On March 26, Dr. Anna Loengard, Chief Medical Officer of Caravan Health hosted a video webinar to dive deeper into the use of telehealth services and appropriate billing and documentation during the COVID-19 pandemic.

With providers and clinicians experiencing different levels of the novel coronavirus in their communities, the webinar provided more depth regarding the new legislation for emergency telehealth provisions and considerations for the preparation of adapting workflows.

Dr. Loengard detailed the changes to telehealth (slide 7) during the public health emergency, including the imminent legal change allowing RHC and FQHCs to provide telehealth services and how it will positively impact rural providers and their communities.

To add further clarification, a review of virtual care options (slide 10) was provided to help practices understand the distinctions between telehealth, digital E/M, virtual check-in, remote evaluations, and an e-consult.

A comprehensive Q&A followed, and a recap of Dr. Loengard’s responses is below.

NOTE: After the webinar was held, the proposed legislation was signed into law on March 27. On March 30, CMS released new flexibilities, waivers, and CARE implementations. The responses below were provided by Dr. Loengard on March 26 and predate the new information from CMS with regard to E/M and other guidance from CMS. Updated information and answers to your latest questions will be provided in a webinar scheduled for April 3.
Are we to be promoting patients to come in for A1Cs at this time?
No. If you have significant concern about someone you’ll want to ask if they are able to check their sugars at home – to whatever extent you can keep people at home makes more sense and re-evaluate a month from now. Unless you have concern of them ending up in the hospital, I would use telehealth and other care management tools to manage that.
Can an LPN answer triage calls while consulting a provider and charge for the virtual check-ins?
No, the virtual check-ins are very clearly provider time and provider time on the phone, so there is no accommodation for additional team members. For more information, refer to this link.
Are there any CMS updates on Rural Health Clinics providing telehealth?
Yes, the recently enacted CARES act allows rural health clinics and federally qualified health centers to provide telehealth visits.
Are there any restrictions to bill CCM services in the same month as a telehealth visit for fee-for-service practice?
No, the telehealth visit is just an E/M visit – it’s not a specific type of visit, it’s simply how it is provided. So, E/M and CCM can be billed in the same month, there is no restriction there.
If we elect to waive the cost sharing, how is this accomplished. Do we notify CMS or is there a modifier that has to be submitted with the claim?
I have not seen anything about notification, I thinks it about simply that you can elect to not bill for that. In all circumstances you’re able to not collect on that but by my understanding, I don’t see anything that says you have to report if you’re doing this or not. Please see below for further clarification from our billing consultant.

From our billing consultant: No, no modifier or notification is required. As a consultant, I would track the amounts reduced/written off via adjustment or write-off code in the AR system so that the wavier is clearly identified on each patient account for future reference. The following is excerpted from OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak-March 17, 2020:

“OIG is committed to protecting patients by ensuring that healthcare providers have the regulatory flexibility necessary to adequately respond to COVID-19 concerns. Ordinarily, routine reductions or waivers of costs owed by Federal health care program beneficiaries, including cost-sharing amounts such as coinsurance and deductibles, potentially implicate the Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, and the civil monetary penalty law prohibition on inducements to beneficiaries. Nonetheless, recognizing the unique circumstances resulting from the COVID-19 outbreak, OIG will not subject physicians and other practitioners to OIG administrative sanctions for arrangements that satisfy both of the following conditions:

1. A physician or other practitioner reduces or waives cost-sharing obligations (i.e., coinsurance and deductibles) that a beneficiary may owe for telehealth services furnished consistent with the then-applicable coverage and payment rules.

2. The telehealth services are furnished during the time period subject to the COVID-19 Declaration.”
Are the care plan requirements being laxed or waived on CCM patients? Should we sign these patients up for CCM?  In other words, do we still need to follow all care plan requirements?
Yes, we have not seen anything that changes the requirements for these care management services so the same requirements that have always existed are still in place. It’s just the relaxation of the billing for the co-insurance.
Can you give examples of what constitutes a Digital E/M service and how others are documenting this and billing?
If someone contacts you through your patient portal and has symptoms like a UTI or URI-type symptom and you don’t think this elevates to the level of a telehealth visit and you go back and forth with this patient around their symptoms and the entire communication is done through your portal or a secure messaging system, you would actually have a note that you could start on that patient and use a code that is in the slide with all of the virtual visit codes. You would count all of the time spent with the patient and bill accordingly. For additional information, click here.
We were under the impression that for the telehealth visit charge we would charge the regular office visit code, 99213 but add at GT modifier.  Is this not correct?
If you are billing in a fee-for-service environment and billing a 99213, you don’t need a modifier – you just add a place of service code, 02, which is a telehealth visit. There are a few exceptions to that in terms of the modifiers need. For additional information, click here.
Any word on the quality measures and requirements from CMS/ACO?  How are people handing this for AWVs done via telehealth?
There has been a delay in the MIPS and Quality Reporting and there’s an extension for all of us. At Caravan, we have actually submitted all of our Quality Reporting for 2019. We don’t know what they will decide for 2020, we expect that there will be some relaxation for the first six months of the year, we just don’t know what that looks like yet.
Our Quality Team has produced some information about quality measures and the AWVs done during telehealth and we will be publishing that to our COVID-19 Resource Page.

Can the virtual check-in be done by a RN or a MA and are they able to bill?
No, this is very clearly a provider service.
If the provider has audio and video capabilities but the patient only has audio, can telehealth E/M codes be billed?
No, it needs to be real time and you need to be able to see the patient. As previously noted, this will be updated with new CMS guidance.
Can the follow up visit required for TCM be done as telehealth or via portal or phone?
This TCM visit is essentially an E/M visit so it can be done via telehealth. TCM is an allowable service but telehealth requires both video and phone. To be clear, any service that is to be billed to telehealth must a have video and audio component. As previously noted, this will be updated with new CMS guidance.
For additional information, click here.
Do we know for certain if Commercial insurances are going to pay for telehealth?
This is by commercial payer so it will depend – Medicaid as well – on a state-by-state basis. By looking at your state medical societies or whoever would be able to disseminate this information in your state is where to look for guidance on this. We have an AMA resource on our COVID-19 Resource Page – it is a short list of some of the national providers and what their policies are. Some have come out with blanket statements on what they’re providing in terms of telehealth or waiving payments, etc. I encourage you to think about who your major payers are and contact them or look at their sites to see what guidance they’re giving. 
Just to confirm, the emergency regulation allows the provider to be in the clinic and the patient to be in the distant location?
To make sure we are all using the right nomenclature, wherever the provider is located is the distant location and the emergency regulation allows for RHCs and FQHCs, who have historically been the originating site can now be the distant site and the patient may be in their home so the originating site can be in the home, where the patient is.
Do you have any telehealth (telephonic/video) care coordinator workflows that could be shared?
This is something that we are working on. We will be sending out updates on what documents we have added to our COVID-19 Resource Page.
I am also curious about the AWV completion during telehealth? We are RHC, I know that may make a difference.
If you’re an RHC, I would do your AWV as you always have and your staff can help with a lot of it regarding collecting information, reviewing medications, and the diagnosis reconciliation, but then the provider would have to close out that visit. I think it really is unchanged and that is something that we can work on in terms of a workflow and what that looks like.
How are we looking at doing the mini-mental exam for the AWV via telehealth?
I think that the mini-cog can still be done. I’ve heard that the MoCA can be done from a distance and I haven’t yet looked at it, but this is something that we can include in terms of escalating those people who have a positive mini-cog form the AWV.
Are you expecting CMS to change any benchmarks?
This is unclear at this point. We are wondering what this will do to the performance year as there are so much less procedures and elective services happening right now and we’re just not sure if this is going to be a very expensive year or a very inexpensive year. This is still evolving and something we will stay on top of and bring you information as we know it.
You mentioned a modifier for commercial insurance. What is that modifier?
That is something that you should ask your insurance plans what they require.
Is using a telephone call and billing an E/M code allowed?
This is an emphatic, no. You are not allowed to do a telephone call for an E/M visit – you must have audio-visual capacity. As previously noted, this will be updated with new CMS guidance.
Can the AWV and the E/M be provided and billed together in an RHC?
My understanding is no at this point. Once this bill is passed, we will be waiting to see what the billing requirements are for telehealth services. My guess is this will be one service billed on a day, so that would be either an annual wellness visit or an E/M, but since the patient is a home, let's see how this plays out. It might be that you could do an AWV on one day and an E/M on another day and the patient might be willing to do that – they don’t have to go anywhere which has been the biggest impediment to getting patients to come back in. We’ll see what the language is around this new rule and we’ll come back to this.
Will you provide clarification on changing benchmarks both $ and quality metrics, for example, can we truly expect the mammograms rate to happen?
We are waiting guidance from CMS for this. It’s a very valid comment.
Usually AWVs require height, weight, BMI & BP, is this requirement being waived?
It’s not being waived. Our recommendation around this is to simply do your best. If your patients have the ability to weigh and measure themselves and take the pressure at home with a cuff, just note that it is patient-reported and make a note that in this health care emergency you were not able to obtain these. AWVs are clearly an allowable service so that’s what we’re recommending that you do in this time of crisis.
If we are performing CCMs by phone not telehealth can we waive the co-pay and bill as telehealth 02 modifier?
No, the CCM is a distinct service and it is not a telehealth allowable service. To clarify, for CCM, you will always bill CCM service codes depending on if you are fee-for-service, FQHCs, or RHCs, however, you can waive the co-pay for those services. You can refer to our COVID-19 Resource Page where we will have these telehealth allowable services.
I’m wondering about a modifier waiver and just not collect for the co-insurance.
It’s not about not submitting a bill; you’re still billing for the Medicare reimbursed part of it – it is the beneficiary co-insurance that you would waive. We will consult with our billing specialist and we’ll provide some documentation fairly quickly on this and how you actually accomplish this.
Due to the co-pays cost shares being waived are the insurers paying back the responsibility to the providers on the remit?
I have not seen that. We will clarify this with our specialist but what I’m seeing is that they are saying they will waive it, but they aren’t saying they will actually make up the difference.
Any standards on the RVUs assigned to these visits?
The RVUs are exactly the same as for other E/M visits – there’s no change in that.
Have the 7- or 14-day follow-up visit requirements been relaxed for TCM during this time?
Not to my knowledge – I’ve not seen anything about that. Setting people up to the extent that you can – TCM is an allowable telehealth visit.
We are not allowed to provide a telephone visit only?
For patients without access to audio-visual, we recommend that you look into provider provided CCM for your most complex patients or PCM if they only have one condition. I understand from our polling today that for many of you, this is going to be extremely challenging. As previously noted, this will be updated with new CMS guidance.
Can AWV be done on the telephone in the event the patient does not have capability for telehealth? 
No. AWVs are an allowable telehealth service but not an allowable telephonic service. As previously noted, this will be updated with new CMS guidance.
The virtual check-ins can be performed by telephone only for established patients. Must they be performed by the Physician/NP/PA?
Yes, they must be performed by the physician, NP, or PA.
Can CCM copays be waived after the pandemic crisis?
It’s going to be very interesting to see all of this relaxation that is likely to change how people practice and what this will look like afterwards. There has been a bill in Congress around waiving or un-doing the requirement for co-insurance for CCM that pre-dated COVID. It will be interesting to see if there is more pressure going forward to relax this even after the emergency.
Can you speak to ongoing advocacy that Caravan is doing around these issues?
Yes, this is something that Tim Gronniger and Lynn Barr are very much advocating for. All of these recommendations that essentially are trying to un-do barriers that preferentially effect rural areas – this is all part of our on-going political advocacy, trying to elevate these issues so they are recognized.
How are we looking at doing the mini mental exam for the AVW via telehealth?
The mini-cog can be done through telehealth. The circle for the clock could be sent through email, the portal or the patient or caregiver would have to draw the circle to be filled in.
Can the originating site be a patient's home and distant site be CAH for AWV performed via telehealth and billed out of the CAH with the expansion of telehealth services? Part A telehealth distant site services are billed on the UB04 or electronic equivalent.
Physician or practitioner services when distant site is in a Critical Access Hospital (CAH) that has elected Method II and physician, or practitioner has reassigned his/her benefits to CAH. In all other cases, except for Medical Nutrition Services, distant site telehealth services are billed to Part B.
Can hospitals, nursing homes, home health agencies or other healthcare facilities bill for telehealth services?
Billing for Medicare telehealth services is limited to professionals. (Like other professional services, Critical Access Hospitals can report their telehealth services under CAH Method II). If a beneficiary is in a health care facility (even if the facility is not in a rural area or not in a health professional shortage area) and receives a service via telehealth, the health care facility would only be eligible to bill for the originating site facility fee, which is reported under HCPCS code Q3014. But, the professional services can be paid for.
Will CMS require specific modifiers to be applied to the existing codes?
When a telehealth service is billed under CAH Method II, the GT modifier is required. Finally, when telehealth service is furnished for purposes of diagnosis and treatment of an acute stroke, the G0 modifier is required.
We have providers who normally see patients that are in nursing home facilities. (We are ProFee provider as well). Because of the pandemic, we have looked at telehealth options as well as virtual check-in (G2012). Most of the patients (who are at SNF/LTC facility) that the providers deal with have memory loss and cannot communicate with them directly. So they are wondering if there is a way to bill a telephone visit or other telehealth option in which they (providers) review all the information with the nursing staff relating to the patient they are caring for OR would the providers have to actually speak or talk to the patient?
Nothing has been published by CMS to address a situation that is this granular. Skilled Nursing Facilities have always been an eligible Telehealth originating site. With COVID-19, CMS has waived the HPSA (Rural) and MSA (Metropolitan Statistical Area) restrictions and is allowing providers to render telehealth services to all patients in all locations. Our billing consultant offered the opinion that since SNF/NF Subsequent E/M services are on the list of eligible telehealth services and E/M regulations allow for the participation of other individuals (documented in the progress note) OR E/M services can be provided under the E/M Counseling and Coordination rules (time must be documented appropriately), this could be an acceptable practice. Note: Initial Nursing Facility Care is NOT on the list of telehealth services and therefore would not be allowed. This was changed as of March 30 and has been added to the list of approved services.

See page 48 of this link: Guidelines for Mngt Services
Virtual Check-in visits are not telehealth services and although CMS has lifted the HIPPA PHI restrictions to allow communications through “non-secure” communication methods, as recently as March 17, in a Press Release CMS stated a Virtual Visit requires beneficiary consent. If the patient is cognitively compromised, consent may not be possible or could be questioned.
I am concerned about the "Second Tsunami" regarding unmanaged chronic diseases. Is there a ranked list of conditions that pose the most risk by going unmanaged (or under-managed)? I know there has been a focused list that the ACO has emphasized (Diabetes, Hypertension, ESRD, Etc.) but my understanding is that those were typically the highest COST conditions.
All patients over 65 years of age with the following conditions have been identified as high risk for COVID-19 related morbidity/mortality– HTN, CVD, COPD/Asthma, DM, Chronic Kidney Disease, taking Immunosuppressants. We have previously encouraged our clients to focus on many of these same risk groups and would encourage that teams continue efforts to identify via EMR or other risk query and initiate proactive outreach efforts to maintain continuity via telehealth, CCM or other virtual options to avoid unnecessary exposure during this pandemic. 
From a purely patient care standpoint, I wonder if there are some other less expensive conditions that are at increased risk of landing someone in the ER when they are not closely followed?
All patients over age 65 are at risk of COVID-19 complications. Depression, frailty and isolation pose a significant risk for all elderly during this time. If there is available staff resources and time, we encourage health systems to establish methods to proactively connect with, educate on COVID-19 risk, orient to novel remote treatment options, assess isolation risk and continue offering continuity of care remotely for all 65+ patients until further notice. We additionally encourage you to do a community scan of resources/volunteers available to support those isolated patients in need of food/medication delivery, etc.
Will a telehealth visit count as a F2F to establish Home Health services?
The CARES act provided this language regarding Home Health services and telehealth:
Sec. 3707. Encouraging the Use of Telecommunications Systems for Home Health Services in Medicare. This section would require the Health and Human Services (HHS) to issue clarifying guidance encouraging the use of telecommunications systems, including remote patient monitoring, to furnish home health services consistent with the beneficiary care plan during the COVID-19 emergency period.

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