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Overview

Updated July 6, 2020

The use of telemedicine and remote care services are critical to the safe management of the COVID-19 pandemic, while also ensuring uninterrupted care for 100 million Americans with chronic conditions. 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.

The AMA Digital Health Implementation Playbook series offers comprehensive step-by-step guides to implementing digital health solutions, specifically telemedicine, in practice based on insights from across the medical community. Each Playbook offers key steps, best practices and resources to support an efficient and clear path to implementation and scale.

Our newest Playbook in the series focuses on the implementation of telehealth (PDF), defined as real-time, audio-visual visits between a clinician and patient. We have also created this quick guide for key implementation tips and the latest updates on telemedicine expansion amid COVID-19.

Telehealth Implementation Playbook

Critical integration of new digital tools in medicine is lacking. We want to change that.

 
If you are looking for more comprehensive implementation guidance for remote patient monitoring, check out our first Playbook in the series.

Additional resources for implementing telemedicine include: 

AMA STEPS Forward Module on Telemedicine  

—Through our recent interactive virtual discussion on the AMA Physician Innovation Network, physicians had 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. While this discussion is no longer active, you can still view the transcript (PDF). 

Telemedicine during the COVID-19 public health emergency FAQs (PDF)

Practice implementation

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.
        —During the COVID-19 emergency, physicians and practices can leverage technologies such as FaceTime, Skype, Zoom, etc. This will help speed up the implementation process. OCR guidance emphasized that physicians are encouraged, but not required, to notify patients of the potential security risks of using these services and to seek additional privacy protections by entering into Business Associate Agreements (BAAs) as able.*  
    —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?) 
    —Recognizing that many physicians and care teams are working remote, the AMA and American Hospital Association created guidance to help you ensure your personal and home devices are secure.

* 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. Additionally, ATA, in collaboration with the Consumer Technology Association, created a Digital Health Directory to support identification of various digital health technologies including telemedicine.

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.

—Download the workflow tools and resources.  
    —Telehealth workflow best practice (PDF), ensuring your workflow addresses the entire life cycle 
    —Key considerations when designing a telehealth workflow (PDF), key questions and criteria for designing a workflow  
    —Telehealth workflow example (PDF), sample flow for scheduling, check-in, visit, and post-visit  
    —Telehealth etiquette checklist (PDF), tips on conducting a successful telehealth visit  
    —Patient take-home prep sheet (PDF), patient education on telehealth, how it works and how to prepare/what to expect from your appointment

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 in Federal policy. 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. The AMA’s Advocacy Team has been tracking state executive orders, regulatory activities or legislation (PDF) related to telemedicine. 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 for telemedicine services are listed below. The AMA’s coding scenarios (PDF) provide real-world examples of how to code for telehealth services.


 

Online digital visits codes chart

 

Graphic for remote patient monitoring codes chart

 

Self measured blood pressure (SMBP) telehealth chart

 

Graphic for Telephone Evaluation and Management Service

—For commercial payers, we have 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.
    —Aetna
    —America's Health Insurance Plans
    —Blue Cross Blue Shield
    —Humana
    —United Healthcare

COVID-19 telehealth payment policies–Comparison between Medicare FFS and other payors (PDF)

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. The AMA’s Advocacy Team has been tracking state executive orders, regulatory activities or legislation (PDF) related to telemedicine. Also see AMA’s state policy options to address COVID-19, as well as state policy guidance on telemedicine (PDF), including links to state best practices. 
    —Texas Medical Association has created a significant suite of telemedicine resources.
    —Massachusetts Medical Society telemedicine and virtual care resources.   

—The American Telemedicine Association has created a series of webinars discussing the impact COVID-19 has had on telemedicine.   

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

—To help physicians and patients get started with telehealth services, HHS launched the telehealth website with resources and best practices for accessing care virtually. For physicians, there are tips for getting starting, preparing patients for telehealth visits, billing and payment and legal considerations. AMA resources, including the telehealth quick guide, are featured.   

—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 (PDF)

—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