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COVID-19 Telehealth Primer

 

FREE Telehealth Training for COVID-19

Introduction

Telemedicine is now essential to assure patients receive uninterrupted medical care during the COVID-19 pandemic. To support clinicians during this COVID-19 pandemic, the Telebehavioral Health Institute offers this telehealth primer.

Rules and regulations change rapidly. We understand the urgency you feel to provide care for your patients. Since it is so vital to stay abreast of these changes, we have collected this information so you have one reliable source. 

Each section receives regular updates, with linked articles, webinars and course options. Check back regularly to keep up on the latest news. 

Telehealth Definition

The definition of telehealth has broadened over the decades. As technology moves forward, the definition of telehealth shifts and changes, too. In a general sense, remote health services all fall under the broad telehealth definition, such as:

    • Diagnostic processes
    • Consultations
    • Treatments
    • Patient education
    • Patient monitoring
    • Healthcare administration

The prudent use of various types of technology facilitates ongoing interactions between clinicians and patients. The definition of telehealth also includes clinician communications with other physicians, residents, students, administrators, plus both professional and family caregivers.

The COVID-19 Crisis and Telehealth

As a rapid response to the COVID-19 pandemic, telehealth services now expand for patients across the nation. The current regulatory shifts are in the areas of:

    • Eligible Services
    • Eligible Providers
    • Prescriptions and the Ryan Haight Act
    • Approved technology
    • Coverage and reimbursement policies
    • Coding and Billing
    • Patient Location
    • State Licensure Limits
    • Documentation (including informed consent)
    • COVID-Related Psychological Perspectives

Eligible Services 

How do I know if my telehealth services are eligible for reimbursement through Medicare?

The waiver includes all services previously eligible under Medicare telehealth reimbursement policies. The eligible codes list is available on the Centers for Medicare and Medicaid Services website HERE.

Eligible Providers

I heard they were adding FQHCs and RHCs. How do I know if my clinic is now an eligible provider?

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) added to the eligible providers’ list is not a permanent change. HR 748 added these FQHC and RHC providers for this emergency pandemic period only.

For more information about Federally Qualified Health Centers (FQHCs), see the CMS website HERE. For additional information about Rural Health Clinics (RHCs), see the CMS website HERE.

Prescriptions and the Ryan Haight Act

What are the new rules for scripts? I’m specifically concerned about my patients who need stimulants, benzodiazepines and narcotics.

A new waiver was announced by the U.S. Drug Enforcement Administration for patients with substance use disorders, under the Ryan Haight Online Pharmacy Consumer Protection Act. Telehealth assessments are now sufficient to allow physicians to prescribe medications to patients.

The waiver now permits “practitioners in all areas of the United States may issue prescriptions for all schedule II-V controlled substances.” The provisos being:

    • The medications must be for legitimate medical reasons.
    • Two-way, real-time telehealth-style communication between patients and clinicians.
    • Clinicians otherwise act “in accordance with applicable Federal and State laws.”

Clinicians can now prescribe the common psychiatric drugs, plus stimulants, benzodiazepines, and potentially even narcotics with telehealth systems.

The current waiver does not make permanent changes. These 60 days are critical to the mental and physical health of our nation, yet there is hope that these changes become permanent to support both patients and clinicians across the country. Many of the previous regulations will probably be reinstated, but these new changes do help during the crisis period.

Plus, Medscape Medical News reported that SAMHSA relaxed some regulations on telehealth for opioid treatment. The FAQ section on the SAMHSA website outlines the guidelines for buprenorphine and methadone treatments.

Approved Technology for COVID-19 Telehealth Services

I have patients with pre-existing appointments and I don’t have enough time to set up a new HIPPA compliant platform to see them. I am setting one up, but what can I do in the meantime?

The American Medical Association announced on March 17, 2020:

In light of the COVID-19 nationwide public health emergency, the HHS Office for Civil Rights (OCR) is exercising its enforcement discretion and, effective immediately, will not impose penalties on physicians using telehealth in the event of noncompliance with the regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA).

The federal agencies announced they are not performing audits during the global COVID-19 public health emergency. 

    • Reduced technological requirements make treatment more accessible. A laptop, smartphone or tablet is all that is necessary for both the patient and the clinician. Clinicians now see the value in telehealth as never before. So, chances are many clinicians will invest in more specific technology in the future. But for right now, Skype, FaceTime and Google Hangouts work for everyone.
    • These platforms are not HIPAA compliant, which is why the waiver is necessary. There is a commercial health system Skype version that is HIPPA compliant, but the consumer-download version anyone can use is not. HIPAA-compliant programs are the best choice in the long run, but during the pandemic, there is some leeway.
    • Clinicians using the consumer version of Skype, for example, should be careful to watch as names from previous patient conversations could be visible.

HR 748 also removed the language previously used in HR 6074, allowing a phone if it uses audio/visual components. Now, the only reference in the law to telecommunication systems and store-and-forward is for Alaska and Hawaii, but there is no further telehealth definition.

APRIL 30, 2020 UPDATE: Telephone reimbursement for regular psychotherapy and counseling has now been approved by Medicare. See this page for details: 

HIPPA Compliant Technology

Whenever possible, HIPPA compliant technology should still be used for telehealth involving Protected Health Information (PHI)

  • Compliant telehealth technology includes common telecommunications platforms like Skype for Business, GoToMeeting, or Microsoft Teams.
    • These platform options can be safely used with PHI discussions when the clinician enters into a business associate agreement (BAA). The agreement says that while you interact with the other person using the platform, the company cannot see the interview. Sign this agreement.
    • Several specialized health technology companies facilitate HIPAA-compliant communications like Amwell, Doximity Dialer, InTouch Health, Starleaf, and Teladoc.
    • When clinicians evaluate potential platforms, it is suggested they check reviews, specifically on telehealth review sites, and ask colleagues who already use a telehealth platform.
    • Firstly, look for a system with high video quality. Then ensure the platform can ‘lock’ the rooms. Plus, be sure there is an app that mobile device users can use.
  • Non-compliant telehealth technology includes social communication technologies like Zoom, Facetime, WhatsApp, text messaging, and email. These options are now open and may be appropriate during the pandemic if no other alternatives are available.

HIPAA Guidelines on Telehealth during COVID-19

Choosing a platform for telemedicine usually requires medical professionals to comply with the HIPAA guidelines on telemedicine. Several platforms allow real-time audio, video, or messaging, and the ability to store and transfer medical records and images.

Electronically protected health information (ePHI) is produced, saved, transferred or received in any electronic form. These rigorous standards for electronic telehealth communications stipulate that:

    • Only authorized users have access to ePHI.
    • Secure communication protects the integrity of the ePHI.
    • Monitor communications containing ePHI to prevent breaches.

As a result, only HIPPA compliant platforms were previously suitable for telehealth visits before the pandemic.

As federal and state policy responds to the pandemic, policies regarding reimbursement, privacy, and coding via telehealth may be temporary. Reimbursements and adoption of telemedicine models evolve quickly in times of crisis.

Shifting policies currently incorporate nonphysician providers, too. Consult a healthcare compliance attorney, your compliance officer, or the Centers for Medicare and Medicaid Services, or the U.S. Department of Health and Human Services directly.

Telephone vs Video Chat

Some patients prefer to talk on the phone. Older patients are more likely resistant to video chats, usually because of unfamiliar technology. Some patients need help to set up, while others have additional barriers. Video is better than audio-only, so making systems as easy as possible for patients to access makes sense.

    • The American Medical Association website provides information about the coding for phone and video visits. Plus, check state-by-state rules for whether a clinician needs a patient’s written consent to conduct telepsychiatry sessions.
    • California allows verbal consent. A note saying how consent was given, including the patient’s location address, is often sufficient. If the patient sits in their car for the telehealth session, use the parking lot’s address.

Best practice also includes noting the patient’s cell number and an alternate contact for safety reasons.

Coding and Billing Reimbursement Policies for COVID-19 Patients

Most of the codes I use aren’t changing, but what if I encounter a patient specifically directly affected by COVID-19? What codes should I use for reimbursement?

COVID-19 ICD-10 Coding Guidelines were released effective February 20, 2020. These codes are reserved for the COVID-19 Coronavirus Outbreak.

Patient Location

My patients and I are all staying home. Can I still hold their appointments using telehealth and get reimbursed?

Both rural and site limits are removed. Medicare reimbursement is now available for telehealth services regardless of the geographical location of the enrollee. The removal of the site limits allows the patient to remain at home as an eligible originating site. If patients are in their car for the telehealth session, use the address of the parking lot. All prior existing policies on facility fees still apply.

State Licensure Limits

During COVID-19, are mental health professionals allowed to see clients in other states, especially if they are pre-existing clients? I’d imagine abandoning a client would be very harmful at this time.

Most states have approved inter-jurisdictional practice – but no blanket rule applies. To be sure, download the check this state-by-state report published for COVID-19 changes on a regular basis to see about practice in your state(s) of licensure. The organization publishing this report is the Center for Connected health policy.

For the most current information check HERE.

Previously, clinicians had to hold a license in the same state where they provided telehealth services.  With the recent increased popularity of telehealth patient services, legislation supporting telehealth across state lines produced the Interstate Medical Licensure Compact (IMLC)

TBHI Iis keeping track of telebehavioral health jurisdictional issues for you in this blog post: COVID-19: Telehealth Across State Lines & International Borders?

Qualify Out of State

Physicians can now qualify for licensing outside of their principal state through the IMLC.

    • This expedited voluntary pathway for interstate licensure allows qualified physicians the opportunity to practice in more than one state. The additional patient access to health care specifically assists underserved and rural areas. As clinicians obtain licenses to practice in multiple states, the IMLC strengthens patient protections because the states easily share disciplinary and investigative information.
    • The IMLCC agreement between 29 states, the District of Columbia and the Territory of Guam, has physicians licensed by 43 Medical and Osteopathic Boards. So, licensed physicians qualify to practice across state lines if they meet the eligibility criteria. About 80% of physicians meet these requirements.
    • Currently, expedited applications leverage existing information in the state of principal license (SPL). The SPL verifies the information and conducts a new background check. Then, the qualified physician selects any number of states where they want to practice.
    • During the COVID-19 pandemic, CMS waived interstate licensing limits, allowing clinicians to cross state lines. Although individual states determine final approval for Medicaid and CMS, several states have already eased restrictions concerning the practice of telehealth services across state lines.

Private payers have begun to expand policies to align with the recent state and CMS changes. The licensure issue continues to change rapidly.   For more information, check the Federation of State Medical Boards COVID-19 updates and State Emergency declarations or licensing waivers.

Documentation for COVID-19 Telehealth Visits (including informed consent)

Have the rules for documentation or consent changed? Can I get verbal consent? If so, how do I document that?

Despite the more relaxed policies, proper documentation for telehealth visits remains critical. Many telehealth technologies link or embed the electronic medical record (EMR) for streamlined documentation.

Written informed consent should be obtained when possible. Verbal consent is acceptable during the pandemic period.  Documentation should include:

    • Details of the informed consent discussion.
    • A statement outlining the fact that the service was provided using telehealth. Certainly, mention any use of non-HIPPA compliant technology.
    • The locations of both the clinician and the patient.
    • Documentation that supports coding for reimbursement.

COVID-Related Psychological perspectives

National and state associations are beginning to light up with informed articles reflecting issues of interest to many behavioral professionals seeking to help with COVID. The American Psychological Association recently released an article that might be of interest to behavioral professionals working with people from marginalized communities. See COVID-19 heightens the need to end health disparities Research by psychologists shows that communities are more successful at meeting challenges when we address the needs of all people. 

If you’d like to suggest similar research, please comment below.

Your comments would also be appreciated if you have additions or corrections to the rest of this article, too.

Summary

In conclusion, policies and regulations change rapidly as we respond to the COVID-19 pandemic. Please send us your questions so we can collect the information you need most urgently.

Telehealth Clinical Best Practices for COVID-19 presents a live, interactive training experience to improve your telehealth clinical skills while bringing you up to date with COVID-19 policy changes.  Join the 4-hour Emergency Telehealth Best Practices Clinical Training for COVID-19  developed as a deep dive into clinical evidence-based models, tips and strategies for telehealth practice – as well as a quick overview of COVID-19 policy updates.

Large commercial insurers have already started to expand their telehealth definition for reimbursement policies. Certainly, these policy changes could become permanent, even after the COVID-19 public health crisis resolves. However, regardless of reimbursement policies, providing telehealth services is never prohibited, discussions only revolve around coverage and reimbursement.

Your TBHI Professional Training Options

Looking for specialized legal and ethical training during COVID-19? You may be interested in the following.

To assist behavioral professionals seeking other evidence-based telehealth training to help deal with COVID-19, TBHI is honored to offer you these CME and CE-accredited programs at 50% off from the convenience of your desktop or digital device: 

 

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17 comments on “COVID-19 Telehealth Primer

    • Yes, “02” goes in the Place of Service (POS) area of the 1500 form. The latest news is that you should NOT use the “-GT” or “95” codes at all. Leave the modifier code section EMPTY next to the CPT code box.

      • The “not using the modifier codes (GT or 95),” is this for ALL insurance plans?
        Also, what’s the difference between GT and 95? I use Doxy.me for my telemental health sessions.

        • Linda, Recent guidance is to use “95” for the telehealth modifier code. It goes into the two boxes to the right of the ones for your CPT code. GT is the telehealth code used prior to 2018 or so. Also, be sure to use “11” as your place of service code for telehealth.

        • Linda, The “95” is for Medicare and Medicaid. Other insurers usually follow suit, but you will need to contact the individual to know for sure (yes, real pain). I wish we knew what each payor wants, but keeping us in the dark is part of the game they play.

  1. Hi, thank you all for this information & all that you are doing to prepare & equip clinicians during this time! I am considering the Micro Certification, but was wondering if there is a “live” option for the course, as my licensure board requires that most of my CEU hours are presented with the availability for “live” interaction. Thanks for your help with this!

    • Candace,

      Thank you for your interest in our professional training. Many boards are allowing Internet-based training-on-demand hours to be acceptable when their licensees are seeking telehealth training. you may want to send your board a quick email and check their website to see if they have made any modifications to their requirements during COVID-19.
      As for our offerings, the Level II program includes a 4-hour LIVE, interactive Clinical Issues II training that we offer LIVE every Saturday through April. To get into that LIVE training as part of the Level II discounted package of courses, send a note to our Customer Service desk. We will send you a link that includes both.

      Our All-Access Pass program offers an additional six hours of live training as well. SSee details compared for both programs here..
      At this time, that is the only LIVE training that we offer. All conferences and workshops that we’ve had scheduled for this year have been canceled.

      Let us know if you have any other questions.

      • Thank you so much for that recommendation! You were right, they have made that change to the required hours for this time. Looking forward to getting signed up!

        Take good care!

    • Shelly Lynn,

      It is our understanding that ABA providers can have our CE hours approved because of the many other accreditations and approvals that we’ve earned. To know if your board will approve your training with us if you use any of our existing approvals, please send them this link and ask them to review and get back to you in writing: TBHI Accreditations and Approvals for CME and CE Hours

  2. Are you using traditional cpt codes for therapy? All of my telehealth sessions have been denied. Has anyone had success?

    • You are allowed to resubmit with the correct codes. use “95” for the telehealth modifier code. It goes into the two boxes to the right of the ones for your CPT code. GT is the telehealth code used prior to 2018 or so. Also, be sure to use “11” as your place of service code for telehealth.

    • CK,

      Traditional codes should work if you use the modifier codes described in the blog. Then again, insurance companies have been notorious about refusals for decades, so why should this be any different… You may want to send in your billing into them again, and contact your State Insurance Commissioner through your state professional association. Ask them to help you file a complaint against the insurance companies in question. You are probably not alone in your state.

      If you need direction with the basics of telehealth billing, see our courses here and look for the 3-hour course related to telehealth reimbursement: https://telehealth.org/individual

  3. Telemedicine is making a very positive contribution to healthcare during this pandemic, and is being used in a variety of ways. Thanks for sharing.

  4. Thank you for professional training. I am leading group-therapy for older adults for who the only option is stationary phone of cellular phone without Wi-fy, so using pin codes or email notification poses difficulty, but during COVID time Group therapy is crucial and essential for them. I want to know whether UBER CONFERENCE platform (so far the only one that i found has the dial out feature), meets the requirements of HIPPA and what other platforms that are approved and have the simple use for this category of patients. What paperwork could i complete to get Uber Conference platform for Telehealth be approved for group therapy with older adults (as it is simple and could easily reach out to any device that patient has). Thank you.

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