MATRC
matrc-covid19
MATRC > MATRC Telehealth Resources for COVID-19 Toolkit

MATRC Telehealth Resources for COVID-19 Toolkit

We have compiled our most frequently asked questions and requested resources into this COVID-19 Toolkit.  We are continuing to update this Toolkit every day as new questions and resources come to our attention.  We encourage you to bookmark this page and check back regularly!  Please note that there are sections and subsections within sections that may be "invisible" until you click on the section header or subheader link!.

WHAT IS THE DIFFERENCE BETWEEN TELEMEDICINE, TELEHEALTH & REMOTE MONITORING?


  • Telemedicine typically refers to the practice of medicine using technology to deliver care at a distance. A physician/clinician in one location uses a telecommunications infrastructure to deliver care to a patient at a distant site.  Telemedicine is a subset of telehealth.
  • Telehealth refers to a broader scope of remote health care services than telemedicine. Telemedicine refers specifically to remote clinical services between a provider and a patient/client, while telehealth also refers to remote non-clinical services (for example, clinician to clinician consults, patient education services, interprofessional care team communications, etc).
  • Remote patient monitoring refers to using technology to gather patient data outside of traditional healthcare settings, for example, using digital scales, glucometers, pulse ox devices, etc…to monitor a patient’s condition while they are at home (or wherever else they may be living).  It too is a subset of telehealth.
  • So where does mHealth fit in?  mHealth is an abbreviation for mobile health.  It simply refers to the subset of telehealth that use mobile technologies.  Examples include apps and peripheral devices designed for use on smart phones and tablets for videoconferencing or gathering patient data or providing patient education or secure communications. 

GETTING STARTED WITH TELEHEALTH


If you are one of many clinicians and practices getting ready to ramp up with telehealth offerings for the very first time in response to COVID-19, and you don't even know what you don't know, then start here for the Big Picture!  If you are a mental/behavioral health clinician/practice, feel free to jump directly to the next section on Getting Started with Telemental/Behavioral Health.
  • What do I need to think about before I get started with telehealth?
    • This approximately 45 minute video will help walk you through the high level essentials you’ll need to think through as you get started:   

If you don't have time for the video, or want something in paper format after watching the video,  download this companion infographic: Telehealth Essentials Checklist: For Those Getting Started and/or take a look at this Quick-Start Guide to Telehealth During a Health Crisis developed by the American Telemedicine Association.

    • If you want to kill two birds with one stone and get trained while obtaining 1 credit/contact hour of CME/CE credits, this Foundations of Telehealth Course is also a good option for you (there is a $95 fee associated with this course).
  • Now that I have the high level basics, what next?
    • Work your way through the rest of the information in this COVID-19 Toolkit!   We strongly recommend that you get familiar with all sections in this toolkit, but if time is of the essence, then proceed to the section on Best Practices for Conducting a Telehealth Visit as this will help you think about workflow, consent, documentation and more.  You may also want to check out our Resources for Specialty Providers and Settings where we have specialized resources for dentists, genetics counselors, hospice and palliative care providers, rehabilitation professionals and more!   
    • After reviewing all of the resources and information found here, if you have additional questions, join us for our Virtual Office Hours where you can ask questions, bounce ideas and more. 

(Hot Tip: Due to the overwhelming interest and need for telehealth during this pandemic, using the online form will generally get you a quicker response than calling and leaving a voicemail message.  It is much more difficult to return calls after hours and on weekends, but we CAN respond to your emails.  The more specific you are with your question or request (e.g., what type of provider you are, what type of setting you work in, what you specifically need), the better we will be at getting you timely and useful information.)

 

GETTING STARTED WITH TELEMENTAL/BEHAVIORAL HEALTH


If you are one of many mental/behavioral health clinicians and practices getting ready to ramp up with direct to consumer telehealth offerings for the very first time in response to COVID-19, and you don't even know what you don't know, then start here for the Big Picture! 
  • How can telehealth be used by mental/behavioral health clinicians and practices?

  • What do I need to think about before I get started with telemental/behavioral health?
    • This approximately 40 minute video will walk you through the essentials you'll need to get going:quickly with providing Direct-to-Consumer Telebehavioral Health:

    • If you are a psychiatrist, another alternative is this free webinar on Telepsychiatry in the Era of COVID-19 developed in conjunction with the American Psychiatric Association and the Substance Abuse and Mental Health Services Administration (SAMHSA).
    • And if all the isn't enough, Insight + Regroup is offering this online 1.5 CME credit training course on Telebehavioral Best Practices free of charge during the pandemic. 
    • Work your way through the rest of the information in this COVID-19 Toolkit!   We strongly recommend that you get familiar with all sections in this toolkit, but if time is of the essence, finish reviewing the additional materials in this section, and then proceed to the section on Best Practices for Conducting a Telehealth Visit as this will help you think about workflow, consent, documentation and more.  You may also want to check out our Resources for Specialty Providers and Settings where we have specialized resources for providers of autism care, early intervention services, substance use disorder and recovery services and more!
    • After reviewing all of the resources and information found here, if you have additional questions, join us for Virtual Office Hours where you can ask questions, bounce ideas and more.

(Hot Tip: Due to the overwhelming interest and need for telehealth during this pandemic, using the online form will generally get you a quicker response than calling and leaving a voicemail message.  It is much more difficult to return calls after hours and on weekends, but we CAN respond to your emails.  The more specific you are with your question or request (e.g., what type of provider you are, what type of setting you work in, what you specifically need), the better we will be at getting you timely and useful information.)

 

Resources for Special Situations and Needs

The Mental Health Technology Transfer Center Network funded by SAMHSA has a Clinical Innovations in Telehealth Learning Series, a weekly online series targeting high-priority clinical issues for providers using telehealth.  These one hour learning sessions take place on Tuesdays at 1 PM (ET) and will be recorded and posted online.  Session topics include things like Telehealth and Suicide Care, Telehealth and CBT for Psychosis, Telehealth and Health Disparities and Telehealth and Trauma.  
    • This International Journal of Psychiatry in Medicine publication on Suicide Risk Management During Clinical Telepractice provides information about safety protocols and suicide risk assessment procedures used with U.S. military service members and veterans with depression.
  • How should I manage victims of intimate partner/domestic violence or abuse? 
    • CASA is encouraging  telehealth professionals to develop a code word to use when working with survivors to indicate if a perpetrator is in the room or within earshot.  You would need to have done this in advance or during a time when you know for certain that the perpetrator is not around.  For example, if you have met with a client and pre-arranged a code word (e.g., Walmart), and you notice a behavior change (or consider doing this at the start of every session), you could say following:

You: Have you gone to Walmart today?

Client: Yes (perpetrator is present), No (all clear)

You: Did you find what you needed?

Client: Yes (everything is fine and I am safe), No (please call 911 I am unsafe)

If they say yes then continue with your check in but do not go much deeper (e.g, avoid discussion of safety plans etc) so that you don’t tip the perpetrator off that you know they are there.  In addition, if a Client brings up a statement about Walmart such as “I need to go to Walmart today”, it is an indicator that the perpetrator has walked in or is close by so you can begin to wrap things up.

      • Here is a video on COVID-19 & Survivor Confidentiality:

  • Are there any special considerations for working with rural populations, particularly the elderly?
  

GETTING STARTED WITH REMOTE PATIENT MONITORING


If you are one of many clinicians and practices who would like to monitor disease or symptom progression of patients with pre-existing conditions at-risk for COVID-19 without increasing their exposure and risk of infection or needing to better manage patients who have been diagnosed with COVID-19, then Remote Patient Monitoring might be the perfect fit for you!
  • Help me understand remote patient monitoring?
    • Check out this brief under a minute introductory video taken from our Remote Patient Monitoring Toolkit  on our website.  This toolkit is dedicated to helping providers get started.  Visit the toolkit and make sure you download the actual RPM Toolkit (it's an 8 page PDF document with lots of great information).

  • What kinds of devices can be used for remote patient monitoring?
    • The US Food & Drug Administration (FDA) has issued a new policy that allows manufacturers of certain FDA-cleared non-invasive vial sign-measuring devices to expand their use so that health care providers can use them to monitor patients remotely.  The devices include those that measure body temperature, respiratory rate, heart rate and blood pressure.
    

ABOUT HIPAA, TELEHEALTH TECHNOLOGY AND VENDORS


Telehealth and HIPAA

If you are exploring telehealth technologies for the first time in order to get started quickly, we encourage you to take a few minutes to understand telehealth in the context of HIPAA Compliance.
  • Give me the quick and dirty basics about HIPAA and Telehealth
    • For a quick introduction to HIPAA Compliance and Telehealth, watch this brief video:

  • Is it true that I don't have to worry about HIPAA during the pandemic?  Since most of you are frantically trying to get started yesterday, if you don't currently have any technology that you could use for a telehealth visit, please know that as part of its response to the pandemic, a change was made regarding HIPAA. The HHS Office for Civil Rights (OCR) is exercising enforcement discretion and waiving penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype.  See FAQs on Telehealth and HIPAA during the COVID-19 Nationwide Public Health Emergency.

The intent of the OCR response to the pandemic is for providers to act responsibly and to make every effort to comply ("in good faith")  with HIPAA in terms of technology selection and communications channels.  This is particularly important when working with patients who might have sensitive health information.  If you are using everyday communications technologies without encryption on a public wi-fi network, this is extra risky and you need to seriously weigh the risks against the benefits.  If the situation is urgent/emergent, and you don't have other methods, by all means.  However, if the situation is less urgent and you can arrange for a platform with encryption and/or move to a more private setting, you would be strongly advised to do so.  With that said, please check your State policies, as not every state has waived enforcement of their HIPAA requirements.

    • To check your State policies, Click Here, select the state of interest and then scroll down to the lower half of the page to see the original guidance documents and any new guidance related to COVID-19.  Alternatively, just go up to the top menu bar and select your state under "Our Region".
  • What's all this news about Zoom-Bombing and what is the risk to privacy and security?  While the "free" version of Zoom is not recommended for telehealth visits (there is a paid health care version that has more of the elements required by HIPAA), we know many of you are using it as a stopgap measure or for administrative meetings.  In order to make Zoom user friendly, Zoom had set its "default" settings to be as open as possible.  The majority of the issues you've heard/read about in the media were related to users not bothering to make adjustments to these default settings.  This article on How to Prevent Zoom-Bombing provides some very practical information on how to mitigate the majority of  the risks.  Since this time, Zoom has updated their platform several times, changing many of the problematic default settings to more secure default settings.  
  • Are there any privacy/security issues related to using bluetooth headphones or other bluetooth devices for telehealth?  Bluetooth can be a privacy/security risk. Bluetooth is an open standard for short-range radio frequency communication. If your mobile device has Bluetooth capability, turn off or set the Bluetooth connection capabilities to “nondiscoverable.” When in discoverable mode, Bluetooth-enabled mobile devices are “visible” to other nearby devices, which may alert a hacker to target them. When Bluetooth is turned off or in nondiscoverable mode, the Bluetooth-enabled mobile devices are invisible to other devices not authorized to access or monitor the data in your device. It is definitely not advisable to use Bluetooth in a public place or with a public network.   Additionally, as with passwords, you should never share your Bluetooth pairing codes with anyone. For more information, take a look at this NIST Guide to Bluetooth Security.
  • What do I need to know about HIPAA and audio only/telephone visits?  The FCC issued a Declaratory Ruling and Order to clarify HIPAA rules and how they apply to telephone calls with patients.  A very good summary of the rule may be found here.  The enforcement discretion and waiver of penalties granted by OCR in response to the pandemic also applies to landline and wireless communications. 
  • I am trying to prepare for telehealth post-pandemic.  What do I need to know about HIPAA and Telehealth?   Here are several resources that can be used to help you prepare to do your own risk assessment:

Working with Vendors (Technology and Service Providers)

  • How do I got about selecting a vendor for telehealth technology or services? If you have a budget for technology and infrastructure and the luxury of taking a little time, we would recommend your using our Vendor Selection Toolkit.to better help you determine your technology and/or clinical requirements before selecting a vendor(s).   

    

  • There are so many technologies out there.  How do I figure out what will meet my clinical requirements?
    • The National Telehealth Technology Assessment Resource Center (TTAC) has put together a number of Toolkits to assist you with learning the fundamentals of the various technologies and how to assess those technologies.  They have also created an Innovation Watch section that takes a closer look at new technologies as they come to market.
  • How do I know what types of vendors are out there?  If you are exploring what types of vendors are out there (both for technology and for service providers):
    • The American Telemedicine Association, in partnership with the Consumer Technology Association, has started putting together this Digital Health Care Directory to connect the health care industry with digital health technologies so you can get a feel for the massive number of options available in the marketplace.  The directory has a mixture of both telehealth technology vendors and service providers.

Free/Low Cost Telehealth Platforms, Technologies and Services

Telehealth Access for Seniors provides seniors and low-income communities with devices, instructions and free tech-support to connect them to their physicians via telehealth through the generosity of donations and volunteers. Visit their website to donate, request technical support (individuals) or to request assistance with accessing phones/tablets for your patients (clinics only).
If you don't have a budget for telehealth technology or services, the following are vendors who are offering either free or significantly reduced prices as a response to COVID-19.  Please note that MATRC is not in a position to either endorse or recommend any of the vendors on this list. We strongly encourage you to do your due diligence when making a vendor selection. There may be other vendors also making available platforms for free or at a significantly reduced price in response to COVID-19. These are the ones that have been brought to our attention thus far:
Communications eConsult Cellular/Wireless Service:  All four of the major United States carriers have signed on to the FCC’s Keep Americans Connected Pledge. Under this agreement, carriers have agreed to take the follow action for at least the next 60 days:  1) Not terminate service to any residential or small business customers because of their inability to pay their bills due to the disruptions caused by the coronavirus pandemic; 2) Waive any late fees that any residential or small business customers incur because of their economic circumstances related to the coronavirus pandemic; and 3) Open its Wi-Fi hotspots to any American who needs them.
  • AT&T is currently offering home internet wireline customers unlimited data. New customers who are eligible for public assistance programs can subscribe to Access from AT&T for two months of free service. All public WiFi hotspots are open to anyone who needs them. AT&T will not terminate service of any wireless, phone or broadband residential or small business customer due to an inability to pay your bill. All late payment fees will be waived. 
  • Verizon will not charge late fees or terminate service to customers who are experiencing hardships because of COVID-19 and cannot pay their bill in full.
  • Sprint is providing unlimited data for 60 days to customers with metered data plans effective 3/18/20. 
  • T-Mobile is providing customers on smartphone plans unlimited data for 60 days effective 3/13/20. Customers should dial 611 on their T-Mobile phone if they have concerns about bill payments due to COVID-19. 
Internet Service:  In response to the coronavirus pandemic and its impact on society, multiple Internet Service Providers (ISPs) have made updates to their low-cost internet service programs to ensure individuals and families stay connected to the internet.  To find low-cost Internet Service and Computers in Your Area, use this tool from everyoneon!  Peripheral Devices:
  • AireHealth Portable Nebulizer Kit on sale at significantly reduced rate with additional $25 off first nebulizer kit and free shipping with code WELCOME25
  • Eko Telehealth is giving health systems 30 days of complimentary access to their stethoscope live streaming software and cardiac screening AI platform.
Remote Monitoring: Screening Telehealth System Performance Monitoring
  • Free trial of Vyopta Platform for automating compliance reporting and system utilization and capacity monitoring  for hospitals and health systems scaling up to 1K end users or more.
Video/Virtual Care

BEST PRACTICES FOR CONDUCTING A TELEHEALTH VISIT


Now that you have possibly figured out what you want to do and the technology you would like to use to do it, this section is designed to help you with the administrative, operational and clinical best practice information you will need to actually successfully perform a telehealth visit.
 

Policies and Procedures

It is always a best practice to develop written policies, procedures and protocols for your telehealth operations.

  • Policies define your practices' position on what you plan to do and why you plan to do it.  It is generally pretty brief.  For example, is your policy to temporarily address urgent care needs with telehealth and to delay non-urgent care visits in response to COVID-19?  Or is your policy to develop a comprehensive strategy for addressing all patients' needs, as appropriate, using telehealth technologies that will be sustainable beyond COVID-19? 
  • Procedures describe how a policy will be put into action across all aspects of your operations.  Procedures define roles and responsibilities regarding things like who will do what, what forms will be used, what will need to be documented, and any limits to professional discretion.   You will want to develop procedures regarding the scheduling of telehealth visits, paperwork and documentation requirements, when and how to make referrals for lab tests, etc..  For example, if a patient calls to cancel an appointment because they want to mitigate exposure to the virus, who will they be speaking with when they call?  Will that person offer the patient the option of a telehealth visit?  If your policy is to only schedule urgent care issues via telehealth and not routine wellness checks, then what will staff need to look for (e.g., appointment.visit type) or ask  the patient to determine if the scheduled visit was urgent vs. non-urgent? 
  • Protocols define particular sets of operating procedures and are sometimes accompanied by workflow diagrams.  Protocols define the order of operations and the specific tasks and expectations, serving as a formal agreement and commitment between two or more parties.
Following are some examples of policies and procedures:

The subsequent subsections address many of the components that should be considered when developing procedures and protocols.

Thinking About Workflow

A workflow is the sequence of physical and cognitive tasks performed by different people within and between organizations. There are often multiple levels involved (one person, between people, between departments and across mulltiple organizations). These tasks may occur sequentially or simultaneously.  
  • This less than 10 minute video snippet will help you think about a few considerations that may impact your workflow as you get started.  These are considerations related to both the patient and provider experience:

If time allows, the National Consortium of Telehealth Resource Centers (NCTRC) hosted a webinar on Mapping and Designing Telehealth Clinic Workflows, with a more in-depth focus on how to develop workflow diagrams for your team.

  • The following are sample workflows for a variety of settings that can serve as a starting point and then customized to fit your specific situation(s) and needs:
      • The American Academy of Pediatrics has provided Swimlane Workflow Diagrams (see Appendix A) for Provider-Patient (after hours), Provider-Patient (during office hours) and for Provider to Other Medical Facility/Office.
 

Thinking About Consent

  • Is informed consent for telehealth required?  Medicare does not require that informed consent be obtained from a patient prior to a telehealth visit, but Medicare reimburses for a set of Virtual Communications Services that they do not consider "telehealth" (learn more about Telehealth vs. Virtual Communication Services in our section in this toolkit on Telehealth Reimbursement and COVID-19.  Additionally, many states either require informed consent within their Medicaid program or in their statute or rules regulating health professionals.   Some states define very specific required elements within the consent process.  To find out if and what your state requires in terms of consent, click here and then follow the instructions below:
    • Using the filter boxes:
      • Select your state of interest
      • Select "All Categories" (this is the default)
      • Select "Consent" as your topic
      • Click on "Apply" and soon you will see if/where there are consent requirements within your state's policies (please note that this database does not include every regulation for every single health profession). 

MATRC maintains guidance documents related to state Medicaid programs and SOME health professions regulations and guidance documents for states in the MATRC coverage area.  To see if what you might be looking for is available on our website,  Click Here to select the state of interest and then scroll down to the lower half of the page to see the various State policy guidance documents.  Alternatively, go up to the top menu bar and select the state of interest under “Our Region”.

  • What goes into telehealth consent?  In telehealth, informed consent is used to explain what telehealth is, lay out the expected benefits and possible risks associated with it, and explain security measures. We think it's good practice to get consent, whether it is required or not.

The Federation of State Medical Boards has established a Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine.  In this document, they recommend the inclusion of the following when getting consent for telehealth:

    • Identification of the patient, the physician and the physician’s credentials;
    • Types of transmissions permitted using telemedicine technologies (e.g. prescription refills, appointment scheduling, patient education, etc.);
    • The patient agrees that the physician determines whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter;
    • Details on security measures taken with the use of telemedicine technologies, such as encrypting data, password protected screen savers and data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures;
    • Hold harmless clause for information lost due to technical failures; and
    • Requirement for express patient consent to forward patient-identifiable information to a third party.

If you are not a physician, your particular profession (or professional organization) may have guidance about consent and recommended elements of consent as well.

  • Do you have some sample consent form templates?  Following are several sample consent forms for a variety of practice types.  You will need to adapt these forms to your clinical use case and your state's policy requirements.  You may not need every element or you may need to add elements.   Unless your state explicitly requires the consent form to be signed (most places do not), it may be done verbally.  Make sure you have a written process and protocol developed that is considered standard operating procedure.   Once that is in place, you just need to note in the medical record that your consent process was used and that the patient provided consent.   

Documenting a Telehealth Visit

Documentation requirements for any form of virtual care (telehealth service or non-telehealth virtual communication services) are the same as those for documenting in-person care so you should include everything you usually need to document for the CPT or E&M code being billed.  In addition, you should also document the following:
 
  • Patient's location (with enough detail to satisfy a Medicare audit, i.e., eligible facility in an eligible geographic location).
    • There have been many exceptions made during this pandemic as a result of the different waivers, so this is not as important during the state of emergency, but in general you should do this so you might as well make it a practice!
    • If the patient's home is the location of service, and the address is already somewhere in the medical record, then you just need to include in your note that the visit took place at the patient's home.  You do not need to capture the address again.
    • It is always good practice to verify the patient's location at the start of every virtual visit.  Do not assume they are at home!  Remember that if the patient experiences an emergency/crisis when they are in the middle of a visit with you, if you don't have easy access to their physical location address (a PO Box will not work), it will be impossible to contact first responders and have them deployed to the patient's location.
    • We have encountered situations where the patient is actually traveling (e.g, in a car) during a telehealth visit.  Should this be the case, note that the patient was in a vehicle, but do ask what State the patient is in.  Note this in the patient record to ensure documentation of compliance with any licensure requirements.
  • Provider's location (under normal circumstances, this would be the usual place of practice – for most, it would be the office location, but if home is a routine or the only office location, then the provider’s home location should be registered as a site of service and used).  With that said, please note that during the period of the COVID-19 emergency declaration, CMS is allowing physicians and other practitioners to render telehealth services from their home without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location.
  • That the encounter was conducted via telehealth (defined by both audio and visual communication) or whatever other means was used (telephone, patient portal, etc.)
  • Start and stop time
  • That the patient consented (unless otherwise documented).  Please refer to your State's laws/licensing board regulations and guidance documents regarding specific requirements.  See section on consent above for how to do this.
  • Any other providers involved or individuals present, including telepresenters and family members
  • Optional:  A reason for using telehealth (medical or otherwise), and any criteria used to evaluate whether the case was appropriate for telehealth.

In addition to the above general guidance, CaravanHealth has deveoped some excellent information sheets regarding documenting Telehealth E/M Visits: 

Telehealth Etiquette

  • What is telehealth etiquette?  Telehealth etiquette, sometimes referred to as "webside manner" is an important, but often overlooked contributor to the overall patient experience with telehealth.  Interacting through telehealth technology requires some attention to detail that may be different than the in-person encounter.   Following is an outstanding quick video for providers to capture some of the most important best practice elements of videconferencing etiquette.

Video developed by the State of Hawaii Department of Health Genomics Section and Western States Regional Genetics Network (UH7MC30774-01-00) in collaboration with the Pacific Basin Telehealth Resource Center.

If time allows, explore this FREE Telehealth Etiquette Video Series developed by the South Central TRC.  It provides an excellent introduction to how a telehealth encounter should (and should not) be conducted!  If you have never seen or participated in a telehealth encounter, we would strongly recommend running through these very real life situations.  

Here are two checklists on telehealth etiquette that you might find useful.  We recommend printing one of these out and having it with you as you get started with telehealth visits.  Take notes and add/adapt it as you discover new lessons learned!

 
  • What about telephone etiquette?  The American Academy of Family Physicians has developed two good resources for those conducting telephone visits:

Clinical Assessment and the Physical Exam

    • Depending on the type of provider you are and the type of service you offer, there are other specific clinical guidelines and best practices for telehealth that have been developed. The ATA has some of these other practice guidelines in their Practice Guidelines Archive.
  • How do I perform a physical exam by telehealth?  Following are some great resources to help you with this!
    • This series of Telehealth training videos was developed through C-TIER, the Center for Telehealth Innovation, Education and Research at Old Dominion University. They  were produced during the COVID-19 pandemic in April 2020, in response to the growing demand for telemedicine services and providers trained in conducting exams by Telehealth:

    • The American Academy of Ophthalmology has developed this guidance on the Home Eye Test for Children and Adults.  This website guidance page also includes downloadable home eye testing charts.

What Should I Do If My Patient/Client Needs An Interpreter?

Title VI of the Civil Rights Act prohibits discrimination on the basis of national origin. Title VI and Department of Health and Human Services regulations, 45 C.F.R. Section 80.3(b)(2), require recipients of Federal financial assistance from HHS to take reasonable steps to provide meaningful access to Limited English Proficient (LEP) persons. See A Practice Guide to Implementing the National CLAS Standards for more information and resources.  Additionally, federal disability discrimination laws mandate equal access to and an equal opportunity to participate in and benefit from health care services, and effective communication with individuals who are deaf or hard of hearing.  These laws include:
  • Section 504 of the Rehabilitation Act of 1973 – applies to federal health care services and facilities; and health care providers who are also recipients of federal financial assistance, usually provided by direct funding (such as federal Medicaid funds) or by grants (such as a federal research grant).
  • Title II of the Americans with Disabilities Act – applies to all public (state and local) health care providers.
  • Title III of the Americans with Disabilities Act – applies to all private health care providers.
Many practices have developed ways to provide these services during an office or hospital visit, but what happens when you are providing care by telehealth?  Below are several options for addressing this need.
  • If you have access to a trained healthcare interpreter:
    • There are many videoconference platforms that allow for multi-point videoconferencing. There is no reason not to continue to use your interpreter remotely by video.      
  • If you don't have access to a trained healthcare interpreter: 
    • The National Board of Certification for Medical Interpreters has a searchable registry of interpreter training programs.  These programs may be able to direct you to certified medical interpreters in your state.  These individuals may or may not have had training in video/remote interpretation.
    • There are some telehealth platforms that have integration of healthcare interpreter services as part of their license agreement with end-users.
    • There are remote interpretation companies that provide interpretation by video.
    • Do not use Google Translate for important healthcare communications.  Google Translate has only 57.7% accuracy when used for medical phrase translation!  If you have no other options and can't reschedule the visit at a time when an interpreter is available, a somewhat better alternative would be the Instant Language Assistant app being made temporarily available to providers for free during the pandemic. 
  • How do I help my non-English speaking patients navigate technology?
    • Telehealth Access for Seniors has developed a large number of easy to understand downloadable Tech Guides that may be useful.  There are guides in Spanish, Korean, Chinese and Arabic.
    • Many of the video based language interpretation services for LEP patients also provide ASL interpretation services. 

Other Useful Implementation Resources for Clinicians and Practices

  • Here you will find links to medical and advanced practice nursing specialty specific guidance developed by different professional associations/organizations:
    • The American Academy of Pediatrics has provided a number of Sample Documents, including a Telehealth Visit Protocol, Patient Recruitment Sample Letter, Swimlane Workflows and Start-up Checklist for Connecting a Specialist to a Private Practice.  In addition, they have developed this webinar on Telehealth and COVID-19.
  • If you or others in your practice will be providing any kind of logistical/administrative support for telehealth visits, this is a great training  (FREE, but registration required) Telehealth Coordinator Online Training 
 

Please also make sure you take a look at our section in this COVID-19 Resource Toolkit on Resources for Specialty Providers and Settings.    We have subsections of materials and resources for dentists, rehabilitation professionals, genetics counselor, hospice and palliative care providers and more.  We have been slowly adding more specialized resources for different provider types and settings, so check back frequently!

HELPING A PATIENT/CLIENT UNDERSTAND TELEHEALTH


  • What can I help my patients understand telehealth?
    • Here are a few infographics that can help patients better understand what a telehealth visit 
      • Virtual Healthcare for Patients/Consumers  (this was created to help patients navigate the emergence of Direct-to-Consumer telehealth companies and not with COVID-19 in mind, but it has some really good practical information that you and/or your patients might find useful).
      • Telebehavioral Health (this was created by the Upper Midwest TRC and provides a brief overview of Telebehavioral Health) 
  • How can I help my patient be prepared for a telehealth visit?
    • Here is an outstanding video for patients developed by the State of Hawaii Department of Health Genomics Section and Western States Regional Genetics Network (UH7MC30774-01-00) in collaboration with the Pacific Basin Telehealth Resource Center to help patients understand telehealth, what to expect and how to prepare.

    • The Center of Excellence for Protected Health Information through funding by SAMHSA has developed this Infographic on Tips to Keep Your Telehealth Visit Private.  This has some very practical advice for patients/clients related to protecting communications, creating the right environment and protecting their devices.
    • The Upper Midwest TRC has created this infographic about Your Telemedicine Appointment.  This easy to understand one-pager providers an excellent overview for patients on how to prepare for an appointment.
 
  • Do you have a script for me to use to explain telehealth and virtual care to my patients?  
 
  • How do I help my patients navigate technology?
    • Telehealth Access for Seniors has developed a large number of easy to understand downloadable Tech Guides that may be useful.  Their website includes guides for Gmail Setup, Wifi, MyChart App, MyChart Website, Apple-ID Setup, Android Device, Amazon Fire and Play Store.  There are also several guides in Spanish, Korean, Chinese and Arabic.

RESOURCES FOR SPECIALTY PROVIDERS AND SETTINGS


Teledentistry

While teledentistry has become popular in several States, it has not had as widespread an adoption as many other health professions.  Nonetheless, there have been many resources developed by those that have been laying the groundwork for many years.
    • Now take a look at this webinar by Dr. Paul Glassman on Teledentistry and Minimally Invasive Procedures in the Time of COVID-19:

  • How do I get started?
    • Virginia Health Catalyst has developed these two very practical tools along with the following video showing a practice teledentistry visit for dentists getting started::

  

Telegenetics

We have partnered with the Northeast TRC and the NYMAC Regional Genetics Network to develop a Telegenetics Program Planning Guide and Toolkit for developing a telegenetics program (it's free, but registration is required).  This would be the perfect starting place for program planning and development!
Here are some additional resources that you might find useful as well:  

Telehealth and Autism Care

WORKING WITH CLIENTS
  • Behaviorbabe has a great website on ABA and Telehealth.  Following is video about ABA, Telehealth and COVID19 from their website (many more videos and other resources on the website as well):

  • The Behavioral Health Center of Excellence has developed the following webinars to assist providers:
 WORKING WITH FAMILIES/PARENTS
  • MSU Autism Lab hosted this webinar on Parent Coaching through Telehealth:

 

You may also want to visit our section of resources on Telerehabilitation, Telepractice and Early Intervention Services!

Telehealth in Post-Acute and Long-Term Care Settings

CMS has implemented a number of temporary regulatory waivers that have an impact on post-acute and long term care settings.  These waivers are summarized by provider/agency type in the following: CMS has also developed a Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes.
  • West Health, in partnership with the AARP and the National Consortium of Telehealth Resource Centers has put together this webinar on The Use of Telehealth in Long Term Care Settings During this National Emergency (click here for Powerpoint slides)

Telehospice, Telepalliative and Tele-Home Care

CMS has implemented a number of temporary regulatory waivers that have an impact on hospice care.  These waivers are summarized by provider/agency type in the following:
  • The Shiley Institute for Palliative Care is offering a FREE Open Forum Series via Zoom on telehealth and palliative care.  
  • The National Care Planning Council has put together About Telehospice Care as part of their Guide to Long Term Care Planning.
   

Telerehabilitation, Telepractice and Early Intervention Services

The American Telemedicine Association (ATA) Telerehabilitation Special Interest Group has developed Principles for Delivering Telerehabilitation Services.  This guide addresses general administrative, clinical, technical and ethical principles for implementing telerehabilitation services.  Below are resources more specific to particular service types/providers. 

Please note that MATRC is not in a position to either endorse or recommend any of the above vendors. We strongly encourage you to do your due diligence when making a vendor selection. There may be other vendors with a PT specific focus, these are simply ones that have been brought to our attention thus far.

   
  • Early Intervention Services (you may also want to visit our earlier section of resources on Telehealth and Autism Care):
    • The Family, Infant and Preschool Program (FIPP)  has put together an amazing set of resources on Early Childhood Intervention Telepractice, including a set of Tele-Practie Infographics and this video on Providing Early Intervention Services Through Distance Technology:

They also hosted this webinar on Telepractice in Early Intervention:

    • Sweet Pea Pediatric Wellness has made available this video on Getting Started with Telehealth for Early Intervention Providers - Tips & Tricks

    • The Early Childhood Technical Assistance Center has put together a presentation on Use of Tele-Intervention in Early Intervention (IDEA Part C): Strategies for Providing Services Under the COVID-19 Public Health Emergency
 

Tele-Substance Use Disorder Treatment and Recovery Services

  • The Addiction Technology Transfer Center (ATTC) Network, funded by SAMHSA has developed the following resources:
   

TELEHEALTH POLICY AND COVID-19


Impact of COVID-19 on Federal and State Policies

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

  • The US Health and Human Services officially renewed the public health emergency (PHE), a status that allows many of the waivers and expansions for telehealth that have occurred since the COVID-19 pandemic began in March 2020 to remain active.  The latest renewal, which occurred on October 2, 2020 now extends the public health emergency until January 21, 2021.  
 What Telehealth Related State Medicaid, Licensure and Other Policy Changes Have Taken Place As a Result of the Pandemic?  
  • This video will provide you with a good overview of State policy actions in addressing COVID-19:

Here you will find a written summary with up to date information on COVID-19 State Actions

Licensure, Interstate Practice and Credentialing/Privileging

LICENSURE AND INTERSTATE PRACTICE
  • Patients/Clients From Multiple States See Me In My Office.  May I Continue to See Them Using Telehealth During This Pandemic?  In general, a clinician must be licensed in the state where the patient/client is physically located at the time of service.  President Trump declared an emergency on March 13, 2020. As a result, the Centers for Medicare & Medicaid Services (CMS) has authorized the 1135 Waiver that took effect retroactively to March 1, 2020.  This waiver is limited in scope to conditions of participation and payment for Federal health care programs such as Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  Authorization of this waiver alone DOES NOT waive the requirement for physicians and other healthcare providers to maintain licensure in states where they are practicing a licensed profession, including via telehealth.  What the waiver does is that it gives States the option of being able to do so.  State law continues to govern whether a provider is authorized to provide professional services in that state without holding an active license from that state’s medical board.   Many state medical and other health professions licensing boards have created mechanisms that either waive or expedite state licensure requirements in response to  the pandemic. 
  • We Work with College or University Students and They Are Now Dispersed Throughout the Country.  May I Continue to See Them or Assist Them?  As mentioned earlier, in general, a clinician must be licensed in the state where the patient/client is physically located at the time of service.  However, in conversations with multiple state licensing boards, most provide leniency around this when it comes to pre-existing relationships and continuity of care.  Additionally, many state medical and other health professions licensing boards have created mechanisms that either waive or expedite state licensure requirements in response to  the pandemic.  If the state where your student is has not already made provisions for interstate practice during the pandemic, I would recommend contacting the licensing board for your health profession and just verifying that they will be OK with going across state lines to maintain continuity of care for a college student. 
    • On April 15, 2020, student representatives from over 130 universities across the country signed onto a Letter Addressed to the State Medical Licensing Boards for Mental Health Providers encouraging them to mandate an update on interstate licensing requirements so that mental health care providers can meet the needs of their students who happen to be residing in different states as a result of COVID-19.  This is a developing issue that we will be monitoring.
  • Which state medical and other health professions licensing boards have created mechanisms that either waive or expedite state licensure requirements in response to  the pandemic?  Here are several professional organizations and associations that have been tracking changes to telehealth licensure policy during the pandemic:   
 CREDENTIALING AND PRIVILEGING
  • What does the Joint Commission Require in terms of Privileging when Providing Services Via Telehealth During a Disaster?   The applicable requirements that address disaster privileging are found in the Emergency Management (EM) chapter of the Hospital and Critical Access Hospital Accreditation Manuals at EM.02.02.13. NOTE: The disaster privileging option ONLY applies when the organization has implemented their emergency management plan.

Licensed Independent Practitioners (LIP) CURRENTLY credentialed and privileged by the organization, who would now provide the same services via a telehealth link to patients, would not require any additional credentialing or privileging. The medical staff determines which services would be appropriate to be delivered via a telehealth link. There is no requirement that ‘telehealth’ be delineated as a separate privilege.

For volunteer Licensed Independent Practitioners that are NOT currently credentialed and privileged by the organization, disaster privileges may be granted to volunteer LIPs by following the requirements outlined in the Emergency Management chapter of the accreditation manual. 

  • Are there any CMS Waivers Related to Credentialing and Privileging of Medical Staff?   CMS is waiving requirements under 42 CFR §482.22(a)(1)-(4) to allow for physicians whose privileges will expire to continue practicing at the hospital and for new physicians to be able to practice before full medical staff/governing body review and approval to address workforce concerns related to COVID-19.  CMS is waiving §482.22(a) (1)-(4) regarding details of the credentialing and privileging process.
  

Prescribing of Controlled Substances

  • Due to the declaration of a public health emergency, the Drug Enforcement Administration (DEA) has made changes to their policies regarding its rules related to prescribing.  Review DEA Information on Telemedicine.  With that said, please check your State policies, as many States also have laws and regulations governing telehealth and prescribing and these laws and regulations may not have been changes in response to COVID-19.  

TELEHEALTH REIMBURSEMENT AND COVID-19


About Medicare Reimbursement for Telehealth

  • Fee for Service Medicare and Telehealth Reimbursement
    • Prior to the COVID-19 pandemic, there were a large number of restrictions placed on Fee-for-Service Medicare reimbursement for telehealth services.   These restrictions included:
      • The originating site (location of the patient).  Providers could only get reimbursed for telehealth services if the patients receiving those services were located at specific types of facilities (e.g., hospitals,  FQHCs, physician and practitioner offices) AND those facilities were located in specific geographic locations.  There were a few exceptions to this rule,  such as treatment for Substance Use Disorder, Telestroke and Dialysis for End-State Renal Disease)
      • The distant site practitioner (type of provider providing the telehealth service).    Only a specific subset of provider types are eligible to serve as distant site providers.  This includes Physicians, Nurse Practitioners,  Physician Assistants, Nurse Midwives, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Clinical Psychologists, Clinical Social Workers and Registered Dietitians or Nutrition Professionals.   Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) were specifically excluded from being able to serve as distant site practitioners.
      • Types of service.  Only a limited set of HCPCS/CPT Codes were eligible for telehealth reimbursement.

See below as well as our section in this COVID-19 Telehealth Resources Tookit on Resources for Specialty Providers and Settings for several other guidance documents.   Additionally, CMS has put together this document: COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing.  Questions center around a wide variety of topics, but many relate to telehealth.   

    • Telehealth Services During COVID-19:  CMS views telehealth as a method of care delivery and not a unique service in and of itself.  In order to bill for a telehealth visit, CMS requires that the visit include real time (synchronous) video with a few exceptions noted below,  Following are the most significant changes to Telehealth Services during COVID-19:
      • The most significant change to Medicare telehealth services was the removal of all of the originating site facility and geographic restrictions.  This allows the patient to be located anywhere at the time of service, including in their home. 
      • A second significant and most recent change is the removal of all distant site practitioner restrictions.  This allows all provides eligible to bill Medicare to be able to serve as a distant site practitioner for telehealth services.
      • A third significant change is that CMS now allows for more than 80 additional services to be furnished via telehealth.  Additionally, until now, CMS only added new services to the list of Medicare services that may be furnished via telehealth using its rulemaking process. CMS is changing its process during the emergency, and will add new telehealth services on a sub-regulatory basis, considering requests by practitioners now learning to use telehealth as broadly.
      • A fourth significant change is that CMS now allows individuals to use interactive apps with audio and video capabilities  (e.g., smartphones and tablets) for telehealth visits with their clinicians. HHS is exercising enforcement discretion related to HIPAA.  Please visit the section in this COVID-19 Resource Toolkit on ABOUT HIPAA, TELEHEALTH TECHNOLOGY AND VENDORS, What do I need to know about HIPAA and audio only/telephone visits? for more information about Telehealth and HIPAA during COVID-19.
      • And finally, the fifth significant change is that CMS has waived the video requirement for evaluation and management (E/M) services and behavioral health counseling and education services.  Prior to this waiver, telephone E/M services were not considered telehealth and were thus reimbursed at a lower non-telehealth rate, while behavioral health counseling and education without a video component was not reimbursable services.  While CMS is also allowing FQHCs and RHCs to bill for these codes, there are different billing requirements for them (see guidance below).
      • So during the COVID-19 emergency:
        • Eligible Providers of Telehealth Services:  All practitioners who are eligible to bill for Medicare services, as well as FQHCs and RHCs, are now eligible to serve as distant site practitioners for telehealth.  
        • Billing and Coding for Telehealth Services:  Please note that normally CMS uses the 02 POS Code to denote a telehealth service.  However, during the pandemic, CMS is instructing physicians and practitioners who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person. This will allow the systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. During the PHE, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services furnished via telehealth.  
    • Other Virtual Care/Communication (Non-Telehealth) Services During COVID-19:  Over the course of the past few years, CMS has been adding several types of Virtual Care/Communication Services that they have deemed to be "Non-Telehealth" Services.  Removing these from the definition of telehealth allows these services to be provided without the originating site restrictions that are attached to the traditional definition of telehealth (synchronous video-based) services.
      • Changes to Medicare Virtual Care/Communication (Non-Telehealth) Services as a result of COVID-19:
        • The list of clinicians who can provide Virtual Check-Ins and E-Visits has been expanded to include LCSWs, Clinical Psychologists, Physical Therapists, Occupational Therapists and Speech Language Pathologists.  Additionally, these visit types can now be provided to not only established patients, but also to new patients. 
        • Remote physiological monitoring codes may now be provided to not only established patients, but also to new patients.
        • FQHCs may now bill for some virtual communication services.  See the section in this COVID-19 Telehealth Resources Tookit on Telehealth and FQHCs for more information.
 
    • Other Telehealth-Related Policy Changes During COVID-19
      • CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence and also allowing hospitals to use other practitioners such as PAs and NPs to the fullest extent possible.
      • CMS is loosening "Stark Law" (physician self-referral law) restrictions.
      • CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice and home health. 
      • CMS is waiving certain conditions of participation requirements, including the requirements regarding telemedicine service agreements.
   
  • If you are an FQHC, please visit our section in this COVID-19 Telehealth Resources Tookit on Telehealth and the Federally Qualified Health Center (FQHC) for additional information regarding telehealth related policies such as Scope of Service, FTCA, Medicare Reimbursement, and Telehealth Program Development.
 
    • In response to the pandemic, MA Plans were informed by CMS through this memo that if they wish to expand coverage of telehealth services beyond what has already been approved by CMS, they will exercise its enforcement discretion until it is determined that it is no longer necessary in conjunction with the COVID-19 outbreak. 
 
  • Opioid Treatment Programs and Medicare Telehealth Reimbursement
    • To address the opioid crisis, Congress passed the “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities” (SUPPORT) Act that expands Medicare coverage for Opioid Use Disorder (OUD) treatment services.  CMS created a bundled payment for the management and counseling for OUD for clinicians in an office setting that is similar to the services under the new OTP benefit for Opioid Treatment Programs and these bundled payment codes became effective on January 1, 2020.   Detailed information may be found in the Opioid Treatment Programs (OTPs) Medicare Billing and Payment Fact Sheet.  The individual psychotherapy, group therapy, and substance use counseling included in these codes could be furnished using Medicare telehealth services.   When using telehealth services for substance use disorder:
      • Patients with OUD and SUD can use all originating sites for telehealth services except renal dialysis facilities. 
      • OUD individual therapy, group therapy, and substance abuse counseling services provided by OTPs must use OTP bundled codes for reimbursement. 
      • There are no geographic restrictions for telehealth services for OUD, SUD, and co-occurring mental health treatment. 
      • Patient’s homes can be used as an originating site, but cannot bill a facility fee.
    • In response to the pandemic, CMS is allowing audio-only telephone calls for the therapy and counseling portions of the weekly bundles and the add-on code for additional counseling or therapy for beneficiaries with opioid use disorders without access to interactive audio-video communication technology, provided all other requirements are met.  
   
  • I Submitted a Telehealth Claim and It Was Denied.  Now What?  First make sure that the claim was for an eligible service.  To see all services approved for billing as a telehealth service: List of Temporary and Approved Medicare Telehealth Services.  If you are pretty confident that you have been compliant, it is possible that there was a breakdown in communication or misinterpretation of guidance somewhere between CMS and the Medicare Administrative Contractor (MAC) and on down to the individuals who handle the day to day processing of claims.  There are multiple MACs and each covers a geographic jurisdiction and handles the processing of medical claims.   You will need to contact the MAC for your region to better understand why the claim was denied.

If you have done all of these things and were still denied, please let us know.  We also welcome finding out about any other significant challenges related to Medicare reimbursement for telehealth services you are encountering, specifically in relationship to your ability to provide and be reimbursed for patient care as a result of this pandemic.  Please be very specific if you contact us (what type of facility/provider is doing the billing, what CPT/E&M codes are being billed, where the patient is getting care, what modifiers are being used and what the specific issue is that is creating the angst).  We may be able to get quick attention to some of these issues from CMS if we are hearing the same issues from multiple providers.

About Medicaid Reimbursement for Telehealth   

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

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

About Private Payer Reimbursement for Telehealth   

Most of the states in the MATRC region (DC, DE, KY, MD, NJ, VA) have passed "parity legislation",  meaning that if a service being provided and billed for is considered a covered service in a face to face situation, a commercial carrier may not deny coverage solely because the service was provided via telehealth.  It has been reported that some commercial payers are requiring providers to use their platform/platform vendor in order to receive reimbursement. 

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

AHIP has created posted a summary of how various Health Insurance Providers Respond to COVID-19.

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

Finally, the IRS has issued Notice 2020-15 regarding High Deductible Health Plans/Health Savings Plans.   Specifically, the guidance states that “a health plan that otherwise satisfies the requirements to be an HDHP under section 223(c)(2)(A) will not fail to be an HDHP merely because the health plan provides medical care services and items purchased related to testing for and treatment of COVID-19 prior to the satisfaction of the applicable minimum deductible.” In addition to covering COVID-19 testing and treatment pre-deductible, telehealth services related to COVID-19 with no employee cost-sharing pre-deductible will also be allowed.

 

About Tricare Reimbursement for Telehealth

In mid-May the Assistant Secretary of Defense for Health Affairs (ASD(HA)) issued an interim final rule that addresses the use of telehealth in the TRICARE program with the goal of reducing the spread of COVID-19 among TRICARE beneficiaries. Specifically, it provides a temporary exception to the program’s prohibition on telephone, audio-only telehealth services when appropriate and video capabilities are not possible; authorizes reimbursement for interstate or international practice by TRICARE-authorized providers when in compliance with governing state, federal, or host nation licensing requirements; and eliminates copayments and cost-sharing for telehealth services. Services must be considered medically necessary and conducted by a network TRICARE provider within their scope of professional practice. The changes in the rule would be effective for the period of the COVID-19 pandemic. The new policy applies to any illness or injury covered by TRICARE, including but not limited to COVID-19. 

Other Useful Billing and Coding Resources for Clinicians and Practices

  • Following are several guidance documents related to billing and coding developed for specific professions/specialty areas as a result of COVID-19:
 

COVID-19 Claims Reimbursement for Testing and Treatment of the Uninsured

  • What is the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program?  The COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program provides reimbursements on a rolling basis directly to eligible providers for claims that are attributed to the testing and treatment of COVID-19 for uninsured individuals. The program is authorized via the:
    • Families First Coronavirus Response Act (P.L. 116-127) and the Paycheck Protection Program and Health Care Enhancement Act (P.L. 116-139), which each appropriated $1 billion to reimburse providers for conducting COVID-19 testing for the uninsured; and the
    • CARES Act (P.L. 116-136), which provides $100 billion in relief funds, including to hospitals and other health care providers on the front lines of the COVID-19 response. Within the Provider Relief Fund, a portion of the funding will be used to support healthcare-related expenses attributable to the treatment of uninsured individuals with COVID-19. Funding is provided from the Public Health and Social Services Emergency Fund.
  • Who is eligible for funding?  Health care providers who have conducted COVID-19 testing of uninsured individuals for COVID-19 or provided treatment to uninsured individuals with a COVID-19 diagnosis on or after February 4, 2020, can request claims reimbursement through the program electronically and will be reimbursed generally at Medicare rates, subject to available funding.
  • What services are eligible for reimbursement?   Reimbursement will be made for qualifying testing for COVID-19 and treatment services with a primary COVID-19 diagnosis as determined by HRSA (subject to adjustment as may be necessary) , including the following:
    • Specimen collection, diagnostic and antibody testing.
    • Testing-related visits including in the following settings: office, urgent care or emergency room or via telehealth.
    • Treatment, including office visit (including via telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, DME (e.g., oxygen, ventilator), emergency ambulance transportation, non-emergent patient transfers via ambulance, and FDA-approved drugs as they become available for COVID-19 treatment and administered as part of an inpatient stay.
    • FDA-approved vaccine, when available.
    • For inpatient claims, date of admittance must be on or after February 4, 2020.

View all Frequently Asked Questions about the Program

Visit the COVID-19 Claims Reimbursement Program Portal

Provider Relief Fund for Eligible State Medicaid and CHIP Providers

HHS recently announced the additional distributions from the  Provider Relief Fund to eligible Medicaid and Children’s Health Insurance Program (CHIP) providers that participate in state Medicaid and CHIP programs.  HHS expects to distribute approximately $15 billion to eligible providers that participate in state Medicaid and CHIP programs and have not received a payment from the Provider Relief Fund General Distribution.  Eligible providers must submit their data by July 20.Before applying through the Enhanced Provider Relief Fund Payment Portal, applicants can watch a webinar about the application process for Medicaid/CHIP providers.  An additional webinar is scheduled for Wednesday, July 8 at 4:00 pm EDT, which you can register for here.  You may also review the most recent FAQs on the program and the Medicaid/CHIP targeted distribution here. 

TELEHEALTH AND THE FEDERALLY QUALIFIED HEALTH CENTER (FQHC)


There have been many policy level changes specifically impacting telehealth and FQHCs during this pandemic.  We have gleaned some of the Frequently Asked Questions about Telehealth  from the HRSA Health Center Program website and included additional useful resources specific to FQHCs.  Please make sure you also review our other sections pertaining to general policy changes as a result of COVID-19 that are relevant to all health care providers.

Scope of Service and BPHC Policies

  • Do health centers need to request a change in scope for a provider to deliver in-scope services via telehealth from their home or another site not on Form 5B, assuming all the criteria for doing so (see question above) are met? (Added: 4/7/2020)  Health centers do not need to request a change in scope to deliver in-scope services via telehealth on behalf of the health center from the provider’s home or from another location that is not a Form 5B Service Site. In addition, health centers do not need to have "Home Visits" listed on their Form5C: Other Activities/ Locations in order to provide in-scope services via telehealth.
  • May health centers provide in-scope services through telehealth to individuals who are not current health center patients? (Added: 3/19/2020)  As a result of the Secretary's declaration relating to the current COVID-19 public health emergency, health center providers may deliver in-scope services via telehealth to individuals who have not previously presented for care at a health center site and who are not current patients of the health center for the duration of this public health emergency. This includes triage services, including initial consultations. Telehealth visits are within the scope of project if:
    • The individual receives an in-scope required or additional health service;
    • The provider documents the service in a patient medical record consistent with applicable standards of practice; and
    • The provider is physically located at a health center service site or at some other location on behalf of the health center (e.g., provider’s home, emergency operations center).

Health centers should focus services provided by telehealth on serving patients and other individuals located inside their service area or with areas adjacent to the covered entity’s service area. HRSA recognizes that patients outside these areas may seek health center screenings and triage by telehealth. Health centers that continue to maintain services for target populations in their service area and provide occasional in-scope services via telehealth to individuals outside these areas would be providing services within the Health Center Program scope of project for all such activities. Please review PAL 2020-01: Telehealth and Health Center Scope of Project (PDF – 520 KB) for more information.

  • Can a health center use telehealth to provide services to a patient at a location that is not an in-scope service site? Can this occur if neither the health center provider nor the patient is at an in-scope service site (e.g. both the provider and patient are at their respective homes)? (Updated: 4/7/2020)  From a Health Center Program scope of project policy perspective, using telehealth to provide services to a patient at a location that is not an in-scope service site is allowable if:
      1. The service being provided via telehealth is within the health center's approved scope of project (recorded on Form 5A);
      2. The clinician delivering the service is a health center provider working on behalf of the health center; and
      3. The individual receiving the service is a health center patient.

HRSA strongly encourages health centers that provide, or are planning to provide, health services via telehealth to consult with professional organizations, regulatory bodies, and private counsel to help assess, develop, and maintain written telehealth policies that are compliant with Health Center Program requirements; federal, state, and local requirements; and applicable standards of practice. HRSA also encourages health centers to consider the range of issues that would support successful implementation of telehealth. Please review PAL 2020-01: Telehealth and Health Center Scope of Project (PDF – 520 KB) for more information.

Federal Tort Claims Act (FTCA)

  • Does FTCA coverage extend to telehealth visits with both established patients and non-health center patients? (Updated: 3/27/2020).  When in-scope services are provided through telehealth on behalf of a deemed health center to either established patients or individuals who are not patients of the health center, and all other FTCA Program requirements are met, such services are eligible for liability protections under 42 U.S.C. 233(g)-(n), pursuant to 42 CFR 6.6. Health centers and providers are encouraged to consult with private counsel and/or consider the purchase of private malpractice insurance when undertaking activities that may not be within the health center’s scope of project.
  • Will HRSA issue a particularized determination for health centers related to COVID-19 activities, similar to the particularized determination that was issued during the H1N1 emergency? (Added: 3/31/2020).  HRSA has issued a particularized determination for health center providers (PDF - 35 KB) that clarifies eligibility for FTCA coverage during the COVID-19 pandemic for the provision of grant-supported health services by individuals who have been deemed as Public Health Service employees through the Health Center FTCA Program and the Health Center VHP FTCA Program. It applies to grant-supported health services to prevent, prepare, or respond to COVID-19 (including but not limited to screening, triage, testing, diagnosis, and treatment) to individuals who are established or non-established patients of the health center, whether in person at the health center, offsite (including at offsite programs or events carried out by the health center), or via telehealth.
  • During the declared COVID-19 emergency, do FTCA protections apply to health center providers who provide telehealth services to health center patients located across state lines? (Added: 4/8/2020)   Health Center FTCA Program regulations at 42 CFR Part 6 provide that coverage applies to “grant-related activities.” Therefore, a key determinant for FTCA coverage is whether the covered entity is providing services within the health center’s scope of project, under the Health Center Program authorizing statute. 

PAL 2020-01: Telehealth and Health Center Scope of Project (PDF - 517 KB) highlights some of the relevant considerations for health centers in providing in-scope services through telehealth. Among other things, all providers must comply with applicable state requirements. If they do not—for example, if a provider uses a state license to provide services in a different state where doing so is unlawful under applicable state law—this may jeopardize eligibility for FTCA liability protection. However, some states may have temporarily amended their requirements for providing health care through telehealth to address the needs of the COVID-19 public health emergency.  

Health centers that are uncertain of the applicable legal requirements for the provision of health services through telehealth across state lines should consult their private counsel for advice. HRSA cannot provide general assurance of FTCA coverage in all situations, as such determinations are fact-specific. As stated in the FTCA Health Center Policy Manual (PDF - 407 KB), “[w]hen FTCA matters become the subject of litigation, the Department of Justice and the federal courts assume significant roles in certifying or determining whether or not a given activity falls within the scope of employment for purposes of FTCA coverage.”

  • Will a deemed health center’s providers remain covered by liability protections under the FTCA if they are directed to provide continuous or permanent services to non-health center inpatients at a local hospital as part of a community-wide emergency response during the declared COVID-19 public health emergency? (Added: 4/16/2020)   Continuous or permanent staffing of a hospital or hospital department to provide inpatient care to all hospital patients is not described by the authorizing statute for the Health Center Program, and FTCA coverage generally is not available for such care.

Health centers have discretion to enter into contractual arrangements with hospitals or may allow their providers to enter into arrangements with hospitals to provide hospital-based inpatient care outside the scope of their Health Center Program grants. However, FTCA coverage and other federal benefits directly associated with the Health Center Program would not apply. Providers providing continuous or permanent inpatient care in hospitals through such arrangements may have medical malpractice liability protection through the hospital or another source, and volunteer providers may be eligible for liability protections under federal and state law (including new legal protections for volunteer providers for COVID-19 emergency response via the CARES Act). Health centers should consult with private counsel for legal advice regarding these matters.

Please note that the Health Center FTCA Program regulations and the March 27, 2020, Determination of Coverage for COVID-19-Related Activities by Health Center Providers (PDF - 35 KB) provide for FTCA protection for deemed health centers in the circumstances described in those issuances. The March 27, 2020, Determination of Coverage indicates that health center providers may provide grant-supported health services “to prevent, prepare, or respond to COVID-19 (including but not limited to screening, triage, testing, diagnosis, and treatment)” to individuals who are not patients of the health center, whether at the health center or off-site, and whether in-person or through telehealth. This determination of coverage extends to local COVID-19 community-wide emergency response activities supported by the health center. The Health Center FTCA Program regulations also provide for liability protections for certain described individual emergency situations.

The Health Center Program provides grant support for the delivery of primary and preventive health care service to medically underserved populations and communities. Services provided through the Health Center Program generally consist of outpatient, ambulatory care services for health center patients. As provided for by statute, regulation, and determination of coverage, services may be provided to individuals who are not patients of the health center in limited circumstances.

Medicare Reimbursement

GENERAL POLICY QUESTIONS
  • What policy changes for FQHCs have been instituted as a result of the pandemic?  This video will provide an overview of the CMS policy changes for FQHCs:

This document explains the changes authorized by CMS for FQHCs and RHCs, Medicare has also issued this more specific guidance document for FQHCs and RHCs:  New and Expanded Flexibilities for RHCs and FQHCs During the COVID-19 Public Health Emergency.  Additionally, CMS has put together this document: COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing.  Questions center around a wide variety of topics, but there is a section specific to FQHCs many of the questions relate to telehealth as well as virtual communication services..   

  • Can health centers bill Medicare for telehealth services as distant site providers?  The Coronavirus Aid, Relief, and Economic Security (CARES) Act revises the definition of a distant site in section 1834(m)(2)(A) of the Social Security Act to include FQHCs or RHCs that furnish a telehealth service to an eligible telehealth individual during the COVID-19 public health emergency period.  Rural and site limitations are removed, so that telehealth services furnished during the emergency period can be provided regardless of the geographic location of the Medicare beneficiary, including if the patient is at home. In order to be eligible for reimbursement, providers must use telecommunication systems with both audio and video capabilities for two-way, real-time interactive communication.

Distant site telehealth services can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice.  Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the RHC or FQHC, and can furnish any telehealth service, including medical outpatient office visits, behavioral health services, and other visits currently eligible under the Medicare telehealth reimbursement policies. To see all services approved for billing as a telehealth service, download this List of Temporary and Approved Medicare Telehealth Services.

  • Will I be required to get patient consent for telehealth and virtual communication services?  Consent is not required for telehealth services.  However, beneficiary consent is required for care management and virtual communication services.  During the public health emergency (PHE), beneficiary consent may be obtained at the same time the services are initially furnished.  For FQHCs, this means that beneficiary consent can be obtained by someone working under general supervision of the FQHC practitioner, and direct supervision is not required to obtain consent. In general, beneficiary consent to receive these services may be obtained by auxiliary personnel under general supervision of the billing practitioner; and the person obtaining consent can be an employee, independent contractor, or leased employee of the billing practitioner. For FQHCs, beneficiary consent to receive these services may be obtained by auxiliary personnel under general supervision of the FQHC practitioner; and the person obtaining consent can be an employee, independent contractor, or leased employee of the FQHC practitioner (see: https://www.cms.gov/files/document/covid-final-ifc.pdf).
  • Are there telehealth services where cost sharing has been waived as a result of the pandemic?  There are several CPT and HCPCS codes that describe preventive services and should be billed as G2025.  When provided by telehealth, cost sharing requirements are waived for these services.  .
  • What policies have not changed for FQHCs as a result of the pandemic? 
    • Remote Patient Monitoring (RPM)/Remote Physiologic Monitoring (99453, 99454):  CMS clarified toward the end of 2019 that RPM services are not separately billable under Medicare for FQHCs.  Since the FQHC Prospective Payment System (PPS) rate includes all services and supplies furnished ‘incident to’ the visit,” CMS feels that RPM costs are already included in the FQHC PPS payment.
    • eConsult or Interprofessional Consultations (99446-99449, 99451, 99452):  CMS guidance says that FQHCs cannot bill for eConsults under Medicare.
 BILLING AND CODING GUIDANCE
    • For Telehealth Services furnished between January 27, 2020, and June 30, 2020  that are also FQHC qualifying visits, FQHCs must report three HCPCS/CPT codes for distant site telehealth services: the FQHC Prospective Payment System (PPS) specific payment code (GO466, G0467, G0468, G0469, or G0470); the HCPCS/CPT code that describes the services furnished via telehealth with modifier 95; and G2025 with modifier 95.  For services related to COVID-19 testing, including telehealth, FQHCs must waive the collection of coinsurance from beneficiaries. For services in which the coinsurance is waived, FQHCs must put the “CS” modifier on the service line. FQHC claims with the “CS” modifier will be paid with the coinsurance applied.  Coinsurance should not be collected from beneficiaries if the coinsurance is waived.  These claims will be paid at the FQHC PPS rate until June 30, 2020, and automatically reprocessed beginning on July 1, 2020, at the $92.03 rate. FQHCs do not need to resubmit these claims for the payment adjustment. When furnishing services via telehealth that are not FQHC qualifying visits, FQHCs should hold these claims until July 1, 2020, and then bill them with HCPCS code G2025.  Modifier 95 may be appended but it is not required.   Please note that CMS will recoup any amounts paid beyond the $92.03 rate when these claims are reprocessed in July!

For telehealth services furnished between July 1, 2020, and the end of the COVID19 PHE,  FQHCs will use an RHC/FQHC specific G code, G2025, to identify services that were furnished via telehealth. FQHC claims with the new G code will be paid at the $92.03 rate. Modifier 95 may be appended, but it is not required. For services related to COVID-19 testing and preventive services provided by telehealth where cost sharing has been waived, FQHCs must report G2025 with the CS modifier.. Only distant site telehealth services furnished during the COVID-19 PHE are authorized for payment to FQHCs. If the COVID-PHE is in effect after December 31, 2020, this rate will be updated based on the 2021 PFS average payment rate for these services, weighted by volume for those services reported under the Physician Fee Schedule. . 

    • To receive payment for telephone (audio-only) evaluation and management services (CPT codes 99441, 99442, and 99443) , FQHCs should use HCPCS code G2025. To bill for these services, at least 5 minutes of telephone E/M service by a physician or other qualified health care professional who may report E/M services must be provided to an established patient, parent, or guardian. These services cannot be billed if they originate from a related E/M service provided within the previous 7 days or lead to an E/M service or procedure within the next 24 hours or soonest available appointment. 
    • To receive payment for online digital evaluation and management services (non-face-to-face, patient-initiated, digital communications using a secure patient portal):
      • CPT code 99421 (5-10 minutes over a 7 day period)
      • CPT code 99422 (11-20 minutes over a 7 day period)
      • CPT code 99423 (21 minutes or more over a 7 day period)

and virtual communication services (HCPCS codes G2012 and G2010), FQHCs must submit an FQHC claim with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services. For claims submitted with HCPCS code G0071 on or after March 1, 2020, and for the duration of the COVID-19 PHE, payment for HCPCS code G0071 is set at the average of the national non-facility PFS payment rates for these 5 codes. Claims submitted with G0071 on or after March 1 and for the duration of the PHE will be paid at the new rate of $24.76, instead of the CY 2020 rate of $13.53. MACs will automatically reprocess any claims with G0071 for services furnished on or after March 1 that were paid before the claims processing system was updated.

  • BKD CPAs & Advisors put together an excellent webinar that addresses all the updated coding and billing instructions for FQHCs.  You may also download the slides to the webinar presentation.
 COST REPORTING GUIDANCE
  • Costs for furnishing distant site telehealth services will not be used to determine the FQHC PPS rates but must be reported on the appropriate cost report form. FQHCs must report both originating and distant site telehealth costs on Form CMS-224-14, the Federally Qualified Health Center Cost Report, on line 66 of the Worksheet A, in the section titled “Other FQHC Services”.  Since telehealth distant site services are not paid under tthe FQHC PPS, the Medicare Advantage wrap-around payment does not apply to these services. Wrap-around payment for distant site telehealth services will be adjusted by the MA plans.

Telehealth Program Development

Please make sure you have also perused our general resources in this COVID-19 Resources Toolkit, particularly our sections on Getting Started with Telehealth, Getting Started with Telemental/Behavioral Health, Getting Started with Remote Patient Monitoring and Best Practices for Conducting a Telehealth Visit.  These resources are applicable to all provider and practice setting types.   Following are some resources specific to FQHC settings:
  • We offered a 2-Hour Session on Telehealth in Community Health Centers during our 2019 Telehealth Summit.  In this screencast, you will take a closer look at successful established telehealth program models found in FQHCs.
  • The Health Information Technology, Evaluation, and Quality Center (HITEQ) has put together Getting a New Workflow and Process Started During COVID-19 Pandemic as a quick start guide for health centers (please note that Remote Patient Monitoring billing codes are included in this document - CMS has clarified that RPM services are not separately billable under Medicare for FQHCs.  Since the FQHC Prospective Payment System (PPS) rate include all services and supplies furnished ‘incident to’ the visit,” RPM is theoretically already included in the FQHC PPS payment).
  • The following vendors are offering access to eConsult services for FQHCs during the pandemic.  Please note that MATRC is not in a position to either endorse or recommend any of the vendors on this list. We strongly encourage you to do your due diligence when making a vendor selection:

WHAT HAPPENS WHEN THE PANDEMIC IS OVER?


Transitioning from Temporary to Permanent Policies

  • The US Health and Human Services officially renewed the public health emergency (PHE), a status that allows many of the waivers and expansions for telehealth that have occurred since the COVID-19 pandemic began in March 2020 to remain active.  The latest renewal, which occurred on October 2, 2020 now extends the public health emergency until January 21, 2021.  Key regulatory flexibilities linked to the PHE include the 1135 Waivers, the CMS Interim Final Rule, a number of initiatives under the Families First Coronavirus Response Act and CARES Act  legislation, several State Medicaid and CHIP Program flexibilities, HIPAA Enforcement  Discretion, Fraud and Abuse Enforcement Discretion and Flexibility Regarding Controlled Substances.  
  • Here is a look at what temporary policy changes might remain post-COVID-19 and what could be issues that policymakers my think merit future action:

  • There were some significant changes in telehealth reimbursement as a result of the pandemic and it is likely that the reimbursement, coding and billing policies will eventually revert back to their pre-pandemic guidance.  This Billing for Telehealth Encounters: An Introductory Guide on Fee-For-Service will provide you with an understanding of what this was like prior to the pandemic.  Although much of its focus is on fee-for-service Medicare, it also provides information about Medicaid and private payor coverage.  In addition, this pre-pandemic guidance document also discusses how to bill and code for several types of services that CMS does not consider "telehealth".   These include: Remote Communication Technology, Virtual Check-In, Remote Evaluation of Pre-Recorded Patient Information and Interprofessional Internet Consultation.
    • To get an even better understanding of Fee for Service Medicare policies prior to the pandemic, review this document Fee for Service Medicare Telehealth Services and Click Here to see a compilation of questions to CMS related to telehealth reimbursement for FFS Medicare and their responses. 
  • This video provides you with an overview of how telehealth policy is structured in the U.S: 

 

   
  • A flurry of policy level activities have already started taking place.  Following are some some of the things under way:
    • On Wednesday June 17, the U.S. Senate Committee on Health, Education Labor & Pensions held a hearing on Telehealth: Lessons from the COVID-19 Pandemic.  Our own Karen S. Rheuban joined Joseph C. Kvedar, Sanjeev Arora and Andrea Willis to share testimony, contributing to the discussion about what temporary telehealth changes should be made permanent in federal and state policies.  Watch Here!
    • Additionally, on June 29th, 340 organizations signed a letter urging Congressional leaders to make telehealth flexibilities created during COVID-19 pandemic permanent. Read the Letter Here!
    • The Taskforce on Telehealth Policy had invited public input as it develops policy recommendations for advancing quality and patient experience while establishing a stable, long-term environment that fosters the growth and integration of remote services within the healthcare system.  Learn more here.
    • CMS has released it's Proposed CY2021 Physician Fee Schedule for public comment.  Comments are due no later than 5 PM on October 5, 2020.  See this Fact Sheet  or watch this video for an overview of the policy changes:  
    • The American Hospital Association has written an open letter addressed to President Trump regarding the need to do to enable more for hospitals and health systems to provide virtual care.  
 

Telehealth Quality and Performance Improvement

  • Don't expect "business as usual".  Prepare for a tsunami of patients who have delayed care and will need it.  Prepare also for patients who will continue to delay care because they are fearful of exposure by coming into your office or a health care facility.  Start thinking NOW about how to use the telehealth tools you have started putting into place to address this oncoming wave.  Start thinking now also about quality of care.  Here are a few resources to serve as food for thought:
  • We have now let the genie out of the bottle and hundreds of thousands of providers and patients will have experienced telehealth for the first time.  Some will recognize its value and want to continue.  What data should you be collecting now so you can both demonstrate telehealth quality, assess performance improvement and be prepared to make a case for policy changes if/when needed?