Considering Treating Medicare Patients Via Telehealth During COVID-19? Here’s What You Need To Know

History has shown that patients need to be treated for all kinds of ailments, and health care providers want to help. The Coronavirus Disease (“COVID-19”) pandemic has thrown a wrench into the traditional provider-patient relationship. As the spread continues to intensify, scores of people are following CDC guidelines to engage in social distancing. Unfortunately, COVID-19 does not distinguish between social events and the doctor’s office. Amidst the panic, many health care providers are exploring available ways to treat patients while respecting the need for social distancing. There is no question that telehealth can provide a solution to this critical challenge. Thankfully, the Federal government is paying attention, and has taken emergency action to expand Medicare coverage for telehealth services. The expansion of Medicare coverage is not limited to treatment related to COVID-19. Rather, it applies to all telehealth services covered under the Medicare program. This article provides an overview of the key items health care providers need to know in order to comply with Medicare guidelines in light of the emergency measures enacted thus far. Notably, compliance with applicable state law is also required.

Unfortunately, telehealth does not lend itself to every kind of health care service and every patient. Additional considerations include compliance with the applicable standard of care, appropriate medical record documentation and other issues. The determination of whether telehealth is a feasible option for treatment will need to be made by the health care provider. Those determinations must be made on a case-by-case basis. For specific questions regarding the implementation of a telehealth platform in your health care business during the COVID-19 pandemic, please contact the Johnson Pope Health Care Team.

TYPES OF VIRTUAL SERVICES.

Traditionally, subject to the location limitations below, Medicare covers three types of virtual visits: (1) Virtual check-ins; (2) E-visits; and (3) Telehealth visits. Virtual check-ins are brief (five to ten minutes), patient-initiated communications with a health care provider. These communications can occur through various technology modalities, including telephone discussions, captured video or images, and the exchange of video and audio information in real time (known as synchronous communication). E-visits are similar to virtual check-ins but are conducted online through a patient portal. E-visits can last for up to a seven-day period. Unlike virtual check-ins and e-visits, telehealth visits are treated the same as traditional, in-person visits. For example, telehealth services are reimbursed in the same manner as in-person services.

LOCATION.

Prior to the emergency measures enacted by the government, Medicare coverage of telehealth services was limited to patients located in rural areas at an approved medical facility. Telehealth could not be rendered to patients located in their homes.

In response to the COVID-19 pandemic, the new emergency measures waive each of these requirements. For the duration of the period of time that President Trump has declared a state of emergency, virtual check-ins, e-visits, and telehealth services can be provided anywhere in the United States. In addition, during this period, the services need not be rendered only in an approved medical facility. Thus, telehealth services can be rendered to patients in their homes.

QUALIFIED PRACTITIONERS.

The emergency measures have not changed the requirement that telehealth services be rendered by a qualified provider. Qualified providers include, but are not limited to, physicians, podiatrists, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dieticians, and nutrition professionals.

INITIAL VISITS.

As a general matter, health care providers cannot conduct initial patient visits via telehealth. During the state of emergency,  services can be furnished via telehealth by (i) a provider who treated the patient at any time within the three (3) year period prior to the telehealth visit (the “Initial Provider”), or (ii) any individual who is part of the Initial Provider’s group practice (e.g. same tax ID). However, the Department of Health and Human Services (“DHHS”) has most recently advised it will not enforce the existing physician-patient relationship requirement as it relates to the rendition of telehealth services. This enforcement waiver applies only to telehealth services and does not apply to virtual check-ins and e-visits.  

TECHNOLOGY.

Telehealth visits must be conducted through real-time audio and video communication. In general, such communications must comply with the HIPAA Security Rule. However, the Office of Civil Rights, the office tasked with enforcing HIPAA, issued guidance advising it will waive penalties associated with the use of everyday technology modalities used in connection with telehealth services rendered in good faith during the COVID-19 pandemic. For example, a healthcare provider, in his or her professional judgment acting in good faith, could render telehealth services through a video chat option available on a patient’s telephone or computer desktop (i.e., Skype, FaceTime, Facebook Messenger Video Chat, etc.). Patients should be advised of the privacy risks associated with the use of these technologies. Public forums, including modalities such as Facebook Live and TikTok, are not permitted.

Health care providers are encouraged to use HIPAA compliant technologies and enable available encryption and privacy modes. Technology vendors that certify HIPAA compliance include Skype for Business, Updox, Zoom for Healthcare, VSee, Doxy.me, Google G Suites Hangout Meet.

HOW TO BILL.

Virtual Check-Ins

A health care provider cannot bill for a virtual check-in that relates either to a patient visit that has taken place within the prior week, or that resulted in a follow-up visit within 24 hours of the check-in. The exact code used to bill for virtual visits varies depending upon the technology utilized. Check-ins rendered via telephonic communications are billed under the HCPCS Code G2012. Check-ins rendered via captured videos or images are billed under the HCPCS Code G2010.

E-Visits

E-visits are billed based on the cumulative amount of time spent by the practitioner over a seven-day period. Practitioners permitted to bill Medicare independently for evaluation and management visits (i.e., physicians and nurse practitioners) (“Independent Practitioners”) may bill for e-visits under the codes listed below. Practitioners who cannot bill Medicare independently for evaluation and management visits (i.e., physical therapists and clinical psychologists) (“Non-Independent Practitioners”) must bill for e-visits under separate codes.

Telehealth

Generally, a service provided via telehealth is billed in the same manner as an in-person visit. The place of service code applicable to telehealth services is 02. A full list of services covered through telehealth and corresponding codes is available on CMS.gov. If services are rendered at approved, originating sites, the facility may bill for originating site facility fees. Facility fees cannot be billed for services rendered to a patient located in his or her home. 

COMPLIANCE WITH STATE LAW.

As noted above, this article focuses on changes to Medicare guidelines enacted in response to the COVID-19 pandemic. It is important to note that treatment of patients via telehealth requires compliance with federal law and state law, including Florida’s recently enacted telehealth law. These state-specific obligations include restrictions on the prescription of controlled substances via telehealth, the modalities of technology required for the provision of care via telehealth, and the documentation of patient care rendered via telehealth. Even during these trying times, it is essential that providers comply with both sets of laws.

Additional issues related to provision telehealth, such as the requirement to obtain appropriate patient consent and providing services within the applicable standard of care, are not addressed in this article. The Johnson Pope Health Care Team is happy to assist you with any questions you may have.