Healthcare providers have found themselves under immense pressure to maintain continuity of care during the COVID-19 crisis, but many aspects of the U.S. health system were not designed to support such an effort. To help providers more effectively deliver care that will not only keep patients healthy but also in their homes and away from hospitals, which are largely focused on treating COVID-19 patients, government agencies, commercial payers, and other healthcare organizations have worked to change the system. Approaches taken include the creation of new and expansion of existing telehealth and remote tools and support, including remote patient monitoring (RPM).
For example, we have seen federal waivers and revised state regulations that greatly expand the ability for healthcare providers to deliver telehealth and remote services; commercial payers revising their policies to pay for these services, and healthcare companies offering resources to help providers more effectively leverage telehealth and remote services during the crisis.
If your practice is considering launching or growing an existing telehealth and/or remote services program during the pandemic, here are five things you should know.
1. Three categories of telehealth/remote care
There are essentially three categories of telehealth and remote care services.
First, there's traditional telemedicine. To provide telemedicine services, both audio and video communication is generally required, although as of April 30, 2020, Medicare has waived the video requirements to permit telephone-only telehealth for many services.
Telemedicine essentially mirrors existing in-office services concerning requirements and billing and coding. The COVID-19 emergency has driven federal and commercial payers into temporarily expanding coverage of telemedicine. Common examples of traditional telemedicine services include evaluation and management (E/M), Medicare annual wellness visits (AWVs), and Medicare preventive services.
Second is virtual services. Medicare does not define these as "telemedicine" to avoid legal constraints. Examples of virtual services include virtual check-ins, remote evaluation (i.e., store and forward), and e-visits. These are relatively new, and you should expect their requirements to be adjusted over time. They were created specifically to substitute for unnecessary office visits. As such, they are relatively well-crafted for the crisis.
The third and final category is care management services. These represent Medicare's first experiment into non-face-to-face reimbursable services. They are billable for enrolled patients each calendar month when certain requirements are met within that month. Examples include chronic care management (CCM), behavioral health integration, and remote patient monitoring.
2. Requirements for traditional telehealth
Now let us take a brief look at the general requirements for delivering traditional telehealth services during the pandemic. Traditional telehealth encompasses the services healthcare providers normally deliver within their offices except using telecommunication technology. Medicare typically only reimburses for telehealth in extremely limited circumstances as laid out in 42 U.S.C. §1395m(m)(4)(C). The current federal §1135 waiver has temporarily suspended many of the restrictions. All state Medicaid programs, except for Massachusetts, Iowa and Rhode Island, have some coverage for real-time video telehealth. Specific requirements vary a bit state by state.
For commercial payers, state telehealth parity laws dictate payer policy, when applicable. More than 40 states require some coverage of telehealth. For those states with no parity law, many commercial payers are still electing to cover telehealth services.
Concerning HIPAA, the Office of Inspector General (OIG) has released guidance that it will not enforce HIPAA violations concerning the use of consumer video chat apps like Skype and Facetime during the crisis. Still, it is highly suggested that healthcare providers use secure and HIPAA-compliant technology whenever possible.
3. Telehealth services update: E/M, AWV, and preventive
Each of the three major telehealth services — E/M, AWV, and Medicare preventive services — have been affected in some way by the pandemic.
Normal E/M services can be performed via telehealth using real-time audio and video communications technology. To bill for these services, healthcare providers should use the same procedure codes as they would for a face-to-face visit and they will be paid at the same rate during the crisis. Medicare and most private insurers are allowing providers to use medical decision-making or total time to determine the E/M code level during the pandemic.
The AWV is a telehealth-allowable service — and one that can now be provided entirely over the telephone — that has been largely ignored during the crisis. This is unfortunate as the AWV is particularly suited to increase continuity of care while supporting practice revenue because it:
- can be initiated by the provider;
- is generally furnishable by clinical staff;
- has no co-pay or co-insurance; and
- includes providing patient education on health risks.
There are a few things to keep in mind concerning the AWV. The health risk assessment portion can be completed over the phone or via patient form. Ensure patients provide a current height and weight and ask them if they can also provide a blood pressure reading. Consider using the health risk section of the AWV to educate patients on their COVID-19 risk and steps they can take to mitigate that risk. Finally, advance care planning is an optional and separately reimbursable service that can be provided with a telehealth AWV. It can only be provided at the patient's discretion.
Many Medicare preventive services are allowable under telehealth and, as noted earlier, can now be provided entirely via the telephone. These include the following:
- Alcohol misuse screening and counseling
- Tobacco cessation counseling
- Depression screening
- Cardio risk counseling
- Obesity counseling
- Cognitive impairment care planning
- Medical nutrition therapy
Although these services are unlikely to be the reason(s) for initiating a telehealth visit, they can be important additional services to add during an E/M or tele-AWV. It has been shown that social disconnectedness and isolation increases the risk of major depression in older populations. At the same time, older populations are also at a greater risk for major complications from COVID-19. Given this, there is a good argument that mental health-related preventive services are more important than ever.
4. Virtual services update: phone E/M, check-in, e-visit, and remote evaluation
As with telehealth services, virtual services have been impacted by COVID-19.
In late March, Medicare announced it would temporarily pay for telephone E/M services under CPT codes 99441-99443. Here is what you need to know about phone E/M services:
- They are payable by time spent, cumulative over a seven-day period.
- They cannot be billed if an E/M service has occurred within seven days or if the call leads to an E/M service. Basically, if it is not a self-contained service, it is considered a part of the other E/M.
- As these are considered E/M services, they include the diagnosis and management of a problem and require a chief complaint and medical necessity to be billable.
It is unlikely Medicare will continue to reimburse these services after the crisis as it is a legal grey area concerning whether Medicare can even reimburse for them during the crisis.
Concerning virtual check-ins, also known as "brief communication technology-based services," Medicare reimburses the service under HCPC G2012. This code was accepted prior to the crisis and is not part of the current waiver. Virtual check-ins allow patients to communicate with their doctors via phone or real-time messaging to avoid unnecessary trips to the office. The code expects 5-10 minutes of medical discussion.
With Medicare temporarily allowing phone E/M codes, virtual check-ins are being employed much less during the crisis. With that said, virtual check-in should still be used in situations where the patient and healthcare provider are mainly evaluating whether an office visit or other service is warranted as that would not meet the requirements of phone E/M.
E-visits allow for patients to use secure messaging or email to engage in medical discussions with their doctors. These services are time-based and cumulative over a seven-day period. They are normally only available to established patients, but that restriction is currently being waived during the crisis.
Coding for e-visits is as follows:
- 99421: 5-10 minutes
- 99422: 11-20 minutes
- 99423: 21-plus minutes
Finally, the Medicare remote evaluation service (G2010) allows patients to record videos or images and then send those videos/images to their healthcare providers for review. Remote evaluation includes interpretation of the patient-provided media and a brief follow-up discussion with the patient.
This service is not billable when there has been a related E/M service provided within the previous seven days or if it leads to an E/M service. If it is self-contained, it is billable. However, if it relates to an E/M service for the same problem, it is considered part of that E/M service.
5. Care management services update: CCM, behavioral health integration, and remote patient monitoring
There are several points you should know about how the major care management services — chronic care management (CCM), behavioral health integration (BHI), and remote patient monitoring (RPM) — have been affected by the pandemic.
CCM is the original Medicare remote service. It began as a very restricted service but has been made easier over the last five years. For 2020, Medicare expanded reimbursement and added coverage for some patients with just one chronic condition.
The major requirements of CCM are as follows:
- Patients must have two or more chronic conditions (more than two-thirds of Medicare beneficiaries meet this requirement).
- Patient consent is required to be included in a CCM program.
- A care plan must be developed.
- Services require at least 20 minutes of clinical staff time under general supervision.
- CCM is billable every 20 minutes, up to 60 minutes total.
COVID-19 risk is highest for older individuals with existing chronic conditions, making CCM an important tool to coordinate care and keep vulnerable patients engaged with their healthcare providers and care teams.
CCM has an offshoot called behavioral health integration. This provides greater reimbursement but adds the requirement of conducting a monthly, validated mental health assessment. This is particularly well-suited for helping patients cope with depression and/or anxiety during the crisis.
Remote patient monitoring is a relatively new service that is covered by Medicare and an increasing number of commercial payers. In 2020, the RPM codes were overhauled, making RPM one of the most lucrative Medicare care management programs. Remote patient monitoring has also proven to significantly reduce hospitalization, which has added to its appeal during the COVID-19 crisis.
There is a small payment for initial patient enrollment and a monthly base payment for management of the remote patient monitoring device and patient readings. There is an optional service for each 20 minutes of care management (which can be provided by clinical staff), up to 60 minutes total. The most common RPM devices are blood pressure monitors, weight scales, and blood glucose meters. Pulse oximeters are becoming more common as the health crisis continues.
There are essentially two ways healthcare providers can approach remote patient monitoring: via full-service programs or those requiring a self-managed approach.
For a full-service program, a practice contracts with an RPM company to supply patients with devices. The practice can either hold a stock of the devices to distribute to patients or have the vendor ship devices directly to patients as the office enrolls them. Many full-service programs allow practices to lease the devices, eliminating upfront costs for each new patient. Devices are often cellular, which is simpler for patients to use. All they need to do is insert batteries into the devices and power them on. Some full-service programs offer technical support to patients. Monthly costs are a higher percentage of reimbursement, but the initial cost for each device is eliminated and staff time to manage the program is greatly reduced.
For programs requiring a self-managed approach, practices maintain the supply of devices (typically Bluetooth) and contracts with a remote patient monitoring software vendor to manage the data from those devices. This approach requires the practice to perform what amounts to providing ongoing technical support for patients, although this time does count towards the management codes and is therefore not billable. Taking a self-managed approach can prove cheaper in the long run, but practices will need to incur significant initial costs and allocate more office resources and staff time to the program.
Closing Thoughts: Telehealth and Remote Services Post-COVID-19
The expansion of telehealth and remote services in response to COVID-19 will have a long-lasting impact on the acceptance, adoption, and reimbursement of these services. Not all of the temporary measures will become permanent immediately, but the crisis has forced patients and practices to use and implement the technology and systems that allow the remote practice of medicine — and it will be very difficult to unring that bell.