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With the outbreak of novel coronavirus 2019 (COVID-19), many outpatient clinics and facilities find themselves needing support for telehealth visits.

Clinical decision making will determine who is high-risk and needs to avoid exposure, and which at-risk patients need evaluation. Phone calls and patient portal messaging will continue to increase as the pandemic endures.

Important Notes

Liability

Be sure your malpractice insurer allows for remote visits in these capacities. To date, there have been very few malpractice cases in telehealth (most in teleradiology). There is no clear guidance regarding care provision during a pandemic.

Locale

Practicing close to state lines can mean licensing in multiple states. During a telehealth encounter, the service is considered to take place at the physical location of the patient (as opposed to the provider). This requires providers to comply with the laws and regulations associated with the appropriate professional licensing board in the patient's state. In the setting of a pandemic, your legal department may offer alternative guidance.

Documentation

Documentation requirements for a telehealth service are the same as for a face-to-face encounter. The information of the visit, the history, review of systems, consultative notes or any information used to make a medical decision about the patient should be documented. Documentation should include a statement that the service was provided through telehealth.

Identify Appropriate Patients

Follow your local, state or hospital guidelines to ensure identifying appropriate patients. Remember, who you see or talk with remotely is in your control. If someone is too ill, breathless while speaking or unstable, direct them to a face-to-face or urgent/emergent visit. If you are finding it difficult to assess a patient without being physically present, direct them to an in-office face-to-face visit.

Telephone

Many of us call our patients regularly and a visit this way is no different. Your existing scheduling system can be used to list virtual or phone visits.

We strongly recommend creating an encounter and documenting the visit. Use standard templates or a narrative note and bill by time. Again, document as you would during an inperson visit. You also can e-prescribe and place orders, although diagnostics will require an inperson visit. Education and counseling can be provided through these visits.

Masking your phone may be necessary to block your personal phone number.

Here are the steps:

• Dial *67 prior to placing the call or use a dialer to help.
• Consider using free software like Doximity Dialer. You can download the Doximity App for your phone (Apple Store or Google Play) and set this up to dial as if you are calling from your institution's main number.
• Use a hospital phone line if you are at your institution.

Telephone Visit Billing

Telephone services without face-to-face discussion is infrequently reimbursed at a significant level. These codes are not billable if the call results in the patient coming in for a face-to-face service within the next 24 hours (or next available urgent visit).

Note that these telephone billing codes are not covered by Medicare.

• 99441 - 5-10 minutes
• 99442 - 11-20 minutes
• 99443 - 21-30 minutes

These calls are also not billable if they refer to an E/M service performed within the last seven days. The documentation may aid your institution in capturing the work done during the pandemic. It is important to note that coverage and payment vary across payers, thus coverage of these services is not consistent.

Video Conferencing

Many of us routinely video conference for meetings, administrative events, education, and more. Does this mean you should Skype or Facetime with your patient? Not exactly. Until your hospital has a fully integrated solution, consider HIPAA-compliant video conferencing services, such as Zoom.

Ask for a list of HIPAA-compliant conferencing systems already contracted with the institution. These will be essential for meetings as well as potentially patient care. Alternatively, your institution may already have telemedicine services established in your own or another department. Neurology, psychiatry and behavioral health, pediatrics, and dermatology are robust users of telemedicine at many institutions and a good place to look to see if you have a contracted telehealth provider. If there is an existing system, onboarding new providers can be expedited in several ways.

• Instead of waiting for Epic integration, if there is a separate application launch (a few systems with this capability are Amwell, Vidyo, Intouch, among others) may be a lighter lift for your telemedicine technology support team.
• If the telemedicine program needs to train your staff and providers, send a provider and staff member for a "train the trainer session" and take that workload off the central telemedicine group. This will likely significantly shorten your "wait time" for onboarding.
• Some electronic health record (EHR)-based video solutions require patients to be active on the patient portal. Start actively and routinely enrolling patients now on your portal platform as it also will be useful in the setting of social distancing and decreasing phone call volume.
• Lastly, consider foregoing patient test calls if you have a robust system that can report these in other ways.

Whether using a makeshift (HIPAA compliant) video tool or a formal telemedicine platform, once set up, the interaction is easy.

• A scheduled visit in your EHR will tell you and the patient the time at which to launch your application. Most applications are quite user friendly and open a Video Window in one click.
• Remember to unmute yourself, raise the volume, and allow video connection. Remind your patient of the same.
• Don't be frustrated with connectivity issues, patients are fine with talking on the phone as you look at each other if the volume doesn't work.

Tips for the Actual Video Visit

• Choosing patients for this technology is less of an issue at this time. If you think you can forego a physical exam, give it a try. You will eventually find your favorite use cases.
• Lead the visit as if the patient is in the room, except with a limited physical exam. The patient can show their scar or push on their skin to demonstrate edema, for example, and your clinical skills will tell you if they look too ill.
• Eventually you can have patients buy (or you can invoke population health to send them) blood pressure cuffs, weight scales, HR and O2sat monitors where either they share their numbers over the patient portal or during the visit, or you adopt a system which uploads to your EHR.
• For now, take a history, answer questions, review medications, provide guidance and reassurance, and even share your screen to review imaging or offer education.

As with an in-person or phone visit, you can have your EHR up and running to document the visit and you can e-prescribe (avoid controlled substance prescription over televisits without speaking with your legal team), and place orders. Diagnostics will need to be in person.

Telemedicine Virtual Video Visit Billing

The CPT codes for virtual video visit billing are 99201-99215; 0 indicates a new patient and 1 indicates an existing patient. (E/M visit codes should not yet be used for telehealth services with traditional FFS Medicare patients pending additional instructions from CMS.) We recommend limiting televisits to established patients.

A complete list of codes that can be used for telemedicine visits can be found in CPT 2020 and are designated with the ★ symbol. Please note that American Medical Association CPT rules may differ from CMS guidelines. It is important to know which guidelines your commercial carrier is following.

The documentation for these encounters mirror in-person requirements (except the exam). For example, the code 99213 requires either:

• Expanded problem-focused history and low complexity medical decision-making, or
• 15 minutes spent face-to-face with the patient if coding based on time

In addition, a telehealth modifier is needed. The specific one may vary based on the service provider:

• GT Modifier: Used to indicate a service rendered via synchronous telemedicine
• GQ Modifier: Used to report services delivered via asynchronous telecommunications system
• Modifier 95: Used when billing to some private payers
• Place of Service 02: Defined as "the location where health services and health-related services are provided or received, through a telecommunication system."

Look for additional information to come about wearables/remote monitoring/sensors, detailed reimbursement, legal pearls, pitfalls when scaling, and more.

Telemedicine Resources

The following information is from the CMS Medicare Telemedicine Healthcare Provider Fact Sheet which describes the types of virtual services for Medicare Beneficiaries. Refer to CMS for a complete list of telehealth services payable under the Medicare Physician Fee Schedule.

Medicare Telehealth Visits

This type of visit is defined as "a visit with a provider that uses telecommunication systems between a provider and a patient."
The HCPCS/CPT codes for common telehealth services include:

• 99201-99215 (Office or other outpatient visits)
• G0425-G0427 (Telehealth consultations, emergency department or initial patient)
• G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or skilled nursing facilities)

These visits are designated for new* or established patients. (*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.)

Virtual Check-in

This type of visit is defined as "a brief (5-10 minutes) check in with your practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient."

The HCPCS/CPT codes for this type of visit include:

• HCPCS code G2012
• HCPCS code G2010

These codes are used with established patients.

E-visits

This type of visit is definied as "a communication between a patient and their provider through an online patient portal."

The HCPCS/CPT codes for this type of visit include:

• 99421
• 99422
• 99423
• G2061
• G2062
• G2063

These codes are used with established patients.