COVID-19: The Telehealth Imperative · COVID-19 Map NSR-012-20200325-APP | | Proprietary &...

COVID-19: The Telehealth ImperativeDr. Anna Loengard

March 26, 2020

• Virtual care in COVID-19 Strategy

• Telehealth Emergency Provisions

• Preparation & Workflow Considerations

• Billing & Documentation

• Connecting Telehealth Across Providers

• Discussion

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Agenda

COVID-19 Map


COVID-19 Preparedness

• Immediate preparedness response• Triage, Test and Treat• Possibly limited testing • Quarantine at home

• Transitioning practice to telehealth and virtual care options• Patient/provider protection• Preserve practice revenue

• “Second Tsunami” preparedness• Chronic disease• Social isolation


Telehealth: Imperative for the Future


84%

16%

Has telehealth been prioritized as a health system initiative?

YES

NO

Telehealth: Imperative for the Future


82

612

0

10

20

30

40

50

60

70

80

90

Slower Busier About the Same

Comparative Primary Care Clinic Activity

Telehealth Changes During National Public Health Emergency

Residential restrictions for access removed1

Originating sites expanded to include patient home

Medicare services approved for telehealth delivery are unchanged

New patients can access telehealth services


HIPAA compliance is not enforced

Providers may practice across state lines2

Providers may waive patient cost sharing

Provider home may be a qualifying distant site3

1 Changes for Original Medicare only2 Subject to state laws and regulations3 FFS only

CARES Act: Third Coronavirus Stimulus Package

• Currently passed Senate, in the House

• CARES Act Provisions for RHC/FQHC

• Can be Distant Site

• Will be reimbursed based on composite FFS rate


Important Updates

• OIG clarified that provider ability to waive cost sharing for telehealth during National Public Health Emergency is intended to be used across multiple services to assist providers in caring for patients outside of hospital and clinic settings (3/24/20)• Telehealth• Digital E/M• Virtual Check-In and Remote (Virtual) Monitoring• Care Management: CCM, PCM, TCM• Remote Patient Monitoring

• Families First Coronavirus Response Act: COVID-19 testing and physician visits or hospital observation related to testing not subject to deductible/co-pay


https://www.oig.hhs.gov/fraud/docs/alertsandbulletins/2020/telehealth-waiver-faq-2020.pdf

http://*https:/www.congress.gov/116/bills/hr6201/BILLS-116hr6201enr.pdf

Medicare Telemedicine 101

Service Synchronous Audio & Video Duration of Service Billed as Unique Service

Telehealth Visit ✓ ✓ Typical Office Visit, ~10-15 min

NoUse E/M or preventive care code & place of

service 02

Digital E/M Portal or secure message

5 to 21+ minutes,cumulative over 7 days

YesUse codes 99421-99423

Virtual Check-In ✓ Audio required, image/video optional ~5 min

YesG2012 or

G0071 in RHC/FQHC

Remote Evaluation Image or video required ~5 min

YesG2010 or

G0071 in RHC/FQHC

E-Consult Most require audio for consultative discussion 5 to 30+ minutes

Yes99446-9944999451, 99452


Medicare Telehealth 101

Traditional VisitBilling Codes99201- 9920599212- 99215

Telehealth Visit 1

Billing Codes(distant site)99201- 9920599212- 99215

Place of Service 02 2


Provider at Distant Site

Patient at Originating Site

1 Not all traditional face-to-face services can be performed via telehealth2 In limited circumstance, a modifier may apply

Where to begin:• What video platform to use?• Do we start with smart phones as we

implement something more permanent?• Is EHR integration possible?

• Payor mix and commercial coverage of telehealth• What percent of visits get transitioned?• What will new schedules look like?

• Do we need to check malpractice coverage, compliance and credentialing considerations?

• What group will redesign workflows?


Decision Point

Telehealth Platform Options

HIPAA Compliant

Sign-up Fee Monthly Fee Mobile

App More Information

Doxy.me ✓ Free $35 per provider$50 for 1 Clinic/provider https://doxy.me

Facetime Free Free ✓ https://support.apple.com/en-us/HT204380

Sitka Virtual Visits ✓ Waived $15 per provider(First 3 months free) https://www.trustsitka.com/telehealth

Skype Free Free ✓ www.skype.com

Vidyo ✓ $65 per account https://www.vidyo.com

WhatsApp Free Free ✓ www.whatsapp.com

WebEx ✓ $26.95 per account ✓ www.webex.com

ZOOM ✓ $200 $200 per account ✓ https://zoom.us


https://doxy.me/

https://support.apple.com/en-us/HT204380

https://www.trustsitka.com/telehealth

http://www.skype.com/

https://www.vidyo.com/

http://www.whatsapp.com/

http://www.webex.com/

https://zoom.us/

Preparing Workflows and Staff: Scheduling Patients

• Prioritization of patients scheduled for telehealth visits• Incoming calls• Existing appointments• Referral to centralized fever/respiratory clinics

• Proactive outreach to high-risk and rising risk cohorts• One or multiple risk factors for COVID-19

• EHR query• Population health software solution

• Staff education and protocols


Preparing Workflows and Staff: Providers & Patients

• Provider considerations• Time & coordination of providers• Technology setup• Physical space

• Confirmation that providers can work from home (FFS)

• Patient considerations• Patient preparation- what to expect• Access- technology and internet

• Who will confirm technology access with patient?• How will you check patients in/out for each visit?


Established Patient Documentation


New Patient Documentation


Performing a Telehealth Examination

18

Constitutional• Vital signs • General appearance• Pain

Eyes• Appearance of conjunctiva, lids,

pupils• Patient-reported vision

Ears, Nose, Mouth, Throat• External appearance of anatomy• Assessment of hearing• Inspection of lips, mouth, teeth, gums• Gross inspection of throat• Appearance & movement of face• Sinus or ear pain on palpation

Neck• External appearance of neck• Gross movement

Respiratory• Assessment of respiratory effort• Audible wheezing• Presence and nature of cough

Cardiovascular• Presence and nature of edema• Capillary refill• Patient report of temperature of

extremities

Gastrointestinal• Gross anatomy of abdomen• Presence and nature of tenderness

Musculoskeletal• Examination of gait• Inspection of digits and nails• Exam of extremities

Skin• Rashes, lesions, ulcers• Cracking, fissures• Mottling, petechiae• Cyanosis• Diaphoresis

Neurologic• Cranial nerve assessment• Numbness, tingling, pain• Examination of sensation Psychiatric

• Orientation• Memory• Mood and affect• Speech• Judgment and reasoning

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Preparing Workflows and Staff: Coding & HIM• Diagnosis reconciliation and HCC capture• Documentation requirements for level of service

• Existing patients• New patients

• New codes & Medicare billing• ICD-10

• Possible exposure to biological agent- Z03.818 • Actual exposure to biological agent- - Z20.828• 2019-nCoV acute respiratory disease – U07.1 (effective April 1, 2020)

• CPT- 87635 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) amplified probe technique)

• HCPCS• U0002 – Lab testing for SARS-CoV-2/2019-nCoV (COVID-19) using non-CDC tests• U0001 – Lab testing for RT-PCR Diagnostic Test Panel- CDC Protocol with CDC test


https://www.cdc.gov/coronavirus/2019-ncov/lab/rt-pcr-detection-instructions.html

Telehealth AWV Guidance

• Preventive care via telehealth: Annual Wellness Visit, Advance Care Planning, Annual Depression Screen

• AWV Workflow Modification Recommendations• Nurse-led visit

• HRA & screenings• Medication reconciliation• Diagnosis reconciliation

• Provider close visit• Review Personalized Prevention Plan• Fulfills face-to-face requirement for telehealth

• Dual visit is possible


Telehealth Across Your Community

• How is telehealth being utilized across your partners?• Specialists• ED• SNF• Tertiary care center• Home health• Hospice


Barriers and Solutions


Common Barriers Potential Solutions

Patients lost to follow up Outreach with services provided at home

Commercial alignment Confirm coverage with common payers

Patient perceives care as cost-prohibitive

Providers may waive co-insurance for telehealth and telephonic solutions

noted

Patient lacks Internet/smartphone access Telephonic solutions (CCM, PCM,

Virtual Check-In)

DiscussionVisit https://caravanhealth.com/covid-19/ for resources.

Questions or suggestions on future webinars or resources?

Email us at: [email protected]


https://caravanhealth.com/covid-19/

Join Us Next Week


COVID-19: Rapidly Reengineering Primary CareThursday, April 2 | 9am PT | 12 pm ET

Next week’s webinar with Dr. John Findley, ACO Medical Director, will discuss team-based primary care workflows that optimize care delivery as we rapidly shift to virtual care. Learn how to leverage your staff in new ways to generate revenue and prevent a second tsunami of chronic disease.

Register online at https://caravanhealth.com/covid-19/.

https://caravanhealth.com/covid-19/

Thank Youwww.caravanhealth.com | [email protected] | 916.542.4582

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