As part of the ongoing COVID-19 educational webinar series, Dr. John Findley, Caravan Health Medical Director ACO Programs, hosted a webinar on April 2.  A wide range of topics were covered including transitioning to team-based primary care workflows that optimize care delivery during the pandemic as providers rapidly shift to virtual care. Dr. Finley also shared tips on leveraging staff to generate revenue and preventing a second tsunami of chronic disease.

Dr. Anna Loengard, Chief Medical Officer with Caravan Health, also participated in the webinar and helped to field the myriad of questions from the well-attended session.  Key points were made regarding the rapidly developing paradigm of managing a disease in an out-of-office setting, without the capacity to test or easily monitor for complications - or even treat the illness.

The importance of taking action was discussed in order to effectively deliver care while also implementing measures to protect:

  • patients,
  • providers and their clinical teams,
  • practices, revenue and financial sustainability and,
  • jobs and the community.

Based on the new CMS rules that expand telehealth, virtual visits, and the rapidly changing landscape, a comprehensive Q&A followed the presentation which is recapped below.
Are telephone E&M visits available for RHCs?
Not currently. CMS has expanded Medicare coverage to include CPT codes for telephone evaluation and management (E/M), including services provided to a caregiver in Fee for Service Environments only during the Public Health Emergency. CMS will allow RHC/FQHC providers to bill for G0071, Virtual Check-In. This service represents a 5-10-minute interaction with the patient by telephone. Digital interactions with the patient, such as communication through a portal or email, would be billed as Digital E/M services in FFS but can also be billed by G0071 in RHC/FQHC. With the interim rule, G0071 has been re-valued to account for these types of interactions.  We will be responding to the CMS Interim Fee Schedule Comment Period as this will have a negative impact on access to care in many rural communities with limited access to internet or smart phones.
What is considered a non-physician provider than can charge the telephone E/M codes?
CMS has specified a group of service codes 98966-98968 that describe a level of service provided by qualified healthcare providers (QHP), such as Physical Therapists, Occupational Therapists, Speech Language Pathologists, Licensed Clinical Social Workers, and Clinical Psychologists. Please keep in mind that although clinical support staff can assist in facilitating these services, only the provider or billing practitioner’s time counts toward the service for telephone visits and other types of time-based services. For example, support staff can do the intake, open up a note, and complete the initial assessment of the history of the present illness in a chief complaint, but the provider time is the only time that can count toward the actual billable service.
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Would anyone be willing to share their plan/guidelines for ongoing monitoring/home support for patients with/suspected COVID?
On our COVID-19 Resource page we have some nice references from the CDC. The issue that we recognize is access to an availability of oximeters as well as other equipment. We also have a telehealth physical exam infographic.

We are going to have to rely on our visual skills and what we can note by inspection by video. Still, there will be concerns for patients who are not doing well that will require triage to either an in-person office visit, the urgent care or the emergency room.
Should we promote the 6 feet social distancing or 10 feet? We’ve heard about some areas that say 10 feet for their older patients. We are trying to prepare our community.
We have not seen specific guidelines discussing six versus ten feet, however, there has been recognition that the virus can be spread by aerosol. The CDC has recently advised the use of masks to decrease transmission of these smaller particles that can be spread even in conversation within six feet. I think most practitioners are using masks for patients who come into the office but encouraging your patients to use masks in enclosed public settings is likely to decrease spread. Please check with the CDC frequently for the most recent recommendations.
Do we need to get a signature specifically agreeing to a telehealth visit?  How do we accomplish this without them in the office?
This does not need a signature – you can get verbal consent by the patient. The verbal consent must be documented in the record and will need to be renewed annually.
Are there any restrictions on what platform you use for tele-health? For example, can we use Google Duo or WhatsApp?
HIPAA regulations are not being enforced during this time, which opens up a variety of apps and technologies that could be utilized while getting started in telehealth. The platform must support real-time audio and video, such as FaceTime, WhatsApp, and Facebook Messenger. A smartphone is likely the most accessible technology for most patients.
Any resources/recommendations for getting consent/informing patients of charges for telephone or portal-based services (other than full telemedicine visits)?  My staff is struggling with how to tactfully communicate that we may now be charging for services that we have been providing at no cost to this point.
We do not have specific resources on obtaining patient consent. Please note that during this emergency Office of Inspector General (OIG) issued a Policy Statement to notify physicians and other practitioners that they will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations Federal health care program beneficiaries may owe for these services.
To be clear, there are no issues with identifying and then reaching out to patients to schedule AWV's via telehealth, correct?
Correct. You can proactively reach out to patients to provide AWV services. This is an optimal time to connect with them on COVID-19 and let them know you’d like to establish a care continuity plan during periods of social distancing. If you have the time, you can use the AWV to make that connection with the patient. Remember that 80% of patients in Caravan ACOs are hypertensive (a noted COVID-19 risk factor), which makes the AWV an essential thread to connect with your community, and an ideal opportunity to start that connection now. Guidance for completing a telehealth AWV is now available on our COVID-19 Resource page.
We're going to have to get lean and extremely efficient, nimble, and flexible, as well.  We believe that there will be 1 physician working with 4-6 APRNs or extenders.
Absolutely. High functioning teams should have a physician working with, and overseeing, a group of Advanced Practice Providers, nurse leaders, and other Qualified Health Professionals. Additionally, CMS has acknowledged possible shortages of health care providers due to potential exposure and quarantine and has removed many of the previous supervision requirements to allow these providers to function more independently during this time.
Has there been any updates in policy re: RNs / nursing making calls / telehealth visits to patients without provider participation real time, but supervising or signing off in the end and be able to bill?   Eg: Nursing calling out to check on our patients, offer support, if available complete AWV, CCM, etc.?
In terms of nurses doing telephone-only support, outside of CCM, TCM and other currently established care management models, nurses cannot independently bill for telephone E&M, Virtual Check-In or Digital E&M, only billing provider time spent providing these services counts toward billable time.
Is the face-to-face still being required with telehealth calls for RHC's doing AWVs?
This question seems to get at two different questions. First, can AWVs be delivered by phone call? No, AWV is an approved service for telehealth, with real-time audio and video. Note that the IPPE is not an approved telehealth service, only initial and subsequent AWV.

Second, how do RHCs provide AWVs via telehealth? To be clear, CMS has not offered any guidance about how RHCs and FQHCs should provide telehealth services. However, services provided via telehealth do not change in their required elements. So, in an RHC or FQHC, where a face-to-face with the provider would be required for an AWV, the face-to-face element would remain in place.

In addition, telehealth services billed by physicians and non-physician providers (NPPs) do have a face-to-face component. It is our recommendation that all AWVs, regardless of clinic type, end with a billing provider closing the visit. This would typically include a review of the Personalized Prevention Plan but may also include Medication and Diagnosis Reconciliation and review of any pertinent positives from the AWV, such as a positive depression screen.
Is the Telephone E/M service an option for RHC?
No current language allowing this service in RHCs is noted. RHC/FQHC are allowed to provide and bill for Virtual Check Ins (G0071) by phone.
Why are telephone/telehealth more desirable than virtual/video?
When it is available, the best option for E/M care is generally a telehealth visit that utilizes real-time audio and visual. Telehealth can be used to perform many services, including E/M services as well as preventive services. Being able to see and examine the patient adds value to these visits because the allow a greater assessment of the patient. Additionally, they are reimbursed at the same rate as office-based E/M visits.
If telehealth is not available, telephone-only E/M visits are the best option for managing conditions requiring that level of decision-making or care. Telephone E/Ms allow provides to more accurately represent the care they provided and the amount of time they spent providing that care.

Virtual Check-Ins, which can be furnished by telephone only, are useful for brief (5-10 minutes) interactions with patients requiring a touchpoint or management of a patient that does not rise to the level of an E/M. As such, in FFS settings, they are valued as brief interactions rather than patient management and medical decision-making that rises to the level of an E/M.
How can elements of the AWV be done via telehealth? BP, ht, wt, vision, etc?
A lot of the vitals can only be done if the patient has the ability to measure those and self-report during the AWV.  Be sure to document that the AWV was done via telehealth due to the emergency and thus patient self-reported vitals were used or unobtainable. Full guidance about conducting a telehealth AWV is available on our resource site.

All providers will need to use best clinical judgement. There will be circumstances when you will need to have the patient come into the office for in-person examinations. Many primary care practices are securing “clean” locations separate from spaces that are triaging COVID suspected patients. 
What do we expect for telehealth expansions and allowances by multiple payors – will they be extended or stopped after the emergency is officially cancelled?
CMS and many payors have moved quickly to address the immediate risk of exposure to both patients and providers. Although there is language specifically noting that these policy changes apply during the Public Health Emergency, there has been no policy statement regarding exactly how and when specific services will be tapered or stopped.
How do you consent people for telephone visits?
This is something we’ve always heard as a challenge – if you start billing for something that historically you provided for free, how do you do that? CMS has been clear that you can actually get consent when you’re providing the service – you don’t have to get it in advance. Have some basic scripting that states for the protection of your patients, physicians, and other providers you are moving your practice to virtual and that Medicare is allowing you to do telephone and video visits. It’s ok to let them know that you want to provide the best care possible and in this environment visits are moving to telephone calls and video visits so they are aware that these will be billed in the same way that their normal office visits have been billed in the past. We have provided a template for introducing patients to new types of care delivery on our COVID-19 resource page.
Has there been consideration for pharmacists being able to bill for CCM, TCM, etc.?
Pharmacists can contribute time toward CCM services under general supervision rules, however, they cannot currently bill independently for these services.

What is the difference between telephone E/M vs Virtual Check-in visits?
These services are essentially the same for the first 5-10 minutes of time spent managing a condition or acute patient concern. Telephone E&M visits have several time-based codes above 10 minutes that can be used to account for this additional time. Telephone E/M visits generally require a level of care or medical decision-making that typically would have required an office visit, while Virtual Check-ins can be used for care management decisions that typically have always been managed via brief telephone interactions.
What should the process be for obtaining consent from a patient for charging for a telephone E/M?
This consent can be obtained by support staff prior to, or at the time of, service. Beyond typical consent requirements, you should note that cost sharing may apply, and whether or not your organization will be waiving these costs during the PHE. The consent can be obtained verbally and must be documented in the patient record.
Will rural health clinics be able to have virtual dual visits for Annual Wellness and E&M together?
There has been no change in language specifying allowing RHCs to bill for dual visits at this time. We assume the same requirements of provider involvement will apply to telehealth services.

Can non-providers do telehealth for Home Health, and can we bill for it?
We aren’t sure what this question refers to. APRN/PA can now order home health and should therefore be able to provide the needed face-to-face visit, which is allowed via telehealth. This would be a billable service. Physicians can also contract with outside Home Health Entities to provide home based services under direct audio/video supervision of the billing provider.
Can FQHC's bill telephone E/M visits?
No current language allowing this service in RHCs is noted. RHC/FQHC are allowed to provide and bill for Virtual Check-ins (G0071). We hope CMS will provide further guidance on this as we recognize that rural areas need this ability most urgently.
Is it still only established patients that qualify for virtual or phone visits correct?
During the PHE these policies have been relaxed. Providers can provide these services to new and established patients. It was felt that limiting access to established patients only would potentially compromise patients at risk of COVID-19 related illness.
Are we still able to allow patients to come into the office for scans such as X-rays & CT's scheduled before COVID-19?
At this point it is recommended that all patients with established risk factors should avoid unnecessary or non-urgent services to avoid potential exposure. There has been no language specific to diagnostic procedures at this point. Providers will have to use their clinical judgement to determine whether or not the study is necessary during this time.
Does Caravan expect that the telehealth expansions and allowances by multiple payers will be extended, or stop cold after the emergency is officially cancelled?
CMS and most payors have moved quickly to address the immediate risk of exposure to both patients and providers. Although there is language specifically noting that these policy changes apply during the Public Health Emergency, there has been no policy statement regarding exactly how and when specific services will be tapered or stopped.
Now that CMS has allowed telephone-only visits, are billing providers still the only ones able to perform AWV?
The AWV is an allowable telehealth service (which includes video and audio capabilities), however, the AWV is not an allowable telephone E/M service. Only providers can bill for telephone E/M and Qualified Health Care Professionals can bill for Telephone Assessments.

Although support staff can provide portions of a telehealth AWV, current policies state that providers must complete a face-to-face component in order to bill for telehealth services. It is our recommendation that nurses initiate and contribute to much of this visit with providers closing the visit to review the Personalized Prevention Plan and other relevant clinical issues that may come up.
How do you suggest minimizing risk when a physical exam is not applicable during a telemedicine visit, even if video is available?
Please see our NEW telehealth physical exam document here to consider many findings that can be noted by inspection only.
NOTE:  Providers must use clinical judgment and bring patients into the office for a more thorough examination and/or testing when believed to be clinically necessary. To mitigate risk, many organizations we are working with have designated “clean” sites that are distinctly separate from the clinical areas managing suspected COVID-19 patients.
Is TCM now billable as a phone visit?
Telephone-ONLY TCM is not allowed, however, the initial contact with patients can still be performed by phone followed by a telehealth visit with the provider to fulfill the E/M component of this service.
Do these codes apply to hospital-based clinics as well?
The therapy codes are on the telehealth list, but Therapists are not eligible providers for Telehealth.   Should this be incident to billing then under doctor NPI?
Therapists are not eligible providers for telehealth services, however, that are noted as Qualified Health Professionals and can bill for Telephone E/M and Digital Assessments. CMS has recognized that approximately 10% of the time, therapy services are billed by physicians/APPs and have thus allowed therapy services to be provided by telehealth in these circumstances only.
What providers can bill for TCM and CCM?
There have been no new policy changes regarding which individuals can contribute toward these services. Please refer to our COVID-19 Resource page for information about these services.
I had read that a Registered Dietician can now bill for Telehealth visits.  is this applicable to RHC's?
RDs cannot bill for telehealth services at this time. Although they can provide Telephone and Digital Assessments in FFS, they are not allowed to bill in RHC/FQHC. Please note that RDs time can be counted as contributing towards CCM time/services.
It was my understanding that the Virtual be initiated by the patient. Does the Telephone E&M require the patient to prompt the visit or can it be set up by the provider just like the telehealth?
The patient must initiate the following services – Digital E/M, Digital Assessment, Virtual Check-in, Remote Evaluation. All other services can be initiated by the provider.
The CPT manual indicates that 99441-99443 codes require the patient to initiate the service; essentially, practices cannot solicit telephone visits.

However, practices are encouraged to educate patients about services that are available to them. For instance, if a patient requests an office visit, the front desk should educate patients about options such as telehealth visits and telephone visits. Then the patient can be scheduled for the type of visit that works best for them.

We have created a template that offices can modify as a starting point for educating patients about virtual care options. The template is available here.
There are some carriers that are allowing codes for telehealth to be done by telephone only, correct?
Medicare does not allow this service. Please check with individual providers to verify coverages.
Can remote ABN signatures be captured electronically?
The ABN is only for covered services that you believe are potentially not covered because of medical necessity or service limits. That does not apply to telehealth, virtual care, or care management. However, if it is necessary, your verbal consent process should be followed.
Are face to visits going to be waived for home health and be able to be performed via telehealth?
Home Health recertifications and any previously required face-to-face encounter can now be performed via telehealth.

Visit our COVID-19 resources Page 

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