Certintell

COVID-19 Telehealth Guide: Virtual Check-ins, VCS, e-Visits & RPM

Grant A.
COVID-19

Code Summary Covered in this  COVID-19 (Coronavirus Disease 2019) Special Report:

INTRODUCTION

Over the last month, the Centers for Medicare and Medicaid Services (CMS) has taken action to curb cases of COVID-19. On February 6, CMS released information to help the country’s health care facilities take critical steps in preparation for the outbreak.¹ Since then, it has issued 2 new HCPCS codes, U0001 and U0002, used for billing when testing for COVID-19 in both CDC and non-CDC lab tests. These codes can be used by the Medicare claims processing system starting on April 1, 2020, for dates of service February 4, 2020, and after. CMS has also issued a call to action to ensure that health care providers are following infection control procedures and has released three facts sheets that cover information and care options regarding the outbreak.²

 

On March 6, the President signed H.R.6074, or the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. This bill grants $8.3 billion to address COVID-19 and permits the Secretary of Health and Human Services to waive some telehealth limitations currently in place through Medicare. These limitations define where telehealth services take place and limit patients to certain designated geographic sites if they wish to be reimbursed. Currently, the originating site cannot be a patient’s home, but with H.R.6074, the Secretary can waive that rule and allow the patient’s home to be an originating site regardless of current rural or urban geographic restrictions. With the easing of requirements, community health centers still won’t be able to provide care as a distant site, but if they partner with an organization like Certintell they can add referred clinical staff remotely to their care teams allowing billable telehealth events, all while patients are in the comfort of their own home. MARCH UPDATE: “Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.”⁵ This is significant because many potential carriers of COVID-19 may be self-quarantined, and the spread of the disease can overall be reduced if patients can receive treatment without leaving their homes. APRIL UPDATE: Applicable during the PHE, CMS is waiving the location restrictions of FQHCs and RHCs, allowing the flexibility to expand services locations. Now, services can be furnished in more than one location, including areas outside of the previous location requirements.⁷

 

This is significant because many potential carriers of COVID-19 may be self-quarantined, and the spread of the disease can overall be reduced if patients can receive treatment without leaving their homes.

 

Dr. Anthony Fauci, director of NIH’s National Institute of Allergy and Infectious Diseases, states that preparing a vaccine for COVID-19 for widespread use could take up to a year and a half.³ Even with everything done as quickly as possible, creating a reliable and safe vaccine takes time. Scientists are currently working on tests involving mice, and testing on humans would require more time and thousands of human subjects to ensure that the vaccination is protective and not harmful. MARCH UPDATE: A trial on 45 healthy adults from the ages of 18 to 55 has begun in the U.S. The trial will last for about six weeks, but Dr. Lisa Jackson, one of the leaders of the study with Kaiser Permanente, states that it could still take over a year to be widely administered if proven effective and safe.⁶

 

Currently, elderly individuals affected by COVID-19 have a higher Case Fatality Rate (CFR) than younger patients. Those 70-79 years old have a fatality rate of 8 percent while those older than 80 have a fatality rate of 14.8 percent. The fatality rate decreases as age decreases, with a 3.6 percent fatality rate for those 60-69 years old and 1.3 percent for patients 50-59 years old. Additionally, those with pre-existing conditions such as diabetes, cardiovascular disease, chronic respiratory disease, hypertension and cancer have higher death rates than those without these conditions and have a greater chance of catching COVID-19.⁴ 

 

That said, those over 65 years old, or Medicare-eligible patients, have a higher risk of fatality from COVID-19 than younger patients. With a growing Medicare population, Federally Qualified Health Centers (FQHCs), commonly referred to as Community Health Centers, have many at-risk patients. For FQHCs, $100 million of the funding from H.R.6074 was designated for them. 

MARCH UPDATES:

APRIL UPDATE: New guidance comes from CMS for FQHCs and Rural Health Clinics (RHCs) during the COVID-19 Public Health Emergency (PHE) crisis as covered by the Center for Connected Health Policy (CCHP):

In the guidance, CMS clarified that:

  • For telehealth, the modality to be used is an interactive audio and video telecommunications system. For Virtual Communication Services which are not considered telehealth services, other modalities may be used.
  • FQHCs and RHCs will not receive their PPS or AIR rate. They will receive $92 for a telehealth delivered service. This amount was arrived to based upon a calculation using fee-for-service physician fee schedule (PFS).
  • Any health care practitioner working at an FQHC/RHC may provide a telehealth delivered service as long as it is within their scope.
  • The health care practitioner can be at home when they furnish services via telehealth.

CCHP has created a fact sheet of this guidance, as well as a short video on these new developments.

Furthermore, CMS is waiving the requirement that a nurse practitioner, physician assistant, or certified nurse-midwife must be available to provide care services at least 50 percent of the operating time of a RHC or FQHC. The requirement that a nurse practitioner, physician assistant, certified nurse-midwife, physician, clinical social worker, or clinical psychologist must be available to provide care services the entire time the clinic or center operates has not been waived. This change, valid during the PHE, should provide some extra flexibility with staffing mixes.⁷ To the extent permitted by law, physicians at FQHCs or RHCs do not need to give supervision to nurse practitioners. CMS released an FAQ with some telehealth questions answered, HERE.

MAY UPDATE: Further updates expand where telehealth can be administered and the health professionals that can deliver services:

Read further updates from CMS in their update titled ‘CMS Flexibilities to Fight COVID-19‘ and see CCHP’s Updated Medicare Telehealth Policy Chart.

 

 

PATIENT-INITIATED TELEHEALTH

Telehealth is a prime tool for combatting COVID-19. Using telehealth also reduces wait times in overcrowded hospitals and clinics and keeps patients from traveling when they are not feeling well. But are health centers adequately prepared to use telehealth with the restrictions that are currently in place?

 

In order to use telehealth, many health centers need to have established patients in place that have consented to use telehealth. For example, “virtual check-ins” have been covered by Medicare since 2018, wither services that include ‘Brief Communication Technology-based Service’ and ‘Remote Evaluation of Pre-Recorded Patient Information’ (HCPCS codes G2012 and G2010, respectively). Additionally, in the 2019 Physician Fee Schedule (PFS) CMS finalized that FQHCs can receive payment for “virtual communication services”(VCS) when at least 5 minutes of communication technology-based or remote evaluation services are furnished to a patient.

Through VCS, (HCPCS code G0071) patients may reach out to their FQHC provider for care, but the patients first must consent to this service for it to be delivered. Note that G0071 is based on the average of the national non-facility PFS payment rates for HCPCS code G2012 (communication technology-based services) and HCPCS code G2010 (remote evaluation services).  Learn how CMS defines VCS as a separate and district service from telehealth, here. 

“Claims submitted with G0071 on or after March 1 and for the duration of the PHE will be paid at the new rate of $24.76”⁷

E-Visits (CPT codes 99421-99423) provide another opportunity for health centers to support patient needs through telehealth, specifically, “patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office” according to the 2020 Medicare Physician Fee Schedule. At this time, FQHCs are not able to be reimbursed for the delivery of e-Visits, but there are models of care available for referred clinical staff to support FQHC workforces remotely to supply e-Visits. Reach out to us for more information on these innovative care models.

 

If health centers are worried they haven’t implemented the proper workflows to consent patients, it’s not too late. Health centers can define a plan of action and begin proactively reaching out to patients through email, texts and phone calls to educate them on COVID-19 symptoms while also getting their consent for these services.

 

If health centers are worried they haven’t implemented the proper workflows to consent patients, it’s not too late.

 

 

REMOTE PATIENT MONITORING

Solutions such as Remote Patient Monitoring (RPM) can support efforts and allow patients to receive care from a provider virtually, allowing potential symptoms to be reviewed remotely instead of having to come in contact with other people or staff. Dr. Fauci has made several recommendations on how to avoid being infected by COVID-19, with many of them having the ability to be supported through RPM solutions. An example is CPT code 99457: “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver,” with CPT code 99458 available for an additional 20 minutes of RPM services, both of which can be provided under General Supervision. MARCH UPDATE: In an effort to further promote telehealth in Medicare, “Clinicians can provide remote patient monitoring services for patients, no matter if it is for the COVID-19 disease or a chronic condition. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.” – CMS, 3/30/2020

 

Recommendations: 

  1.     Elderly people should distance themselves from crowds and places where groups of people gather. 
  2.     People with underlying conditions, especially the elderly, should distance themselves from crowds and places where groups of people gather. 
  3.     Those with diabetes and heart failure, two common pre-existing conditions, need to keep in mind that they are at increased risk of catching COVID-19. 
  4.     Those who believe they may have COVID-19 should call their doctor to establish protocols before going to the ER or another care facility. Going to these facilities will only potentially expose others. 

 

RPM Solutions:

  1. Stay at home and use RPM to take vital readings to send to medical professionals instead of going to a clinic or hospital. This would help isolate at-risk patients from exposing others to COVID-19.
  2. RPM establishes historical trends that would be useful for medical professionals to remotely diagnose health conditions. 
  3. The alert system would quickly establish a medical condition that needs immediate attention. 
  4. The RPM functionality would allow family members to help monitor conditions and give them tools to better care for their family member or friend. 

 

It can be difficult at times to ensure that all health center patients are aware of all Medicare services available to them, but there are solutions available. Additionally, patients should keep in mind that various state Medicaid plans have a say in defining their own coverage for COVID-19. For example, California recently passed AB 1494, which makes exceptions to Medicaid reimbursement for certain telehealth services in states of emergency. It also allows services to be used in the patient’s home in such cases.

 

Telehealth by itself can be of huge benefit to health centers combating outbreaks such as COVID-19. From remotely monitoring patients who are displaying symptoms to having patients proactively message their provider if symptoms appear, this is possible with telehealth to determine if further care and testing are needed. Implementing telehealth, remote monitoring and communication services helps to keep clinics and hospital waiting rooms from getting overly congested, keeping possible at-risk patients away from crowds.

 

 

HELPFUL LINKS:

 

Sources

¹ Centers for Medicare and Medicaid Services. “Center for Clinical Standards and Quality/Quality, Safety, and Oversight Group.” Feb. 6, 2020. PDF File. 

² “CMS Develops Additional Code for Coronavirus Lab Tests.” Centers for Medicare and Medicaid Services, 5 Mar. 2020, https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests.

³ Neergaard, Lauran. “Behind the Scenes, Scientists Prep for COVID-19 Vaccine Test.” ABC News, ABC News Network, 8 Mar. 2020, abcnews.go.com/Health/wireStory/scenes-scientists-prep-covid-19-vaccine-test-69467049.

⁴ “Age, Sex, Existing Conditions of COVID-19 Cases and Deaths.” Worldometer, 29 Feb. 2020, www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/.

⁵ Centers for Medicare and Medicaid Services. “Medicare Telehealth Frequently Asked Questions (FAQs).” Mar. 17, 2020. PDF File.

⁶ Miller, Ryan W. “Photos: Volunteers in Seattle Get First Doses of Trial Vaccine for COVID-19.” USA Today, USA Today, 17 Mar. 2020, www.usatoday.com/story/news/health/2020/03/17/coronavirus-vaccine-trial-underway-seattle-photos-first-shots/5065909002/.

⁷ Medicare Learning Network – CMS. “New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE).” Apr. 17, 2020. PDF File.

 

LAST UPDATED: 9/21/2020

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