documentation) is required.
• Can utilize non-HIPAA compliant technology during the current public health emergency.
• Does not require the modifier 95 for Medicare claims as it is not considered a telemedicine service.

Online digital E/M or e-visits

 Consider using the following codes for e-visits for patient-initiated digital E/M service for an established patient for up to 7 days; the following refer to cumulative time during the 7 days:

• 99421 for 5-10 minutes
• 99422 for 11-20 minutes
• 99423 for 21+ minutes

These codes should not be used for scheduling appointments, non-evaluative electronic transmission of test results, or other communication that does not include E/M.

Other considerations:

• Must be conducted via HIPAA-compliant platforms such as EHR portals or secure emails.
• Must be patient-initiated.
• The patient must be informed and information must be documented in their chart.
• May only be used once per 7-day period.
• Can be a new or established patient.
• Can be done synchronously and asynchronously.
• Must not include clinical staff time as part of the cumulative time.
• Must include more than 5 minutes of service time (and cannot include time reported with other services).
• Other restrictions may also apply, specifically related to reporting, so be sure to do your due diligence.

Similarly, if not billing directly to Medicare for E/M services, the coding may be different (such as codes G2061-G2063, for instance) and modifiers may be necessary if performed by a non-physician practitioner (such as GO, GP, or GN).

Thre are many intricate details included in this telehealth guide. I imagine as this information is published, there are sure to be new changes introduced that will need to be considered. To keep on top of these ever-changing topics, consider partnering with a practice management expert who can help you navigate this telehealth guide. Contact one of our practice management experts today!