Guide to Telehealth-Based Care

During the current public health emergency, many health care providers are turning to telehealth to be able to continue to care for their patients as more patients choose to remain home to reduce community spread of COVID-19. It is important for doctors of optometry to understand the current regulatory framework for the provision of telehealth services, potential state limitations, billing and coding responsibilities, and malpractice considerations.

April 13, 2020

The following information is included in this guide:

1. Preparing for the use of telehealth-based care.
2. Malpractice insurance considerations.
3. State law impacts.
4. Medicare changes under COVID-19 public health emergency.
5. Billing and coding considerations.
6. Medicare telehealth visit coverage summary during COVID-19 public health emergency.
7. Commercial payer coverage.
8. HIPAA-related concerns.
9. Telehealth platform principles to consider during COVID-19 public health emergency.
10. Practice implementation considerations.

Preparing for the use of telehealth-based care

Telehealth is a complex arena with state and federal implications. To start, we recommend doctors:

• Review AOA webinars on billing and coding for telehealth-based care and COVID-19.
• Check with your malpractice insurance carrier to ensure your policy covers providing care via telemedicine. Additional guidance on AOA's malpractice insurance policy and key considerations are included below.
• Understand your state's requirements. Details are included in this guide.
• Prepare your practice and patients for the availability of this type of care.

Malpractice insurance considerations

Many doctors of optometry are seeking clarification to determine if their malpractice insurance policy covers vision telehealth services.

• The AOAExcel endorsed malpractice insurance administered by Lockton Affinity does not include any exclusions of coverage for vision telehealth services provided by doctors of optometry.
• The AOAExcel endorsed malpractice insurance administered by Lockton Affinity provides comprehensive coverage that aligns with the services that doctors of optometry provide to their patients within their state's defined scope of practice, which may or may not include vision telehealth services. The state board of optometry determines the guidelines for providers utilizing telehealth technologies in the delivery of patient care.

If you do not have the AOA malpractice insurance, you may want to take the following actions:

• Ask your insurance provider whether vision telehealth services are covered by your policy. If you are told that vision telehealth services are covered, then make sure to ask your insurance provider to show you where it explicitly says in your policy that you are covered for vision telehealth services.
• In addition to asking your insurance provider to show you proof of coverage for vision telehealth services, it is also good practice to review the exclusions and endorsements in your policy to ensure there is no language limiting or omitting vision telehealth services.
• Ask your insurance provider whether you are covered for the full scope of coverage defined by the state in which you practice. If your state's scope of practice includes guidelines for utilizing telehealth technologies to provide patient care, then that it is covered in your policy.

State law impacts

• Doctors must ensure adherence to their state laws and regulations.
• Many states are reducing regulatory barriers to providing telehealth-based care. The Center for Connected Care Health Policy has additional information on state-specific changes.
• With regard to your Medicare patients, in their COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers fact sheet, the CMS has temporarily waived requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state.
• We are also seeing Medicaid plans expand telehealth coverage.

Medicare changes under COVID-19 public health emergency

• The AOA worked to ensure that doctors of optometry were fully recognized as qualified physicians under legislation signed into law on March 6 which increased funding for the national response to the COVID-19 public health emergency, including expansion of the use of telehealth-based care.
• Under the coverage expansion, the CMS has broadened access to Medicare telehealth services so that patients can receive a wider range of services from their doctors without having to leave their homes.
• The CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority, and Coronavirus Preparedness and Response Supplemental Appropriations Act.
• This action is retroactive to March 6, 2020. Congress made additional changes through the Coronavirus Aid, Relief and Economic Security Act (CARES Act) on March 20. 
• The HHS Office of Inspector General (OIG) is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs.

Billing and coding considerations

As a reminder, only specific codes can be billed via telehealth; these codes are delineated below. You should also review specific payer restrictions and CMS guidance. While certain previous telehealth restrictions have been waived during the ongoing public health emergency, it is important to ensure you are reporting only codes approved for use via telehealth, that you are meeting the requirements of any code billed and that you document appropriately. If you have coding questions, please contact AOA's Coding Experts.  The CMS clarified that telehealth services can be billed for both new and established patients. In some cases, the code description may indicate "established patient" but the service can be reported on both new and established patients.

Modifier and Place of Service Codes (POS) use

POS

The CMS instructs physicians who bill for Medicare telehealth services to report the POS code that would have been reported had the service been furnished in person. This will allow the CMS to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. The in-office POS is 11. 

Modifier 95

• The CMS is finalizing on an interim basis the use of the CPT telehealth modifier, modifier 95, which should be applied to claim lines that describe services furnished via telehealth.
• The CMS is maintaining the facility payment rate for services billed using the general telehealth POS code 02, should practitioners choose to maintain their current billing practices for Medicare telehealth during the PHE for the COVID-19 pandemic.

Evaluation and management codes

• 99201; 99202; 99203; 99204; 99205; 99211; 99212; 99213; 99214; 99215 can be billed to Medicare during the current public health emergency.
• The CMS has clarified these services can be reported when the E/M service is provided via services such as FaceTime or Skype.
• Doctors must meet the E/M requirements for billing the code selected and must meet the standard of care.
• E/M codes can be billed when the patient is in their home and the physician is in his/her clinical setting or elsewhere.

Medicare virtual check-in services

• Medicare pays "virtual check-ins" for patients to connect with doctor in lieu of an office visit.
• Not related to a medical visit in the previous seven days and does not lead to a medical visit in next 24 hours.
• Patient must verbally consent to services and verbal consent must be documented before service—at least annually.
• Medicare coinsurance and deductible apply to these services but can be waived (at the doctor's discretion) during the public health emergency.

G2012

• Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
• This code can be reported for telephone calls with patients.
• Typical reimbursement is approximately $15.

G2010

• Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
• Typical reimbursement is approximately $12.

Medicare online digital evaluations

• Medicare pays for patients to communicate with doctors without an office visit using on-line patient portals.
• Must be patient-initiated.
• Providers may educate beneficiaries on availability of services prior to patient initiation.
• Communication may occur over a seven-day period.
• Not related to a medical visit in the previous seven days and does not lead to a medical visit in the next 24 hours.
• Bill using 99421-99423.
• Medicare coinsurance and deductible apply (Note: providers can waive, if they choose to, during crisis only).
• Under normal operating periods, doctors are required to store communication and ensure HIPAA compliance for all patient communications but this is not enforced during emergency.

99421

Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 5-10 minutes. (National Average reimbursement = $15.52).

99422

Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11- 20 minutes. (National Average reimbursement = $31.04).

99423

Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes. (National Average reimbursement = $50.16).     

Telephone evaluation and management service codes exist and CMS has announced that these services will be covered during the COVID-19 public health emergency. 

• These codes are used for non-face-to-face E/M services provided using telephone.
• Used to report episodes of patient care initiated by established patient or guardian of established patient.
• Some private carriers may allow.

Do not report IF:

• Call results in decision to see the patient within 24 hours or next available urgent visit appointment (considered part of pre-service work for visit).
• Call refers to E/M service billed by the provider within previous seven days whether requested by the provider or not.
• Call is within postoperative period of completed procedure (part of postoperative service).
• Reported 99441-99443 by the same provider for the same problem in the previous seven days.  

99441

Telephone E/M service by a physician or other qualified health care professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. (National average reimbursement = $14.44).  

99442

Telephone E/M service by a physician or other qualified health care professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment ; 11-20 minutes of medical discussion. (National average reimbursement = $28.15).  

99443

Telephone E/M service by a physician or other qualified health care professional who may report E/M services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion. (National average reimbursement = $41.14).

• (Do not report 99441-99443 when using 99339-99340, 99374-99380 for the same call[s])
• (Do not report 99441-99443 for home and outpatient INR monitoring when reporting 93792, 93793)
• (Do not report 99441-99443 during the same month with 99487-99489)
• (Do not report 99441-99443 when performed during the service time of codes 99495 or 99496)

Commercial payer coverage

Coverage varies by plan, so doctors should confirm coverage and reimbursement. Additionally, Medicare Advantage plans also have discretion to increase their telehealth benefits during the current crisis. AHIP has compiled a list of private payer policy changes, many of which also apply to their Medicare Advantage products.  

HIPAA-related concerns

• During the current public health emergency, the HHS Office for Civil Rights (OCR) will not impose penalties on physicians who use telehealth and may not be fully compliant with the regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA).
• Some technologies that are acceptable for use during the emergency period (e.g., FaceTime) do not typically comply with the requirements of the HIPAA rules but will be allowable at this time without the fear of HIPAA penalties.
• Physicians should not use Facebook Live, Twitch, TikTok or other public-facing communication services to provide telehealth services.
• While it is considered a best practice to notify patients of the potential security risks of using these services and to seek additional privacy protections by entering into HIPAA business associate agreements (BAA), this is not required.
• Doctors of optometry may use systems that allow for video chats (Apple FaceTime, Facebook Messenger video chat, Google Hangouts video or Skype) to provide telehealth.  

Telehealth platform principles to consider during COVID-19 public health emergency

Many doctors may be looking for telehealth platform solutions during the COVID-19 public health emergency. The AOA does not endorse specific products, but recommends that doctors consider the following if selecting a platform to use:

• The standard of care must remain the same regardless of whether eye and vision telehealth services are provided in-person, remotely via telehealth or through any combination thereof. Doctors may not waive this obligation or require patients to waive their right to receive the standard of care. Further, a payor may not require either the doctor or patient waive the right to receive the standard of care.
• Be aware of payer policies on telehealth services. As with any product, confirm whether codes recommended for billing by the manufacturer are accurate and appropriate.
• Patients must be made aware of potential limitations of the services that can be provided via telehealth. Doctors of optometry delivering eye and vision telehealth services must, when clinically appropriate, promptly refer patients for an in-person diagnosis and/or care.
• Ensure any telehealth platform you are evaluating is operated by a company that has knowledge and awareness of AOA's 2017 Position Statement Regarding Eye and Vision Telehealth Services and adheres to key provisions outlined therein. 

Doctors should also be aware that under Medicare, services like FaceTime and Skype, used in a good-faith manner to provide telehealth-based care, are acceptable for use.  

Practice implementation considerations

• Determine when you plan to offer telehealth visits. Some practices block out time for urgent in-person care and block time for telehealth-based visits.
• A dedicated space in your practice may be necessary to provide telehealth visits. A quiet and private space is useful for offering this type of care.
• Standard documentation practices should be retained.
• Obtain and document consent to provide care via telehealth. Consent can be sought verbally under Medicare.
• You may want to update your voicemail message and send a message to patients notifying them of the availability of telehealth-based care.  

Additional COVID-19 resources

• For coding questions,  contact the AOA coding experts.
  
• AOA's COVID-19 resources.
• For regulatory issues, contact Kara Webb.
• Your state association remains a resource during this public health emergency.
• Review CMS resources at the  CMS Current Emergencies site and Medicare Telemedicine Health Care Provider Fact Sheet.
• Additional HIPAA information can be found from the  HHS.
• Important HIPAA guidance for doctors providing telehealth during the national emergency.
• Virtual care/check-ins.
• The CMS letter to clinicians.