Using Telehealth to Care for Patients During the COVID-19 Pandemic

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Telemedicine and virtual care have quickly become important tools in caring for your patients while keeping yourself and your staff safe as the COVID-19 pandemic quickly evolves. Here is what you need to know when providing telehealth services.

How Do I Quickly Implement Telemedicine in My Practice?

Expansion of Telehealth and Licensing Waivers During the COVID-19 Pandemic

Coding for COVID-19

The CDC announced a new diagnosis code for coronavirus or the illness it causes, COVID-19, in the U.S.

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How Do I Get Reimbursed?

The Centers of Medicare & Medicaid Services (CMS) has loosened the regulations for telemedicine in response to the COVID-19 pandemic. Telehealth services may now be delivered to Medicare beneficiaries by phone as long as video capability is available. 

Review the links below for more information and read more on the FPM Journal Getting Paid blog.

Selecting Technology for Use

Providing care virtually doesn’t have to be complicated!

Beginning on March 6, 2020, Medicare — administered by the Centers for Medicare & Medicaid Services (CMS) — will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country. For more information please see the FAQ(edit.cms.gov) and Guidance(www.medicaid.gov). It removes the telehealth stipulation that telehealth can only be provided in rural areas with specific audio-visual equipment.

It's as simple as using your phone, smartphone or laptop with a shared link to enable video, or other electronic devices. Free to low-cost telehealth platform options are available. As of the March 17 HHS OCR announcement(www.hhs.gov), effective immediately (and during the COVID-19 National Public Health Emergency) you may use popular apps that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype, to provide telehealth without risk that OCR might impose penalties for noncompliance with HIPAA.

Note: Facebook Live, Twitch, TikTok, and similar video communication apps that are public facing should not be used to provide care virtually.

Examples of Telehealth Platform Vendors

AAFP does not endorse specific products or companies and of course recommend carrying out your own due diligence in investigating, but telehealth platforms we are aware of members using in private practice include:

Doxy.me(doxy.me) – Self-touted to be “a simple, free, and secure telemedicine solution.” The AAFP understanding is Doxy.me has a “freemium” business model, with a free base option and other options available at cost a la carte.

eVisit(evisit.com) – The AAFP has heard member reports eVisit ranges from $50/month to $150/month.

SimpleVisit(simplevisit.com)  – The AAFP has heard SimpleVisit runs approximately $150/month. 

VSee(vsee.com) – The VSee site notes one can “get it free," though the AAFP has heard members report it costing up to $250/month.

Mend (MendFamily)(www.mendfamily.com) – The AAFP has heard of pricing at approximately $250/mo to $500/month, with mention that $500/month includes billable condition-specific questionnaires that can be pushed to patients and info gathered in advance of the visit.
Note: Mend is available only in certain areas; though those are not definitively known to the AAFP and continue to expand.

Spruce Health(www.sprucehealth.com) – Spruce Health is often used by direct primary care (DPC) family medicine practices. Its telehealth capabilities are integrated with Elation Health EHR, though Spruce can be used alongside other EHRs without integration with EHR. The AAFP is not yet aware of pricing info.

Key Questions You Will Want to Answer When Exploring Telehealth Platforms

The AAFP is gathering answers to these questions across vendors:

  • Can I exit my contract at any time (i.e., not locked into a 2-year contract)?
  • Is there a waiting room feature so I can queue my patients up?
  • Is the platform device agnostic (i.e., can physicians/providers and patients use device of their choosing for virtual care)?
  • Is there an out-of-office message noting we’re not available to take your call right now? (i.e., during off hours or overnight)?
  • Does the software has the ability to schedule a visit? Note: This is a more advanced feature; it's not absolutely required to have now, but it's very nice to have
  • Is the platform deployable in days?

Medicare Telehealth Services

  • Are provided using telecommunication technology and include office, hospital visit, or other services that generally occur in person. A list of Medicare telehealth services(www.cms.gov) is available.
  • Should be billed with the Place of Service (POS) code “02.”
  • Are considered the same as in-person visits and paid at the same rate as in-person visits.
  • Can be provided to established Medicare patients via phone if the phone allows for audio-video interaction between the physician and patient.
  • Established patient means a Medicare patient seen either by you (or another physician or provider within the same practice) within the last three years.
  • The Department of Health and Human Services (HHS) has announced that it will not conduct audits(www.cms.gov) to ensure a prior relationship existed for claims submitted during the COVID-19 public health emergency.
  • Can be provided in all settings, including a patient’s home. Originating site restrictions have been waived(www.cms.gov).
  • The HHS Office of Inspector General (OIG) is allowing practices to waive cost-sharing for telehealth visits(www.cms.gov).

Medicare Non-Telehealth Services

Medicare Virtual Check-ins (G2012)  

  • Enable a quick visit with an established patient to determine if an in-person visit is necessary.
  • Are brief (5-10 minutes) conversations with a physician or other clinician, where the communication is not be related to a medical visit within the previous seven days and does not lead to medical visit within the next 24 hours (or soonest appointment available).
  • Can be conducted through multiple communication technology modalities, including
    • Synchronous telephone conversation
    • Exchange of information through video or image
  • Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or use of a patient portal.
  • Are initiated by the patient and patient must provide verbal consent.
  • Are subject to coinsurance and deductible.
  • G2010 can be used when a captured video or image is sent to the physician. The physician must follow-up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment).

Medicare E-Visits (online digital evaluation and management services)

  • Are non-face-to-face patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period and the exchange must be stored permanently.
  • Patients must verbally consent to services.
  • Are subject to coinsurance and deductible.

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

  • 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • 99422: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
  • 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

Clinicians who may not independently bill Medicare for E/M services (i.e., physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can use the following codes:

  • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days, 5-10 minutes
  • G2062: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days, 11-20 minutes
  • G2063: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days, 21 or more minutes

Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans, including generation of prescriptions or ordering of tests, and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication.

Documentation Requirements

Documentation requirements for any form of virtual care (telehealth service or non-telehealth digital online service) are the same as those for documenting in-person care.

  • If a code is time-based, evidence of time must be documented. 
  • If exchanged asynchronously, videos, images and communications must be stored and retained according to state regulation.
  • Real-time (synchronous) videos, such as during a video visit, or video phone call are not required to be stored.

Regulatory Updates

These are the key changes to Medicare telehealth reimbursement made possible through the 1135 Emergency Waiver Authority:

  • Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.
  • These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
  • Starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.
  • While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.
  • The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
  • To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

  • FQHCs and RHCs can serve as the originating site for telehealth services.
  • Geographic and site restrictions for telehealth services provided by an FQHC or RHC still apply.
  • FQHCs and RHCs can bill for Virtual Communication Services.

Virtual Communication Services

*The HHS Office for Civil Rights (OCR) will exercise enforcement discretion(www.hhs.gov) and waive penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care providers that serve patients in good faith through everyday communication technologies, such as FaceTime or Skype, during the COVID-19 public health emergency.

More Payment/Reimbursement Resources

•    Medicare Telemedicine Health Care Provider Fact Sheet(www.cms.gov)
•    Medicare Telehealth Frequently Asked Questions (March 17, 2020)(www.cms.gov)
•    Medicare Telehealth Services Chart(www.cms.gov)
•    Medicare Telehealth Code Visit List(www.cms.gov)
•    Telemedicine Quick Set-up Guide in Response to COVID-19 National Emergency(www.ama-assn.org)
•    Center for Connected Health Policy: Telehealth Coverage Policies in the Time of COVID-19 to Date(www.cchpca.org)
•    Virtual Communication Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Frequently Asked Questions(www.cms.gov)
•    MLN Matters: Communication Technology Based Services and Payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)(www.cms.gov)
•    Medicaid State Plan Fee-for-Service Payments for Services Delivered Via Telehealth(www.medicaid.gov)

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