MATRC Telehealth Resources for COVID-19 Toolkit

• How should I manage a suicidal patient/client?
  • The Center for Practice Innovation has developed Telehealth Tips: Managing Suicidal Clients During the COVID-19 Pandemic.  The document includes a Patient Safety Plan Template for you to use.

• • 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.

• • The National Network to End Domestic Violence has developed a number of resources:
    • Using Technology to Communicate with Survivors During a Public Health Crisis, which also includes links to their Digital Services Toolkit on best practices for using tools such as text, chat and video

• • • Best Practices When Using Mobile Devices for Advocacy.

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

• How do I care for clients/patients who are in inpatient, residential or other non-ambulatory care settings?
  • The American Psychiatric Association and the National Association for Behavioral Healthcare jointly hosted a recorded discussion with experts on How to Address COVID-19 Across Inpatient, Residential and Other Non-ambulatory Care Settings.  The recording is available for free and CMEs are available (registration required).  

• How do I care for clients/patients with serious mental illness?
  • The American Psychiatric Association and the National Association for Behavioral Healthcare jointly hosted a recorded discussion with experts on Serious Mental Illness and COVID-19: Tailoring ACT Teams, Group Homes and Supportive Housing.  The recording is available for free (registration required). 

• • Insight + Regroup is offering this online 1 CME credit training course on Treating Serious Mental Illness via Telepsychiatry free of charge during the pandemic.  

• Are there any special considerations for working with rural populations, particularly the elderly?
  • Insight + Regroup is offering this online 1 CME credit training course on Telepsychiatry for Rural Elderly free of charge during the pandemic.

• Give me the quick and dirty basics about HIPAA and Telehealth
  • For a quick introduction to HIPAA Compliance and Telehealth, watch this brief video:

• • You might also want to check out this HIPAA & Telehealth Infographic

• 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".

• • If you are considering using everyday communications technologies during this pandemic, the Health Information Technology Evaluation and Quality Center (HITEQ) has put together a very nice Issue Brief on Using non-traditional technology for telehealth during COVID-19 Pandemic that would be worth your time to review.

• 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. 

• 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).   

• 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.

• • If you are looking solely for telehealth service providers, the Southwest Telehealth Resource Center has put together this Service Provider Directory for Telemedicine and Telehealth.

• Significantly reduced pricing on Updox Secure Text for 6 months.
• Free Presence Scheduling and Telemedicine Solution  
• Free clinical communication solution secure one-way communication updates through AngelEye Health
• Instant Language Assistant (Medical) software/app temporarily available to providers free during the pandemic.
• Free sign language Virtual Remote Interpretation by linguabee for COVID-19 test sites

• Free access to Safety Net Connect eConsult Telehealth Portal for primary care physicians
• Free access to ConferMED Coronavirus eConsults for Safety Net Practices 
• Free access to The MAVEN Project for eConsults for community health clinics who serve the underserved.
• Free access to RubiconMD for 120+ specialties for qualifying safety net clinicians.  Clinic leadership should contact covid19support@rubiconmd.com  

• 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. 

• Altice Optimum and Suddenlink for new customers with K-12 or college students in the household.
• Charter Spectrum for new customers with K-12 or college students in the household
• Comcast/Xfinity Internet Essentials for customers that are new to Comcast  
• Cox Connect2Compete for new customers with a least one K-12 student in the household who participate in a government assistance program.

• 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.

• Free access to Vivovitals remote patient monitoring platform for providers in the United States
• Significantly reduced pricing on Connected Healthcare Solutions (CHS) Health Guidance Platform for remote monitoring (reduced one time startup fee with no minimum quantities or contractual requirements - and use as many or as few devices as you need with no additional cost)
• LSI Rentals and Leasing Options offers both short and longer term rental and leasing options for patient monitoring equipment
• Free 90 day trial of KangarooHealth intelligent remote patient monitoring platform by contacting Bridget Holm

• Free use of Orbita COVID-19 Screening Chatbot & Knowledge Base through June 2020
• Hospitals can add for free Bright.md's coronavirus screening tool, based on its asynchronous virtual care delivery platform, SmartExam, to their websites. The online tool guides patients through a dynamically adaptive online medical interview, reviewing their symptoms and health history, as well as possible exposure to COVID-19.

• 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.

• Free access to Bluestream virtual care platform
• Free temporary Vidyo video communications platform license
• Free access to Compunetix Video Call Center for Healthcare platform for up to 90 days with no fees or obligations
• Free white-labeled RingMD telemedicine platform for doctors, healthcare groups and other organizations negatively affected by the outbreak.
• Free Cloudbreak Health unified telemedicine and video medical interpretation solution app with free service for hospitals
• Free basic and significantly reduced pricing on full featured  Adaptive Telehealth telemental health platform license
• Free basic doxy.me telemedicine platform
• Free 60 day trial of Nautilus Medical Technologies teleray video & audio communication and dicom image exchange solution.
• Free access to CompuGroup Medical US CGM ELVI web-based video platform
• Free Pulsara ONE + COVID-1g video-enabled platform to all EMS and healthcare organizations
• Significantly reduced pricing on Updox Video Chat for 6 months.

• 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.

• The American Telemedicine Association has developed Operating Procedures for Pediatric Telehealth.

• The Federation of State Medical Boards has established a Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine.  This document was designed for State licensing boards, but is actually an excellent way to think about policies and procedures within an organization or practice.

• This draft  Sample Telehealth Policies and Procedures was developed by an actual organization (they have given us permission to strip the identifiers and to share).

• 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:

• • Outpatient
    • We have put together a few sample workflow templates for your use:
      • Provider to Patient Virtual Visit Sample Workflow
      • Provider Office to Patient Sample Workflow

• • • 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.

• • • CaravanHealth has developed:
      • This set of flow charts/diagrams looks at Re-Engineering Patient Inflow and looks at Triaging Incoming Visit Types to the Best Virtual Visit Types
      • Telehealth E/M Workflow Diagram

• • • This draft Sample Telehealth Policies and Procedures includes a workflow diagram. 

• • • The Center for Care Innovations has put together Telehealth and Telephone Visits in the Time of COVID-19: FQHC Workflows and Guides.  While these were collected from FQHC settings, the sample workflows would be broadly applicable in other clinic settings as well.

• • • The California TRC has developed Specialty Clinic to Clinic Workflows.

• • • Virginia Health Catalyst has developed this Teledentistry Workflow 

• • Inpatient/Facility
    • West Health has developed this Telehealth Workflow for Post-Acute and Long Term Care Facilities

• • • VCU Health has developed this Inpatient Telemedicine Process with Example iPhone Patient Room Setup

• 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.   

• • Here is a sample General Consent Form in English and a sample General Consent Form in Spanish (credit goes to California TRC). 

• • Here is a sample Telemedicine Program Consent Form (credit goes to Southwest TRC) 

• • The Agency for Healthcare Research and Quality (AHRQ) has created a sample Easy to Understand Telehealth Consent Form. The form includes language for healthcare providers that have curtailed in-person visits due to COVID-19. AHRQ has also created how-to guidance for clinicians on how to obtain informed consent for telehealth.

• • Here is a sample Telemental Health Informed Consent Form in English and a sample Telemental Health Informed ConsentForm in Spanish developed by the National Association of Social Workers.

• • Here is a sample Telepsychology Informed Consent Form developed by the Joint Task Force for the Development of Telepsychology Guidelines for Psychologists

• • Here is a sample Informed Consent for the Use of Virtual Early Intervention from the Indiana First Steps Program

• 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.

• Telehealth E/M Visits
• Telehealth E/M Visits Level of Service Quick Reference Guide

• 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!

• • Telehealth Etiquette Checklist.  
  • Telehealth Visit Etiquette Checklist (American Medical Association)

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

• • 10 Communication Tips for Physician Phone Visits During COVID-19
  • Managing a Telephone Encounter: Five Tips for Effective Communication

• Are there any practice guidelines for providing clinical care using telehealth?
  • The American Telemedicine Association (ATA) has developed Practice Guidelines for Live, On Demand Primary and Urgent Care.   

• • 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.

• • In response to the pandemic, Harvard Medical School is waiving tuition for their online course on The Telephone & Telemedicine in Clinical Medicine: An Instrument of Opportunity & Risk (includes 3 AMA PRA Category 1 Credits).

• How do I perform a physical exam by telehealth?  Following are some great resources to help you with this!
  • This article "Why the Telemedicine Physical is Better than You Think" gives some great perspective as well as some very practical ideas about what can be done even without peripheral devices.

• • 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:

• • If you want to kill two birds with one stone, this is an excellent online training developed by Thomas Jefferson University Sidney Kimmel Medical College on Telemedicine: Conducting an Effective Physical Exam Online Course ($100 for this 1 hour online course that includes CME/CE)

• • CaravanHealth has developed detailed guidance on the Telehealth Physical Exam as well as detailed guidance on Adapting the Annual Wellness Visit to 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 if I am using the telephone?
  • The CDC has developed Phone Advice Line Tools: Guidelines for Children or Adults with Possible COVID-19.  This document includes initial phone scripts, accompanying decision algorithm and tailored care advice messages. 

• • In response to the pandemic, Harvard Medical School is waiving tuition for their online course on The Telephone & Telemedicine in Clinical Medicine: An Instrument of Opportunity & Risk (includes 3 AMA PRA Category 1 Credits).

• 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.

• 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.      
    • As an example, Zoom for Healthcare has a built-in feature that allows you to add an interpreter  

• 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.
    • Examples of such platforms include ViTelNet and Cloudbreak
  • There are remote interpretation companies that provide interpretation by video.
    • Examples of such companies include Stratus Video/InDemand Interpreting and LanguageLine Solutions .
  • Instant Language Assistant (Medical) software/app is being made temporarily available to providers for free during the pandemic.

• If you are an interpreter or know one that has never done interpretation by video before:
  • Please take a look at our Telehealth Etiquette video resources found in our section on Best Practices for Conducting a Telehealth Visit in this COVID-19 Resource toolkit..
  • The National Council on Interpreting in Health Care has made available two webinars:
    • Temporary Transition to Remote Interpreting During Health Emergencies: Guidance and Tips for Language Access Stakeholders (recorded webinar is free for NCIHC members and $30 for non-members, but slides and FAQs may be accessed for free by all)
    • The Critical Role of Healthcare Interpreters During the COVID-19 Pandemic: Legal and Practical Implications (free live webinar on April 25, recording will be free for NCIHC members and at cost for non-members)

• What if I have a deaf or hard of hearing patient?
  • The National Association of the Deaf has developed Guidelines for Healthcare Providers - Video Based Telehealth Accessibility

• • TDI  has developed the following resources:
    • COVID-19: Guidelines for Healthcare Providers - Video Based Telehealth Accessibility 
    • COVID-19: Communication Access Recommendations for the Hospital
    • Telehealth Guidelines for Deaf and Hard of Hearing Patients

• • If you are an ASL interpreter, the Southwest Telehealth Resource Center hosted this webinar on ASL Interpreters (on video or in person) in Medical Settings and the Law that might be of interest.  Although some of the materials are specific to Arizona, much of it is relevant to all ASL interpreters.

• • Free sign language is being offered by Virtual Remote Interpretation by linguabee for COVID-19 test sites during the pandemic. 

• • Many of the video based language interpretation services for LEP patients also provide ASL interpretation services. 

• Here you will find links to medical and advanced practice nursing specialty specific guidance developed by different professional associations/organizations:
  • The American Academy of Dermatology has developed this Teledermatology Toolkit

• • The American Academy of Neurology has put together the following resources:
    • Telemedicine and COVID-19 Implementation Guide
    • Telemedicine and COVID-19 FAQ
    • NeuroBytes: The Neurologic Exam Via Telemedicine training course that is free to AAN members
    • NeuroLearn: Introduction to Teleneurology training course that is free to AAN members and for a fee for nonmembers that includes 1.0 CMEs..

• • 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.

• • The American Association of Nurse Practitioners has developed this training on Telehealth: What Nurse Practitioners Need to Know that is free to AANP members and for a fee for nonmembers that includes CE Credits.

• • The American College of Cardiology put together this podcast: Practice Made Perfect: Telehealth  Ensuring Quality Cardiovascular Care During Uncertain Times.

• • The American College of Physicians has developed An ACP Physician's Guide that has a section on telehealth, has developed a curriculum called Telemedicine: A Practical Guide for Incorporation into your Practice and has put together this webinar on Revving Up Your Telemedicine Practice in the Time of COVID.

• • The American Diabetes Association has developed this webinar on Telehealth and COVID-19

• • The American Medical Association has developed a "Quick Guide to Telemedicine in Practice" that has a section on Practice Implementation.

• • The American Society of Cataract and Refractive Surgery has developed this webinar on Implementing Tele-Ophthalmology During COVID-19 Pandemic

• • The American Urological Association has put together this white paper on Telemedicine in Urology as well as a number of other valuable resources in their Telemedicine Info Center for COVID-19.

• • The Association of Community Cancer Centers has developed a resource page on Coronavirus Response for Cancer Care.

• • The Providers Clinical Support System (PCSS) has developed FAQs for Treating Opioid Use Disorder via Telehealth Tips for Primary Care Providers

• • The Society of Critical Care Medicine has developed this "Tip Sheet: Application of Telemedicine and Telecritical Care to Emergency Management of 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!

• What is exactly teledentistry and how will this help me during COVID-19? 
  • Check out these these three resources for a nice overview! 
    • Expanding Oral Health: Teledentistry
    • Teledentistry: Providing Alternative Care During a Public Health Crisis
    • Using Teledentistry to Maintain Services and Contact with Patients During COVID-19

• • 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::
    • Crisis Teledentistry Implementation Guide (a few of the pages are specific to Virginia policies, but but the rest of the document has great information about teledentistry practice recommendations and resources) 
    • Teledentistry Workflow 

• • Teledent has put together this guidance document on Patient Assessment via Synchronous Teledentistry

• The National Coordinating Center for the Regional Genetics Networks has a Telemedicine/Telehealth Resource Page that has a great resource repository.

• The National Genetics Education and Family Support Center has developed a patient facing infographic called TELEWHAT?: An Introduction to Telegenetics that might be useful for you or provide your patients..

• The Council of Autism Service Providers has developed a number of resources:
  • Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis
  • Organizational Guidelines & Standards
  • Webinar on Autism Telehealth in Crises and Beyond
    • Webinar Video (free but registration required)
    • Webinar Slides

• 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):

• There is a Telehealth in ABA Facebook Group with some great ideas.  It is a private group so you will need to request to join.

• The Behavioral Health Center of Excellence has developed the following webinars to assist providers:

• • Telehealth: Strategies for Effective Supervision
  • Telehealth: Clinical Applications to Real Cases
  • Telehealth in Times of Trouble: Considerations for Behavioral Health Providers (available only for members)

• K-Now Solutions has put together this webinar on Telehealth in ABA: The Building Blocks

• Psych Central has this reflection post on Tele-ABA Activities for Kids: 7 Telehealth Activities ABA Providers Can Use with Children with ASD

• Insight + Regroup is offering this online 1 CME credit training course on Telepsychiatry and Children with Autism Spectrum Disorder free of charge during the pandemic. 

• Professionals in Italy developed this paper on a Model of Support for Families of Children with Autism Living in the COVID-19

• This is an excellent blog post on 10 Strategies for Engaging Parents (not Children?) during Tele-Intervention

• 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!

• Inpatient Rehabilitation Facilities: CMS Flexibilities to Fight COVID-19
• Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibitilies to Fight COVID 19
• Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals

• 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)

• West Health has also developed a number of resources for PALTC settings:
  • Getting Started with Telehealth: PALTC
  • Getting Started with Telehealth:  Provider (with PALTC)
  • A Practical Guide to Telehealth: Implementing Telehealth in Post-Acute and Long-Term Care Settings (PALTC)
  • Rapid Deployment: Getting Started with Telehealth Pre-visit Form: PALTC
  • Rapid Deployment: Getting Started with Teleheallth Post-visit From: PALTC
  • Telehealth Workflow for Post-Acute and Long Term Care Facilities

• The Society for Post-Acute and Long-Term Care Medicine has published Standards for the Use of Telemedicine for Evaluation and Management of Resident Change of Condition in the Nursing Home

• The American Psychological Association has put together How to Provide Telehealth in Nursing Homes, with tips for offering essential psychological services to older residents during the pandemic.

• LeadingAge has developed a number of guides for the selection and implementing of technologies: 
  • Telehealth and Remote Patient Monitoring for Long-Term and Post-Acute Care: A Primer and Provider Selection Guide
  • Social Connectedness and Engagement Technology for Long-Term and Post-Acute Care: A Primer and Provider Selection Guide
  • Safety Technology for Long-Term and Post-Acute Care: A Primer and Provider Selection Guide
  • Medication Management Technologies for Long-Term and Post-Acute Care
  • Electronic Health Records (EHRs) for Long-Term and Post-Acute Care: A Primer on Planning and Vendor Selection
  • Functional Assessment and Activity Monitoring Technology: A Primer and Provider Selection Guide
  • Shared Care Planning and Coordination Technology for Long Term and Post-Acute Care: A Primer and Provider Selection Guide

• Home Health Agencies: CMS Flexibitilies to Fight COVID 19
• Hospice: CMS Flexibilities to Fight COVID-19.

• The Center to Advance Palliative Care has put together several COVID-19 Response Resources related to telehealth:
  • Telehealth Startup Guide
  • Telehealth and Palliative Care
  • Epic Note Template: Telemedicine (Video) Palliative Care Assessment
  • Telehealth Visit Outline: Protocols for First Telehealth Visits with Patients and Families

• The Journal of Palliative Medicine as published an article on Top Ten Tips Palliative Care Clinicians Should Know About Telepalliative Care

• The National Hospice and Palliative Care Organization (NHPCO) has put together a number of excellent resources and is also offering Virtual Office Hours:
  • Best Practices for Using Telehealth in Palliative Care.
  • NHPCO COVID-19 Discussion on Effective Virtual Visits – (04/27/20) Download the webinar slides  – PDF version  |   Webinar recording
  • NHPCO COVID-19 Discussion of Latest Updates – (04/16/20) Download the webinar slides   |   Webinar recording
  • Tips for a Successful Telehealth & Virtual Visit (04/13/20) Download the webinar slides   |   Webinar recording
  • Demystifying Hospice Virtual Care in the COVID-19 Emergency (04/08/20); NHPCO members-only can access the webinar recording and slides.

• 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.

• Husch Blackwell has developed this Hospice Telehealth Flowchart: How to Provide Medically Necessary Hospice Physician and Nurse Practitioner Visits via Telehealth to Medicare Hospice Patients During the COVID-19 Pandemic

• The Association of Professional Chaplains has developed is A Quick Guide to Providing Telechaplaincy Services

• Physical Therapy:
  • The American Physical Therapy Association has put together a number of telehealth resources.  Here is just a sampling: 
    • Telehealth in Patient Care
    • Telehealth in Physical Therapy in Light of COVID-19
    • Implementing Telehealth in Your Practice STAT: Practical Guidance from Experienced Telehealth PTs (Recorded Facebook Live Session)
    • Health Policy & Administration Section COVID-19 Resources

• • The Federation of State Boards of Physical Therapy Guidelines: Telehealth in Physical Therapy

• • The Family, Infant and Preschool Program has put together this infographic for Physical Therapists on Tele-Move: I'm a PT, Don't Take My Hands Away From Me

• • There are a few vendors that have developed some technology based solutions for Physical Therapy applications that may be of interest to some.
    • 4DMOTION for Physical Therapy & Rehabilitation
    • SENSORMedica FlexInFit In-Shore Pressure Sensors
    • Reflexion Health VERA and HelloPT

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.

• Occupational Therapy:
  • The American Occupational Therapy Association has put together a number of telehealth resources.  Here is just a sampling:
    • Snapshots of Current Telehealth Applications in Occupational Therapy
    • Telehealth Resources for Managing Your Practice
    • OT and Telehealth in the Age of COVID-19
    • Occupational Therapy Telehealth Decision Guide

• • The American Congress of Rehabilitation Medicine as put together this webinar on Telehealth Resources for Occupational Therapy

• • OTPotential has developed this informative Telehealth Occupational Therapy Guide that you might also find useful.  

• • The Family, Infant and Preschool Program has put together this infographic for Occupational Therapists on Tele-Sense: Making Sense of Sensory Preferences

• Telepractice/Telespeech:
  • The American Speech-Language-Hearing Association (ASHA) has put together a number of resources on telepractice.  Here is just a sampling:
    • Telepractice Checklist for School-Based Professionals
    • Pivoting to Telepractice: Adapting Audiology to our New Virtual Reality

• • We have a recorded webinar on "Innovation and Impact with Speech Language Pathology Telepractice

• • SpeechPathology.com offers a two-part course on Pediatric Telepractice with CEUs for $99/year:  Telepractice: What You Need to Know for Practical Applications in Pediatrics and Telepractice: Day in the Life of a Teletherapist, the Inside Scoop

• • Pearson Assessments provides a brief How To on Telepractice and a video demo of  Q-global Quick Look Demo for Speech Language Pathologists for conducting the CELF-5 and GFTA Assessments.

• • The Family, Infant and Preschool Program has put together this infographic on Tele-Speech: SLPs, Can We Talk? Our Virtual Role

• 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:

• • The Infant and Toddler Connection of Virginia put together this Teleflections Video Series which provides reflections from Virginia early intervention service providers on tele-intervention:
    • Teleflections Video 1 – My First Online Visit
    • Teleflections Video 2 – Tele-What?!
    • Teleflections Video 3 - Bandwidths, Platforms, and Pings?? Help!
    • Teleflections Video 4 - I'm a PT and Rely on my Hands
    • Teleflections Video 5 – Woke Up Worried
    • Teleflections Video 6 - Mom was Over the Moon
    • Teleflections Video 7 - Update from Julie
    • Teleflections Video 8: Getting Creative in Rural Areas

They also hosted this webinar on Telepractice in Early Intervention:

• • This document has some very practical information on Planning for the Use of Video Conferencing for Early Intervention Home Visits during the COVID-19 Pandemic

• • ASHA offers several resources on early intervention services.  These include:
    • Using Telepractice to Provide Early Intervention Services to Families
    • Online Conference Session (free to members) on The State of Telepractice for Delivering Early Intervention Services

• • 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
    • Access Recorded Webinar
    • Download Presentation

• • The National Center for Hearing Assessment and Management has put together A Practical Guide to the Use of Tele-Intervention in Providing Early Intervention Services to Infants and Toddlers Who Are Deaf or Hard of Hearing

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

• • Webinar on Tips for Using Videoconferencing to Deliver SUD Treatment and Recovery Services

• • Telehealth Learning Series for SUD Tx and Recovery Support Providers (live one-hour sessions each week with access to experienced providers, training tools, checklists and more).  There is an archive of recorded past session materials.

• • Curated Resources on Telehealth for SUD Tx and Recovery Support Providers

• We have, as part of our Telebehavioral Health Center of Excellence website, a page of general MAT and Tele-MAT Resources

• The Providers Clinical Support System (PCSS) has developed FAQs for Treating Opioid Use Disorder via Telehealth Tips for Primary Care Providers

• • The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued COVID-19 Public Health Emergency Response and 42 CFR Part 2 Guidance

• The DEA has provided this Policy Guidance on Use of Telephone Evaluations to Initiate Buprenorphine Prescribing

• The DEA has provided this Policy Guidance on Use of Telemedicine While Providing Medication Assisted Treatment (MAT)

• The Center of Excellence for Protected Health Information has developed this slideset from a webinar on Understanding the New SAMHSA/OCR Guidance for Telehealth SUD and MH Services

• The National Council for Behavioral Health made available this recorded COVID-19 Office Hour session focused on Opportunities for Peer Support Workers, Supervisors and Programs

• The Center for Connected Health Policy has put together this report on Barriers & Challenges to FQHC Use of Telehealth for Substance Use Disorder: A Examination of Policies Affecting FQHCs Pre- and During COVID-19 Emergency.

• For a summary of the most up to date information:  Policy Changes at the Federal Level.   This video provides and updated on the most recent set of policy changes from CMS:

• CMS has issued COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.  Quite a number of these waivers have an impact on telehealth.

• CMS has also issued a set of provider/program specific guidance documents pertaining to the waivers and flexibilities.  These include:
  • Home Health Agencies (PDF) 
  • Physicians and Other Practitioners (PDF) 
  • Ambulances (PDF) 
  • Hospitals (PDF)  and Frequently Asked Questions for Hospitals and Critical Access Hospitals Regarding EMTALA
  • Teaching Hospitals, Teaching Physicians and Medical Residents (PDF) 
    • Also note that the Accreditation Council for Graduate Medical Education (ACGME) has provided this Response to COVID-19
  • Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities) (PDF) 
    • Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes
  • Hospices (PDF) 
  • Inpatient Rehabilitation Facilities (PDF) 
  • Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals (PDF) 
  • Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (PDF) 
  • Laboratories (PDF) 
  • End Stage Renal Disease (ESRD) Facilities (PDF) 
  • Durable Medical Equipment (PDF) 
  • Participants in the Medicare Diabetes Prevention Program (PDF) 
  • Medicare Advantage and Part D Plans (PDF)
  • State Medicaid & Basic Health Programs 
  • Medicare Shared Savings Program Participants (PDF) 
  • Risk Adjustment FAQ on COVID-19

• 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 July 23, 2020 now lasts up until Oct. 21, 2020. 

• 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

• 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:   

• • American Speech-Language-Hearing Association Tracking of State Laws and Regulations for Telepractice and Licensure Policy

• • Association of State and Provincial Psychology Boards (ASPPB) Temporary/ Telepsychological Practice and COVID-19

• • Federation of State Boards of Physical Therapy Jurisdiction Telehealth Laws/Guidance for PTs and PTAs

• • Federation of State Medical Boards (FSMB) List of States Waiving Licensure Requirements/Renewals in Response to COVID-19.  

• • Federation of State Medical Boards (FSMB)  List of States Modifying In-State Licensure Requirements for Telehealth in Response to COVID-19.

• 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. 

• • • See FAQ on Requirements for Granting Privileges During a Disaster
    • See FAQ on Credentialing and Privileging - Temporary Privileges

• 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.

• 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.  

• Following is a decision tree summarizing the policy changes regarding How to Prescribe Controlled Substances to Patients During the COVID-19 Public Health Emergency

• 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.

• • WHAT'S CHANGED in response to the COVID-19 pandemic? A large number of policy changes that both directly and indirectly impact telehealth have been put into place by CMS as a result of the President's emergency declaration, emergency legislation, waivers and other flexibilities.  These changes have been fluid and have taken place incrementally over the past several weeks, with the latest update taking place on 4/30/20.  Following are the changes that CMS has authorized: 
    • COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
    • Home Health Agencies
    • Physicians and Other Practitioners
    • Ambulances (PDF) 
    • Hospitals  and Frequently Asked Questions for Hospitals and Critical Access Hospitals Regarding EMTALA
    • Teaching Hospitals, Teaching Physicians and Medical Residents
      • Also note that the Accreditation Council for Graduate Medical Education (ACGME) has provided this Response to COVID-19
    • Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities)
    • Hospices
    • Inpatient Rehabilitation Facilities
    • Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals
    • Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
    • Laboratories
    • End Stage Renal Disease (ESRD) Facilities
    • Durable Medical Equipment
    • Participants in the Medicare Diabetes Prevention Program

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. 

• • 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 What Do I Need to Know About Telehealth Technology and Vendors 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 Telehealth Services: To see all services approved for billing as a telehealth service: List of Temporary and Approved Medicare Telehealth Services.

• • • • 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, including physical therapists, occupational therapists, speech language pathologists and others.

• • • • 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 and to add the GT modifier..

• • 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.

• • • Billing and Coding for Virtual Care/Communication (Non-Telehealth) Services:  Because CMS does not consider these types of service as telehealth services, DO NOT use POS 02 or modifier 95 when billing for these service.  CaravanHealth has developed a set of outstanding resources for how and when these billing codes can/should be used:
      • At-A-Glance Overview of all  Virtual Care and Care Management Services with their corresponding billing codes, examples of their use, brief descriptions and more.
      • Chart showing National Average Reimbursement for Virtual Care and Care Management services.
      • Fact sheet and billing codes for Digital E/M Visits (Patient Portal)
      • Fact sheet and billing codes for Virtual Services (Remote Evaluation, Virtual Check-in)
      • Fact sheet and billing codes for E-Consults (Interprofesional Internet Consultations) 
      • Fact sheet and billing codes for Principal Care Management (Between Visit Care for Specialists)
      • Fact sheet and billing codes for Chronic Care Management (Between Visit Care)
      • Fact sheet and billing codes for Transitional Care Management (Stabilizing and Supporting Patients During Vulnerable Transitions Home)

• • 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.

• Accountable Care Organization (ACO) and Medicare Telehealth Reimbursement
  • CMS has developed this Medicare Shared Shavings Program guidance 
  • CMS has also extended the Next Generation ACO Model to December 2021 (originally set to sunset at the end of 2020).  The Next Generation ACO provides an expanded telehealth reimbursement policy compared to Medicare’s pre-COVID-19 telehealth policy, offering participating entities the option to offer telehealth to patients in any geographic area and originating site (including the home) and allowing asynchronous telehealth coverage of dermatology and ophthalmology.
  • See a Summary of CMS Innovation Center Models COVID-19 Related Adjustments   
  • CaravanHealth has developed this Guidance on Collecting Clinical Quality Measures in a Virtual Visit 
  • CaravanHealth has also developed HCC Capture for Telehealth and Virtual Care Management for ACOs

• FQHCs and RHCs and Medicare Telehealth Reimbursement. In addition to the document above regarding 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.  

• • CaravanHealth put together these two documents that you may find useful:
    • Telehealth Services in Rural Health Clinics and Federally Qualified Health Centers

• • • Guidance for Billing Telehealth Services in Rural Health Centers and Federally Qualified Health Centers

• 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.

• Medicare Advantage (MA) Plans and Medicare Telehealth Reimbursement
  • CMS released final rules for changes to MA plans regarding telehealth in April 2019.  The Center for Connected Health Policy has put together this Final Rules for Medicare Advantage Plans and Telehealth Fact Sheet.  CMS has also issued this guidance document for Medicare Advantage and Part D Plans.  

• • 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.

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 a State Medicaid & CHIP Telehealth Toolkit: Pollcy Considerations for States Expanding Use of Telehealth - COVID-19.

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".

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:

• • Aetna - COVID-19 Service Enhancements
  • Aetna - COVID-19 Approved Behavioral Health Telemedicine Services
  • AmeriHealth New Jersey - COVID-19 Service Enhancements
  • Anthem - COVID-19 Service Enhancements
  • Blue Cross and Blue Shield Companies - COVID-19 Service Enhancements
  • Blue Cross and Blue Shield of North Carolina - COVID-19 Service Enhancements
  • Blue Cross and Blue Shield Federal Employee Program - COVID-19 Service Enhancements
  • Capital Blue Cross - COVID-19 Service Enhancements
  • CareFirst - COVID-19 Service Enhancements
  • CareFirst BlueCross BlueShield - COVID-19 Service Enhancements
  • Centene - COVID-19 Service Enhancements
  • Cigna - COVID-19 Service Enhancements
  • Geisinger Health Plan - COVID-19 Service Enhancements
  • Highmark - COVID-19 Service Enhancements
  • Horizon Blue Cross Blue Shield of NJ  - COVID-19 Service Enhancements
  • Humana - COVID-19 Service Enhancements
  • Magellan Health - COVID-19 Service Enhancements
  • Optima - COVID-19 Service Enhancements
  • United Health Care - COVID-19 Telehealth Services
  • United Health Care - COVID-19 Physical, Occupational and Speech Therapy Telehealth
    • Outpatient PT/OT/ST Codes for Telehealth Services
  • Virginia Premier - COVID-19 Service Enhancements

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.

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

• • The American Academy of Dermatology Code Quick Reference for COVID-19

• • The American Association of Family Physicians At-A-Glance Guide to Coding for Telehealth Visits

• • The American College of Obstetricians and Gynecologists Managing Patients Remotely Due to COVID-19: Billing for Digital and Telehealth Services

• • The American College of Physicians Telehealth Coding and Billing During COVID-19

• • The American Dental Association COVID-19 Coding and Billing Interim Guidance 

• • The American Medical Association  Special Coding Advice During COVID-19 Public Health Emergency

• • The Society for Maternal-Fetal Medicine Coding White Paper: Interim Coding Guidance: Coding for Telemedicine and Remote Patient Monitoring Services during the COVID-19 Pandemic

• 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

• 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. 1. 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.

• 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.

• 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.  

• 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.

• Is there current guidance on the reimbursement methodology for distant site telehealth visits under Medicare?  The Medicare guidance document New and Expanded Flexibilities for RHCs and FQHCs During the COVID-19 Public Health Emergency was released on April 17. See below section on Billing and Coding Guidance for an overview of the reimbursement methodology that will be used.

• 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). 

• 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.

• Following is CMS guidance on the New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the Covid-19 Public Health Emergency (PHE).  Following is a brief summary of the Medicare guidance document  as it pertains to billing and coding:

• • 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. 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!
    • As a reference, see Specific Payment Codes for the FQHC Prospective Payment System (FQHC PPS) 

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 apended, but it is not required.  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 see all services approved for billing as a telehealth service, download this List of Temporary and Approved Medicare Telehealth Services.

• • 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.

• CaravanHealth put together these two documents that you may find useful:
  • Telehealth Services in Rural Health Clinics and Federally Qualified Health Centers
  • Guidance for Billing Telehealth Services in Rural Health Centers and Federally Qualified Health Centers

• 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.

• During the COVID-19 PHE, CMS will pay all of the reasonable costs for any service related to COVID-19 testing, including applicable telehealth services, for services furnished beginning on March 1, 2020. 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, and the Medicare Administrative Contractor (MAC) will automatically reprocess these claims beginning on July 1. Coinsurance should not be collected from beneficiaries if the coinsurance is waived.

• The Weitzman Institute is offering a series of Project ECHO sessions for FQHCs on Preparing for COVID-19.  One of the sessions is entitled "Develop and Define Your Telehealth Strategy".

• 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 National Consortium of Telehealth Resource Centers hosted and recorded the following in their FQHC Webinar Series:
  • Part 1: Telehealth and Chronic Care Management
  • Part 2: Using Telehealth to Treat Substance Use Disorder in a CHC Setting
  • Part 3: Telehealth and Mental/Behavioral Health

• The Center for Care Innovations has put together Telehealth and Telephone Visits in the Time of COVID-19: FQHC Workflows and Guides.

• 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 Health Information Technology, Evaluation, and Quality Center (HITEQ) has put together Using Telehealth to Expand PrEP Access in Health Centers.  This brief highlights how health centers are using telehealth resources and innovations for HIV Pre-Exposure Prophylaxis (PrEP)

• The Center for Connected Health Policy has put together this report on Barriers & Challenges to FQHC Use of Telehealth for Substance Use Disorder: A Examination of Policies Affecting FQHCs Pre- and During COVID-19 Emergency.

• 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:
  • Free access to Safety Net Connect eConsult Telehealth Portal for primary care physicians
  • Free access to ConferMED Coronavirus eConsults for Safety Net Practices 
  • Free access to RubiconMD for 120+ specialties for qualifying safety net clinicians.  Clinic leadership should contact covid19support@rubiconmd.com  
  • Free access to The MAVEN Project for eConsults for community health clinics who serve the underserved (The MAVEN Project is available without charge even beyond the pandemic)