Telemedicine

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unchockey21

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For those of you starting to offer telemedicine, in which state are you practicing? We’re trying to get things running in Florida and our compliance attorney’s initial response was the the orthopedic surgeons could do it but the pain docs couldn’t. They cited Louisiana specifically denying that pain visits were covered. I said they need to dig deeper than that but looking for any help to guide them.
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unchockey21 said:
For those of you starting to offer telemedicine, in which state are you practicing? We’re trying to get things running in Florida and our compliance attorney’s initial response was the the orthopedic surgeons could do it but the pain docs couldn’t. They cited Louisiana specifically denying that pain visits were covered. I said they need to dig deeper than that but looking for any help to guide them.
Click to expand...

FL is going to be vulnerable to a large class-action lawsuit from pain patients!
 
unchockey21 said:
For those of you starting to offer telemedicine, in which state are you practicing? We’re trying to get things running in Florida and our compliance attorney’s initial response was the the orthopedic surgeons could do it but the pain docs couldn’t. They cited Louisiana specifically denying that pain visits were covered. I said they need to dig deeper than that but looking for any help to guide them.
Click to expand...

Right now all previous video rules are ignored and you can bill a telemedicine service as a regular face to face encounter. This is my understanding .
 
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mid|ine said:
Our understanding too. We hope to be ready by monday.
Click to expand...

To be honest u don’t really need anything specific. As long as u have an EMR u can write notes, u can technically used FaceTime or Skype per trumps new guidelines doesn’t have to be hippa compliant
 
painfree23 said:
To be honest u don’t really need anything specific. As long as u have an EMR u can write notes, u can technically used FaceTime or Skype per trumps new guidelines doesn’t have to be hippa compliant
Click to expand...

I would be very careful seeing patients through a non-hipaa compliant platform. Other then that, all you need is an EMR, blessing from your malpractice insurer, and a hipaa compliant video platform.
 
I haven't used it but simple and free is what they say.
doxy.me

The Simple, Free, and Secure Telemedicine Platform | Doxy.me

The world’s most loved telemedicine solution. Sign up in less than 60 seconds to experience why more than one million providers trust us already.
doxy.me doxy.me

Our folks are rolling out some HIPAA compliant thing with Epic

Agree, do what you will, but don't write controlled substances without a two-way audiovisual telemedicine encounter documented.
 
Orin said:
I haven't used it but simple and free is what they say.
doxy.me

The Simple, Free, and Secure Telemedicine Platform | Doxy.me

The world’s most loved telemedicine solution. Sign up in less than 60 seconds to experience why more than one million providers trust us already.
doxy.me doxy.me

Our folks are rolling out some HIPAA compliant thing with Epic

Agree, do what you will, but don't write controlled substances without a two-way audiovisual telemedicine encounter documented.
Click to expand...

as it is written:


Telemedicine
On January 31, 2020, the Secretary of the Department of Health and Human Services issues a public health emergency (HHS Public Health Emergency Declaration).
Question: Can telemedicine now be used under the conditions outlined in Title 21, United States Code (U.S.C.), Section 802(54)(D)?
Answer: Yes
While a prescription for a controlled substance issued by means of the Internet (including telemedicine) must generally be predicated on an in-person medical evaluation (21 U.S.C. 829(e)), the Controlled Substances Act contains certain exceptions to this requirement. One such exception occurs when the Secretary of Health and Human Services has declared a public health emergency under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D). Secretary Azar declared such a public health emergency with regard to COVID-19 on January 31, 2020. (Secretary Azar Declares Public Health Emergency for United States for 2019 Novel Coronavirus). For as long as the Secretary’s designation of a public health emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:
  • The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
  • The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system.
  • The practitioner is acting in accordance with applicable Federal and State law.
Provided the practitioner satisfies the above requirements, the practitioner may issue the prescription using any of the methods of prescribing currently available and in the manner set forth in the DEA regulations. Thus, the practitioner may issue a prescription either electronically (for schedules II-V) or by calling in an emergency schedule II prescription to the pharmacy, or by calling in a schedule III-V prescription to the pharmacy.
Important note: If the prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine, or any other means, regardless of whether a public health emergency has been declared by the Secretary of Health and Human Services, so long as the prescription is issued for a legitimate medical purpose and the practitioner is acting in the usual course of his/her professional practice. In addition, for the prescription to be valid, the practitioner must comply with any applicable State laws.
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Extralong said:
I would be very careful seeing patients through a non-hipaa compliant platform. Other then that, all you need is an EMR, blessing from your malpractice insurer, and a hipaa compliant video platform.
Click to expand...

It looks like FaceTime and Skype are ok...

www.hhs.gov

OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

Today, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced, effective immediately, that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through...
www.hhs.gov www.hhs.gov
 
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BPA1985 said:
It looks like FaceTime and Skype are ok...

www.hhs.gov

OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

Today, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) announced, effective immediately, that it will exercise its enforcement discretion and will waive potential penalties for HIPAA violations against health care providers that serve patients through...
www.hhs.gov www.hhs.gov
Click to expand...
 
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Which cpt code are using for telemedicine visit?
E visit?
 
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From my understanding: If its VIDEO AND AUDIO you can bill a regular E/M Code like 99213.

If its JUST audio: CPT Codes: 99441, 99442, or 99443.

Either way I add the G2012 code as well.

Does this sound right?
 
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Nonphysiologic said:
From my understanding: If its VIDEO AND AUDIO you can bill a regular E/M Code like 99213.

If its JUST audio: CPT Codes: 99441, 99442, or 99443.

Either way I add the G2012 code as well.

Does this sound right?
Click to expand...
G2012
whats this?
 
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GT modifier. btw r u guys mailing out the opioid script or having them pick up? we don't have the e-prescribe capability of narcotic.. i imagine not many do
 
TIVAndy said:
GT modifier. btw r u guys mailing out the opioid script or having them pick up? we don't have the e-prescribe capability of narcotic.. i imagine not many do
Click to expand...

Wats GT? I guess yea have them come by and pick up scripts
 
I’ve know CMS is covering telehealth visits like in office visits during the crisis. Does the executive order require commercial payors to follow the same rules? I’ve seen that some insurance don’t extend telehealth coverage to docs not already established on their platform.
 
Florida here. We do e prescription . Requires 2FA. Currently still open, did 10 injections today and 5 new patients. Seems like it’s gunna slow down next week though. We will be doing FaceTime or google visits if we get locked down.
 
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swamprat said:
Florida here. We do e prescription . Requires 2FA. Currently still open, did 10 injections today and 5 new patients. Seems like it’s gunna slow down next week though. We will be doing FaceTime or google visits if we get locked down.
Click to expand...

Wow your still doing injections?? What if you have a rare complication and you have to send that patient to the ER?
 
Nonphysiologic said:
From my understanding: If its VIDEO AND AUDIO you can bill a regular E/M Code like 99213.

If its JUST audio: CPT Codes: 99441, 99442, or 99443.

Either way I add the G2012 code as well.

Does this sound right?
Click to expand...
For 99213 how you do you Report examination ?
or just the time encounter?
Are commercial insurance are paying for telemedicine?
 
gaseous_clay said:
It is. This code is for a virtual check in and pays around $15. It also has to be patient initiated.
Click to expand...
I spent all day with the arkansas state medical board. They as of now have not lifted the telemedicine ability for opioid patients. The lawyer stated that “I don’t see them changing it, opioid crisis....”. So as far as I know as of next week these patients are all supposed to come in for visits for the damn refills. I am not allowed to do a tele visit for them. I will do tele visits for those who are non opioids. How dumb. I am thinking I will have to be the only staff member. Have my staff work from home, collect copays via phone and schedule from home.
stagger patients for like every half hour so I can social distance. remain in your car until i am ready to take you back.
I will stay in a hotel until this is over out of fear of infecting my family. I am a responsible prescriber, 95% patients under 50 MED. I don’t understand my state.

i have tried calling governor, house member, both senators and no answer
 
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geauxg8rs said:
I spent all day with the arkansas state medical board. They as of now have not lifted the telemedicine ability for opioid patients. The lawyer stated that “I don’t see them changing it, opioid crisis....”. So as far as I know as of next week these patients are all supposed to come in for visits for the damn refills. I am not allowed to do a tele visit for them. I will do tele visits for those who are non opioids. How dumb. I am thinking I will have to be the only staff member. Have my staff work from home, collect copays via phone and schedule from home.
stagger patients for like every half hour so I can social distance. remain in your car until i am ready to take you back.
I will stay in a hotel until this is over out of fear of infecting my family. I am a responsible prescriber, 95% patients under 50 MED. I don’t understand my state.

i have tried calling governor, house member, both senators and no answer
Click to expand...

Wow. How often are they coming in? Once a month? Call CNN. They will be all over a story like this.
 
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I was told, if you go by audio they care about the duration of the visit and that factors into reimbursement. If you have audio video they only care that you “show” AV was working, we take a screen shot and paste it into the note.
 
geauxg8rs said:
I spent all day with the arkansas state medical board. They as of now have not lifted the telemedicine ability for opioid patients. The lawyer stated that “I don’t see them changing it, opioid crisis....”. So as far as I know as of next week these patients are all supposed to come in for visits for the damn refills. I am not allowed to do a tele visit for them. I will do tele visits for those who are non opioids. How dumb. I am thinking I will have to be the only staff member. Have my staff work from home, collect copays via phone and schedule from home.
stagger patients for like every half hour so I can social distance. remain in your car until i am ready to take you back.
I will stay in a hotel until this is over out of fear of infecting my family. I am a responsible prescriber, 95% patients under 50 MED. I don’t understand my state.

i have tried calling governor, house member, both senators and no answer
Click to expand...

Man, Arkansas really has its priorities in order.
 
geauxg8rs said:
I spent all day with the arkansas state medical board. They as of now have not lifted the telemedicine ability for opioid patients. The lawyer stated that “I don’t see them changing it, opioid crisis....”. So as far as I know as of next week these patients are all supposed to come in for visits for the damn refills. I am not allowed to do a tele visit for them. I will do tele visits for those who are non opioids. How dumb. I am thinking I will have to be the only staff member. Have my staff work from home, collect copays via phone and schedule from home.
stagger patients for like every half hour so I can social distance. remain in your car until i am ready to take you back.
I will stay in a hotel until this is over out of fear of infecting my family. I am a responsible prescriber, 95% patients under 50 MED. I don’t understand my state.

i have tried calling governor, house member, both senators and no answer
Click to expand...

in the face of the pandemic, i would do what you think is best. Patient in withdrawal shows up at ER with flu like sx. Not good. DEA says rx for established patient can be done via phone call. You can offer to sue the board member for any damages you or your patients suffer from their stupidity.
 
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Email directive from my hospital system: (Georgia)


Subject: FW: GHA COVID-19 Regulatory Alert - Telehealth Updates - GCMB Rule


After spending half the day yesterday trying to interpret the Medical Board rules, they waived them.



So narcotic prescriptions are ok if it’s a legitimate purpose and within the normal scope of the MDs practice. The telemedicine needs to be two way, audiovisual, real time. The prescription can be sent electronically, by calling in an emergency schedule II prescription, or regular call in of schedule III-V. An emergency call in schedule II has to be followed by a written prescription within 7 days. Under these circumstances, probably mailing to the pharmacy would be the best bet.



Other laws will still apply, for example, checking the PDMP data base. The telemed visit and prescription need to be recorded in the medical record.



Let me know if there are other questions.



Director, Legal Services
 
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lobelsteve said:
Email directive from my hospital system: (Georgia)


Subject: FW: GHA COVID-19 Regulatory Alert - Telehealth Updates - GCMB Rule

Can you post a link to the actual release. The more direct sources I can send to the board the better. Thanks

And if anyone has similar messages from their states can you post here so those with backward thinking medical boards can email?

Thanks


After spending half the day yesterday trying to interpret the Medical Board rules, they waived them.



So narcotic prescriptions are ok if it’s a legitimate purpose and within the normal scope of the MDs practice. The telemedicine needs to be two way, audiovisual, real time. The prescription can be sent electronically, by calling in an emergency schedule II prescription, or regular call in of schedule III-V. An emergency call in schedule II has to be followed by a written prescription within 7 days. Under these circumstances, probably mailing to the pharmacy would be the best bet.



Other laws will still apply, for example, checking the PDMP data base. The telemed visit and prescription need to be recorded in the medical record.



Let me know if there are other questions.



Director, Legal Services
Click to expand...
 
DEA says you can call in scheduled meds. I am doing it on a case-by-case basis with patients I know very well. I would not advertise this.

I’ll be FaceTiming on my iPhone for all telemedicine visits.
 
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unchockey21 said:
For those of you starting to offer telemedicine, in which state are you practicing? We’re trying to get things running in Florida and our compliance attorney’s initial response was the the orthopedic surgeons could do it but the pain docs couldn’t. They cited Louisiana specifically denying that pain visits were covered. I said they need to dig deeper than that but looking for any help to guide them.
Click to expand...


Your attorney is wrong and clueless, as is usual of attorneys, I"m in FL and the attedings are all using telemedicine for patietns that don't want to go in/are sick and can't go in.
The big problem with Fl is that Gov De Santis has declared that all non-essential/non life threatening procedures are to be halted at this time - so outside of pump refills, i cannot think of a single pain procedure that is necessary/essential. That is a problem.
 
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TIVAndy said:
GT modifier. btw r u guys mailing out the opioid script or having them pick up? we don't have the e-prescribe capability of narcotic.. i imagine not many do
Click to expand...
Ours are being mailed out.
 
Doctodd said:
DEA says you can call in scheduled meds. I am doing it on a case-by-case basis with patients I know very well. I would not advertise this.

I’ll be FaceTiming on my iPhone for all telemedicine visits.
Click to expand...

I tried but then my personal phone number shows up ...how are u FaceTiming without this being an issue?
 
I'm doing doxy.me, and I'm all set up for it but haven't started yet seeing pts. That will start this week.
 
Can anyone clarify this section of the waiver:
To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.
Click to expand...
I can’t find what exactly the services are that do require a pre-existing relationship. The table further down does say codes 99201-99215 are included, implying that new patients can be billed, but “we won’t audit claims before paying” isn’t the same as “we won’t ask for that money back afterward.”
1584817247147.png
 
is there a difference in what you can bill by using just the phone vs. phone + video in some fashion?

frankly, getting the video set up for many of my patients may be too difficult for them. a video visit is better, but the audio is delayed, and it makes for a more cumbersome and clunky visit.

also, one more question for those in the know: do I have to state how long i spend on the phone with the patient if i am not using time in my MDM? i usually dont mention the time, and i dont want to have to meet some threshold for billing. i cant tell if this time requirement is specifically for telemedine. my though is that it should not be if we were just billing as we had previously.
 
This might help.....


Best practices for Telehealth

At the minimum, the telemedicine record should contain the following:
• Patient Name
• Identification #
• Informed Consent
• Date of service
• Referring Physician (if needed)
• Provider Name
• Provider Location
• Type of evaluation performed
• Evaluation results


Establish the physician-patient relationship

• The patient’s state of residency or location needs to be established prior to treatment. State laws will require that you be licensed in that state.
• Provide and validate your credentials to the patient.
• Disclose communication and treatment methods to the patients and obtain and document consent.

Evaluation and treatment

• Ensure that your evaluation and treatment is thoroughly documented in the medical record or EHR as if this were a face to face visit.
• If you believe that the evaluation, diagnosis or treatment will be too complicated for telemedicine, request an in-person appointment or direct patient to the emergency room before any medical advice is given. Do not bill for your visit.

• If the visit is for a minor injury, document the cause of injury.
• Have the patient or a family member palpate the specific area for you and have the patient describe what they are feeling during your exam.
• Explain and have the patient or a family member administer stability tests when needed. Document the test by name and explain what you see.

Continuity of Care

• Don’t forget to set up a follow up. The patient will not be walking out to book the next appointment at the front desk.

Billing and coding

• Use the appropriate code for your service: See CPT E/M guidelines:
• Most telehealth visits result in E/ M levels 99201, 99202 or 99212 and 99213, due to the nature of the problem and the limited exam.
• In most cases, time is only a “contributory factor” in determining which level of evaluation and management (E/M) to report for a visit. Usually, a level of E/M service is determined by the “key components” of history, examination, and medical decision making. However, if you end up spending greater than fifty percent of the total visit counseling/coordinating care, you can use time as the key factor in determining the level of E/M service that you report. Typical times are listed below for new and established office or other outpatient E/M services:

• New Patient VisitTypical Time (minutes)Established Patient VisitTypical Time (minutes)
• 99201 10 99211 5
• 99202 20 99212 10
• 99203 30 99213 15
• 99204 45 99214 25
• 99205 60 99215 40


Medicare requires the place of service 02 for Telehealth with no modification
Commercial Payers:

• Aetna requires a GT modifier
• BCBSFL not available
• Cigna not available
• United Healthcare requires GT and 95 modifiers
• Work comp -contact case manager
 
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Doctodd said:
This might help.....


Best practices for Telehealth

At the minimum, the telemedicine record should contain the following:
• Patient Name
• Identification #
• Informed Consent
• Date of service
• Referring Physician (if needed)
• Provider Name
• Provider Location
• Type of evaluation performed
• Evaluation results


Establish the physician-patient relationship

• The patient’s state of residency or location needs to be established prior to treatment. State laws will require that you be licensed in that state.
• Provide and validate your credentials to the patient.
• Disclose communication and treatment methods to the patients and obtain and document consent.

Evaluation and treatment

• Ensure that your evaluation and treatment is thoroughly documented in the medical record or EHR as if this were a face to face visit.
• If you believe that the evaluation, diagnosis or treatment will be too complicated for telemedicine, request an in-person appointment or direct patient to the emergency room before any medical advice is given. Do not bill for your visit.

• If the visit is for a minor injury, document the cause of injury.
• Have the patient or a family member palpate the specific area for you and have the patient describe what they are feeling during your exam.
• Explain and have the patient or a family member administer stability tests when needed. Document the test by name and explain what you see.

Continuity of Care

• Don’t forget to set up a follow up. The patient will not be walking out to book the next appointment at the front desk.

Billing and coding

• Use the appropriate code for your service: See CPT E/M guidelines:
• Most telehealth visits result in E/ M levels 99201, 99202 or 99212 and 99213, due to the nature of the problem and the limited exam.
• In most cases, time is only a “contributory factor” in determining which level of evaluation and management (E/M) to report for a visit. Usually, a level of E/M service is determined by the “key components” of history, examination, and medical decision making. However, if you end up spending greater than fifty percent of the total visit counseling/coordinating care, you can use time as the key factor in determining the level of E/M service that you report. Typical times are listed below for new and established office or other outpatient E/M services:

• New Patient VisitTypical Time (minutes)Established Patient VisitTypical Time (minutes)
• 99201 10 99211 5
• 99202 20 99212 10
• 99203 30 99213 15
• 99204 45 99214 25
• 99205 60 99215 40


Medicare requires the place of service 02 for Telehealth with no modification
Commercial Payers:

• Aetna requires a GT modifier
• BCBSFL not available
• Cigna not available
• United Healthcare requires GT and 95 modifiers
• Work comp -contact case manager
Click to expand...

thanks, that helps. i dont like this sentence, though:

"Most telehealth visits result in E/ M levels 99201, 99202 or 99212 and 99213, due to the nature of the problem and the limited exam"

i will be billing level 3 at a minimum. barely worth making the call (other than it helps the patient) if you bill a level 1 or 2
 
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Seems like facetime with your iphone is the only way to easily be able to do video and audio? Our group is trying to figure out the easiest most efficient way to be able to do both video and audio but its proved challenging. CMS is reimbursing 13 bucks for audio only...
 
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