April 24, 2020

An Expert Answers Your Questions on Telehealth During the COVID-19 Pandemic

On April 7, 2020, APSHO held a webinar titled “Establishing Telemedicine During the COVID-19 Pandemic: Expert Advice for Oncology Advanced Practitioners.” Several insightful questions were posed by attendees, so we’ve made this video answering your frequently asked questions on telehealth.

Wendy Vogel, MSN, FNP, AOCNP^®, Executive Director of APSHO,moderated the webinar. Jason Astrin, PA-C, MBA, DFAAPA, Director, Advanced Practice Provider Services at The US Oncology Network was our expert guest.

Charges

Jason, could you first speak about facility fees? Can you assign a facility fee to a virtual check-in?

That is a good question, and yes, you can. The place of service that gets added to the charge for that particular visit will dictate if there’s a facility fee attached or not. For example, if you’re assigning a place of service of 21, which is a hospital outpatient facility, or 22 hospital inpatient, there will be a facility fee that’s added to the reimbursement from the CMS fee schedule.

The good news is it’s all tied to place of service. As long as you’re appending or adding the correct place of service to where the visit would have occurred if you were seeing a patient live, then the facility fees will be added automatically.

Can you charge for longer than 30 minutes for a telephone visit?

Unfortunately, no. There are three levels of a telephone visit and the 99443 which is the highest level is a 21-to-30 minute call. There is no guidance that you can add to that as a separate code or an add-on code. So 30 minutes is your maximum.

One of our listeners states that she saw a patient for a visit, and the patient didn’t want to do FaceTime. She only wanted to talk via telephone. The listener charged for a virtual check-in, which she wasn’t sure was right. Should she have charged for a telemedicine visit even without video?

One of the requirements to charge or bill for a telemedicine service is that you must have a real-time two-way audio and video interaction. So if the video is missing based on a technology issue or, in this case, a patient who maybe didn’t want to get on video, you cannot use any of the telemedicine codes. (The telemedicine codes are the same codes you would have been charging if you would have seen the patient live, so your traditional E&M visits.)

In this example, I probably would have used the telephone visit codes which are the 99441 and 99443 instead of the virtual check-in codes.

Virtual check-ins are very brief several minute-long interactions with a patient, and they have low reimbursement as well. So in this example, I would have chosen the telephone code.

We had several questions about billing incident-to. If an AP can bill incident-to when doing telemed visits, is that possible for an established patient as long as the traditional incident-to guidelines are met?

There is no clear answer. Medicare has not given any guidance with their recent updates and waivers on how to manage incident-to; however, we can interpret what the guidance looks like.

Now that we’re supposed to be adding the place of service of where that visit would have been if you were seeing the patient live (so in the office setting you would be place of service 11) and CMS has lessened the physician supervision requirements and is allowing physician supervision of anything that would be done in the office now can be done virtual that in the past required onsite, it is worth telling our practices that if the APP is seeing an established patient, particularly if the APP is in the office, but even if they are at home because again we’re still applying the same place of service, which is 11 (and don’t forget there’s a modifier that tells Medicare that it was a telehealth service, modifier 95), as long as the place of service 11 is appended or added to the charge, and all the other requirements were met, as you said, then I see no reason why it couldn’t be billed incident-to.

Jason, are you able to bill a 99402 and a 99401 and get reimbursed? I believe these are counseling codes.

These are preventive medicine individual counseling codes and there’s actually four of them. So it goes to 99404 as well.

The answer is no. Medicare did release the list of codes that they included in their regulations and rules on what would be allowed to be reimbursed via telemedicine and particularly during this crisis as well. And these codes are not on it. The good news is that you can, if you’re seeing a patient or a counseling visit and where time was the factor in the length and intensity of the visit, you could still just bill a traditional E&M visit so 99214, 99215.

If you’re working from home, what would be the appropriate codes for billing while doing telemedicine from home. And along with that, if the provider is working from home, does the claim need to reflect the provider’s home address?

When you’re providing telemedicine services from home, whether it’s a patient who you would have seen in the clinic or one you may have seen in the hospital, you would use the same code as if the service was provided live. For example, if you would have billed a 99214 for seeing a patient in follow-up in the clinic and you’re providing a telemedicine service while you’re at home and the patient’s at their home, you would still use the same 99214. The modifier 95 gets appended to that which tells the payer that was actually a telemedicine service, but the place of service would stay 11.

You don’t need to add your home address to the claim while you are providing services from your home, because again, you’re using the same place of service that’s on file with Medicare. If you’re a Medicare provider and you have a work address, place of service 11 is going to be tied to that.

Is the charge still determined like a regular clinic visit based on time and decision-making?

Yes, Medicare gave guidance at the end of March to update this and it actually ties in with probably what will happen as we go forward. Medicare and CMS were working on a “Patients Over Paperwork” initiative last year and it adds a few things that will lessen our burden when we’re seeing patients, particularly in the office.

In the past, to determine the level of severity or level of intensity of an office visit, you had to look at three parts of your encounter with the patient: first, you had to look at past history and ROS.

Then you had to look at the physical examination. Remember, when you’ve ever done chart reviews for coding purposes, you had to check how many systems did you examine, how many systems did you talk about.

And then you had the medical decision-making portion, how intense was the medical decision-making. Starting with visits from March 1, 2020, on, and I think what we’ll see is even after COVID-19, this is likely how CMS will approach this, as only the medical decision-making and/or the time involved in that visit will be used to determine the level of care or level of service that you bill.

You would still document the history and physical, as you’d still need to provide medicolegal documentation of your encounter with the patient. But from a “Which level of care do I select?” or “Which office visit do I select?” standpoint, all you need is the medical decision-making and/or the time, and, remember, this is only for outpatient, as the hospital work hasn’t been affected by this. But in your clinic, this is an option.

The time, by the way, is not just the time that you spent talking to the patient on the telemedicine visit, but you would add the time that you took to prep for that visit (maybe you had to discuss with an attending, or maybe you had to review records). You keep track of all that time and you would document in the telemedicine note that based on time I spent, maybe 60, 70, 80 minutes in prepping and evaluating and managing patients.

The physical exam is very hard to do virtually, you can add a constitutional assessment, such as the patient doesn’t look toxic, if the patient’s going to show you a rash or their wound, clearly there’s opportunity there. But from a level of service, you determine the level based on the medical decision-making or time.

I imagine we’ll see that stick even post COVID, so it will be very helpful for us going forward.

A participant was using a video platform for the telemedicine visit. But the video was lost or unusable after a few minutes. Is it acceptable then to call the patient on the phone and then add the total time for both the video and the phone call?

No. You can only bill one type of service per encounter and that could happen when patients are on Skype or FaceTime and they just lose the connection. I think that if you get the majority of the visit done on video, and at the last several minutes, possibly you lose video, that I would still bill that as a regular telehealth visit.

But if you log in to a patient on Skype or FaceTime, or any other platform and the video drops off very early, and you’re performing most of the visit on audio, then you’ll have to use the telephone codes.

Reimbursement

Let’s switch gears a little bit to reimbursement. Is reimbursement the same for a 30-minute telemed visit as it is for a face-to-face 30-minute office visit?

Yes, as long as that telemedicine visit is the true two-way live audio and video, so in that case, remember, you would use the same exact codes that you would use if you’re seeing them in the clinic or the hospital, and that would mean the same reimbursement.

There are other types of visits, such as telephone visits and e-visits, and they have lower reimbursement. But as far as just traditional 30-minute encounters, whether it’s a 30-minute face-to-face or 30-minute telemedicine visit with audio and video, it’s the same reimbursement.

If, during a telemedicine visit the patient is determined to need emergent services or has to be seen in the clinic, does that affect reimbursement for the telemedicine visit?

Not for telemedicine visits, because again, think of a telemedicine visit just like our traditional office visits. You can clearly see a patient in the office and discover something that’s going to need a quick follow-up, maybe you see them the next day, for example. You can certainly bill those separately.

If, however, you’re performing a virtual check-in or an e-visit, and during that visit you determine that the patient needs to be seen within 24 hours of performing that virtual check-in, or e-visit, then you can’t bill separately for those, and they would get bundled into the E&M visit.

Do you have to waive the copay?

No, you don’t have to. Medicare gave guidance back in early March that practices have the right to waive the copay or any other out-of-pocket cost sharing that particularly original Medicare, like Part A Medicare patients, would have. And so it’s up to the practice to decide to do that.

What do you say to a patient who asks how much the telemedicine visit is going to cost?

We tell them it’s exactly what if would be if we saw you in the clinic. Of course, unless you choose to waive any patient out-of-pocket costs.

Can you tell us how much commercial payers are reimbursing?

That’s going to be on a case-by-case basis by payer and even that can be somewhat regional, so that would be a question you’d want to go to your individual office and your office manager to determine.

However, most of the private commercial payers are following CMS guidelines and are following similar rules.

Setting Up Telemedicine

There were several questions about having a checklist and implementing telemedicine quickly in a practice.

In my networks, it’s a little unusual because we have the large scale. We have telemedicine deployment teams that are able to go into a practice. We’re putting our practices on VSee, which is one of the HIPAA compliant telemedicine platforms that we were using even pre-COVID.

There is a big group that is onsite and can very easily help with deployment and training and things. But, if we don’t have that kind of scope at a particular practice, then I think practically, the answer would be to first pick a platform. We talked in the webinar about a handful of HIPAA-compliant pre-COVID acceptable platforms. Remember, however, during this crisis, any patient-facing, non-public, two-way video and audio platform can work. You can use Zoom, GoToMeeting, FaceTime, or Skype, for example.

First, pick a platform, get comfortable using it, get the patients comfortable using it, and then figure out how you are going to schedule patients. How will you know if you’re at home as a provider that you have telemedicine patients to see or if you’re in the clinic and you have kind of a mix of a handful of patients that you have to see and you have some telemedicine visits. There needs to be a process for that so that you know that you have patients on schedule via telemedicine, and then get those patients comfortable using that platform as well.

Then, have that relationship with your billing office so they can give you any guidance they might want as far as what you need to put in your note to let them know it was telemedicine.

Some of our practices use a scheduling platform. If the patient is in a particular visit that’s identified as telemedicine, then the coders in the back office pick that up. Some of the practices are just making sure they attach modifier 95 to the charge. Plus, you should always have information in your note that it was a telemedicine visit; just don’t forget all of these visits require documented consent.

Are there certain video platforms that allow providers to share scans with the patient?

VSee is one of them. And there are those HIPAA-compliant platforms that again we were using pre-COVID. They were developed for telemedicine services, so they have a lot of capability that you certainly won’t get on Skype or FaceTime.

If you’re using platforms such as Skype or FaceTime or Zoom, you could email something to them or share your screen.

Scheduling

Let’s talk about scheduling a little bit. Are there any requirements regarding the advance scheduling of telemedicine visits? Can it be same-day scheduling, or can it be sooner?

There are no requirements. You would schedule a telemedicine visit just like you would your traditional office visits. So, there’ll be some that are scheduled and you’ll have patients that are on a follow-up schedule and they need to be seen. And we know that there’ll be urgent care and symptom management patients that you’ll want to see maybe the same day via telemedicine. There’s no guidance there; however you normally schedule your patients will work.

Does a virtual check-in have to be scheduled?

It doesn’t have to be. Virtual check-ins were something that CMS created last year and they just didn’t get a lot of traction. But virtual check-ins are supposed to be patient-initiated, meaning that you wouldn’t schedule it, as the patient would be reaching out to inquire if they need to be seen or to review a new symptom.

Because of the way that we’re using them during this crisis, it’s okay to schedule them. So if you have patients that you’re thinking, I just want to do a quick check-in, then certainly you can feel free to schedule it because I think if you’re working from home as a provider, you lose some of that connection with what’s going on in the clinic. So you’ll want things on the schedule so that you’re clear on who needs to be seen and why.

Does the virtual check-in have to be done by a provider?

No, nurses can provide virtual check-in services; however, these are not billable. When virtual check-ins are performed by other qualified health professionals (such as social workers, physical therapists, etc.), these can be billed.

Management of Patients

Let’s talk about telemedicine and clinical trials. How are you managing patients on clinical trials during this time?

A lot of it’s going to be up to the sponsor. There are many centers delaying research since it’s too hard to get patients into clinic, they’re not able to follow the protocol on follow-ups, scans, imaging, labs, and things like that, so they’ve decided not to continue with any research.

A lot of our practices are still providing research, and they’re doing a lot of visits virtually. We’re making sure we’re reporting any deviations from the protocol and aligning with the study sponsor.

But a lot of it’s up to the sponsor and how they want to manage the trial. We think that it’s important that our patients continue on trials and so we’re trying to ensure minimal disruption.

This was an interesting question. Do you have any recommendations for convincing attending oncologists who are resistant to adapting to telemedicine?

I think the low-hanging fruit is that, if I were an oncologist and a leader within my practice for example, I would want to keep myself, my staff, and my patients safe, and yet at the same time, you can’t stop managing cancer. Providing telemedicine is a very easy way to still be in contact with your patients, manage your patients, but keep them out of the office and keep your staff safe as well.

Otherwise, from just a financial perspective, if you’re limiting your access to the clinic then you’re surely not going to be able to see the numbers of patients that you would have, and the fact that you can bill as we’ve been talking about for telemedicine services at the same level, it makes sense to keep your clinic full. Telemedicine would be an easy way to achieve that.

Are you having patients do telemedicine visits before getting their infusions in the chemo room? And are you doing fewer infusions right now?

For patients on protocol or if they’re in the middle of a regimen, then we try to maintain that schedule because it’s important that we treat them. We want to keep that going.

There are instances where our patients are coming in, let’s say, for bloodwork prior to an infusion, and they’re coming into the clinic at a specified time when the clinic is mostly empty and so we can funnel patients into a lab. Everybody’s wearing PPE and then we can get patients out quickly. If they need an infusion, then they move to another location in the clinic where they’re separated. If they need to go home first prior to the infusion to review labs or get a follow-up or a pre-chemo check, then that can be done via telemedicine.

Some clinics are still deciding just for patient convenience, if they’re already there, again segregated in another location of the office, to see that patient while wearing masks and gloves and the usual social distancing between other patients, and then get them into the infusion room.

So we’re trying to maintain kind of business as usual. But if we have an opportunity to see a patient virtually, we take advantage of that.

Why did your group start telemedicine early, prior to COVID? Most of us are doing this in the emergent setting. How is this improving your practice?

We were starting to focus on supportive care via telemedicine and genetics via telemedicine. In our practices, we have two models on how genetic services are provided to our patients. It’s typically APP-led. The APPs are involved in providing genetic counseling and are supported by genetic counselors. And we have some practices that have genetic counselors that provide this service, but they’re limited by geography. And so we’ve been developing telegenetic opportunities within our practices and sometimes between practices.

We think that providing some of the supportive care and symptom management via telemedicine was something that was coming up, and then this COVID-19 pandemic hit, and we had to really jump into the pool.

Future of Telemedicine

Do you see telemedicine as a channel for new opportunities for APs?

Oh, definitely. Certainly in our network. As we’re settling down and hopefully returning to normal soon, we’re going to start thinking about all the other opportunities to provide telemedicine beyond genetics for things like educational visits, advance care planning, and survivorship. There’s a number of opportunities. I really like the supportive care and urgent care type of opportunities. Patients are used to urgent care visits via telemedicine through their primary care provider, and so seeing your oncology provider in that same scenario I think makes a lot of sense. We’ll see a lot of opportunity to keep expanding telemedicine.

The good news is that, I think as time goes on, with CMS allowing some bending of the rules and relaxation of the requirements during this pandemic, that they’re seeing the benefit to patients and the value and quality that it’s providing. I would hope that as we get back to a normal state post-COVID, that some of these restrictions remain a little loose so that we can expand those services.

Obviously, you’re getting a sense that telemedicine is here to stay, even in the post-pandemic era.

Definitely. When you see what’s going on in primary care and urgent care, we've been providing it for a while.

And I think particularly, we can say that in our population, our patients are typically older and maybe not as tech savvy. Now, they’re getting used to it. Our patients that normally you would think, I don’t know if they would enjoy seeing me in a video, they’re enjoying it. So I think that they’re going to demand and want that as well.

If there’s any kind of silver lining here, it’s that we’re able to expand on this technology and the service pretty quickly, but we’ll be able to be ramped up so there won’t be any need for practices to go through training and onboarding of a platform for telemedicine for several months. They’ll be pretty good at it.

Jason, thank you so much for being with us today and answering all of our listener questions.

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Read more from the  APSHO Advance: Special COVID-19 Series