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Practice implementation

Updated April 2, 2020

–Telemedicine spans a continuum of technologies that offer new ways to deliver care including:

– Real-time, audio-video communication tools (telehealth) that connect physicians and patients in different locations.

– Store-and-forward technologies that collect images and data to be transmitted and interpreted later.

– Remote patient-monitoring tools such as blood pressure monitors, Bluetooth-enabled digital scales and other wearable devices that can communicate biometric data for review (which may involve the use of mHealth apps).

– Verbal/audio-only and virtual check-ins via patient portals, messaging technologies, etc.

If you are planning to implement telehealth (real-time audio/visual visits between you and your patients) into your practice for the first time, below are some key considerations:

Getting Started

 – Set up a team that will help facilitate the expedited implementation of telemedicine services and be able to make decisions quickly to ensure launch as soon as possible.

 – Check with your malpractice insurance carrier to ensure your policy covers providing care via telemedicine.

 – Familiarize yourself with payment and policy guidelines specific to various telemedicine services. 

Vendor evaluation, selection & contracting 

– Check with your existing EHR vendor to see if there is telehealth functionality that can be turned on.

 – Reach out to your state medical association/society for guidance on vendor evaluation, selection and contracting.

 – Introducing new technology into practice quickly can be challenging, but a few things to keep in mind as you navigate a speedy implementation:
      ♦ Ensure HIPAA-compliance*
      ♦ Make sure you understand who has access to and owns any data generated during a patient visit
      ♦ Get clear on the pricing structure (i.e. is there a monthly flat rate for using the technology or is it per call or per visit?)

* Given the special circumstances of the COVID-19 pandemic, the federal government has announced that the Office for Civil Rights (OCR) will exercise its enforcement discretion and will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) in connection with the good faith provision of telehealth during the COVID-19 national public health emergency.

 – Leverage resources available at the American Telemedicine Association to identify possible vendors to work with. Some are actively supporting quick and effective use of telehealth services. 

Workflow & patient care

 – Determine protocols for if/when a telehealth visit is appropriate up front and train clinicians, care team members and schedulers. Consider a short survey or set of questions that patients can either answer electronically or over the phone when your patients are scheduling to properly triage.
      ♦ If you know your payer mix, consider reaching out to the payer with the highest percent of your patient population to discuss telehealth coverage, even if temporarily due to current events.

 – Determine when telehealth visits will be available on the schedule (i.e. throughout the day intermixed with in-person visits or for a set block of time specifically devoted to virtual visits).

 – Set up space in your practice to accommodate telehealth visits. This can be an exam room or other quiet office space to have clear communication with patients. If multiple members of the care team will be helping to facilitate telehealth visits, ensure they know where to support the set-up of the technology and communicate with patients virtually.

 – Ensure you are still properly documenting these visits – preferably in your existing EHR as you normally would with an in-person visit. This will keep the patient’s medical record together, allow for consistent procedures for ordering testing, medications, etc. and support billing for telehealth visits.
      ♦ Ensure you receive advanced consent from patients for telemedicine interactions. This should be documented in the patient’s record. Check to see if your technology vendor can support this electronically.

 – Let your patients know the practice is now offering telehealth services when they call the office. Have your office staff help support pro-active patient outreach. Additionally, post announcements on your website, patient portals and other patient-facing communications.
      ♦ Have a plan for supporting patients on how to access telehealth visits based on your practice’s technology and workflow to keep the clinic flow moving and avoid disruptions to care.

Additional resources for implementing telemedicine include:

– AMA Digital Health Implementation Playbook focused on remote patient monitoring

– AMA STEPS Forward Module on telemedicine

AMA Physician Innovation Network telemedicine discussion: Through our latest interactive and ongoing virtual discussion on the AMA Physician Innovation Network, physicians have direct access to experts gathered to answer questions, share best practices, and help arm the front lines with knowledge to act quickly and effectively in providing virtual care and preventing the spread of COVID-19.

Policy, coding & payment

Disclaimer: Information provided by the AMA contained within this Quick Guide is for medical coding guidance purposes only. It does not (i) supersede or replace the AMA’s Current Procedural Terminology (CPT®) manual (“CPT Manual”) or other coding authority, (ii) constitute clinical advice, (iii) address or dictate payer coverage or reimbursement policy, and (iv) substitute for the professional judgement of the practitioner performing a procedure, who remains responsible for correct coding. 

CPT © Copyright 2019 American Medical Association. All rights reserved. AMA and CPT are registered trademarks of the American Medical Association. More information can be found on our CPT site.

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Policy, coding and payment

The policy and payment landscape around telehealth and telemedicine remains complex; however, as the country navigates this pandemic, change is happening rapidly to expand these services. The AMA’s Advocacy team has been summarizing the latest updates from CMS. Below are some additional key policy and payment considerations to keep in mind:

 – Ensure that you are providing services in accordance with your state laws and regulations. As part of emergency declarations, many governors have relaxed state laws and regulations related to the provision of telemedicine services. For up to the minute information in your state, please contact your state department of health or state medical association. 

 – Licensure:
      ♦ If you are licensed in the state where the patient is located, there are no additional requirements.
      ♦ If you are not licensed in the state where the patient is located:
           • CMS has issued the following waiver for Medicare patients: Temporarily waive requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state. Physicians are still bound by their state licensing requirements (CMS FAQs). Medicaid waivers must be requested by the individual state that wants to use them.
           • Many states have temporarily relaxed licensure requirements related to physicians licensed in another state and retired or clinically inactive physicians. This includes waiving licensure requirements or offering a temporary expedited license for out-of-state physicians. Many, but not all of these measures apply to physicians providing telemedicine across state lines. Please contact your state board of medicine or department of health for up-to-the minute information.
           • The Federation of State Medical Boards (FSMB) is tracking executive orders related to licensure. Stay up to date on the FSMB website.  

 – CMS has expanded access to telemedicine services for all Medicare beneficiaries, not just those that have novel coronavirus, for the duration of the COVID-19 Public Health Emergency. In addition to existing coverage for originating sites including physician offices, skilled nursing facilities and hospitals, Medicare will now make payments for telehealth services furnished in any healthcare facility and in the home.

 – Common CPT codes and Medicare coverage for telemedicine services are listed below. Download specific COVID-19 coding scenarios.

 – Review the list of CPT and HCPCS codes covered for telehealth by CMS (PDF), as well as codes included in the appendix P. Within the CPT code set, Appendix P— "CPT codes that may be used for synchronous telemedicine services" is used to denote CPT codes that may also be provided via telehealth.


 

Online digital visits codes chart
Graphic for remote patient monitoring codes chart

 

Graphic for Telephone Evaluation and Management Service

Additional coding resources

COVID-19 coding guidance 

Review coding scenarios (PDF) to help health care professionals apply best coding practices.

 – Get the quick-reference flowchart that outlines CPT reporting for COVID-19 testing (PDF)

Commercial Payer Policy

 – For commercial payers, we’ve compiled the resources on this page to help track expanding coverage for telemedicine services. You can also check with your local state medical association or society for more information.
      ♦ Blue Cross Blue Shield - Coronavirus updates: Coverage of testing for members and access expansion to care 
      ♦ Humana - Patient responsibility: Waiving member cost share for COVID-19 and urgent care telehealth visits  and How Humana is caring for members (telemedicine cost waived for urgent care needs for next 90 days, online member support, etc.
      ♦ Molina Health - COVID-19 provider notification  
Molina Health is waiving co-pays and cost sharing for tests, as well as offer $0 co-pay and cost share for participating in telemedicine visits for any diagnosis until May 1, 2020.
      ♦ United Healthcare - Provider Telehealth Policies:
UnitedHealthcare is expanding telehealth services policies to cover Medicare Advantage, Medicaid and commercial members through June 18, 2020 at this time.

Other helpful resources

 – For more information, visit the AMA’s COVID-19 Resource Center for Physicians.

 – For more information, visit the AMA Data File requests (CPT data file, etc.)

 – Reach out to your state medical association/society for more detailed information and resources on licensure, coverage, and payment policies. Also, view the AMA's state policy options to address COVID-19. 
      ♦ Texas Medical Association has created a significant suite of telemedicine resources.
      ♦ Massachusetts Medical Society telemedicine and virtual care resources.

 – The National Governors Association is tracking state activities related to COVID-19

 – CMS Telehealth Services Fact Sheet (PDF)

 – For the latest information on federal policy and payment changes related to telehealth in the midst of COVID-19, visit the CMS Current Emergencies site. Below is the most recent fact sheet regarding the Medicare expansion of telehealth services:
      ♦ Medicare Telemedicine Health Care Provider Fact Sheet

 – State Medicaid waivers and information related to telemedicine expansion:
      ♦ California requests federal government waiver to cover Medi-Cal recipients and expand tele-health options
      ♦ CMS approves first state request for 1135 Medicaid waiver in Florida

 – American Psychiatric Association: General resource page and toolkit on COVID-19 and telepsychiatry

 – American Academy of Child & Adolescent Psychiatry: Telepsychiatry Toolkit

 – American Academy of Pediatrics resources on telemedicine.

 – American College of Physicians resources on COVID-19 and telemedicine