COVID-19 Telehealth Primer

Telemedicine is now essential to assure patients receive uninterrupted medical care during the COVID-19 pandemic. To support clinicians during this COVID-19 pandemic, Telehealth.org 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 teleheath primer 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)

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.

HIPAA Compliant Technology

Whenever possible, HIPAA 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.

The downloadable guidelines are on the CDC website here. 

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).

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 requiremens.

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.

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.

Marlene Maheu, Ph. D.

Marlene M. Maheu, PhD has been a technologist-psychologist and pioneer since 1994. She has served various organizations to assist with the development of technology-focused standards and guidelines, including the American Telemedicine Association, the American Psychological Association and the American Counseling Association. She has overseen the development and delivery of telehealth training to more than 26,000 professionals worldwide and consulted with hundreds of hospitals, clinics, agencies, groups and independent practitioners seeking start-up guidance.

Dr. Maheu serves as the Founder & Executive Director of the Telehealth.org, which offers over 64 hours of both basic and advanced telehealth training online and offering two Micro Certifications Telehealth. She is the CEO for the non-profit Coalition for Technology in Behavioral Science (CTiBS). She has authored five telehealth textbooks, including the Telebehavioral Health: Foundations in Theory & Practice for Graduate Learners (2020); the APA-published, A Practitioner’s Guide to Telemental Health: How to Conduct Legal, Ethical and Evidence-Based Telepractice (2016), and Career Paths in Telemental Health (2016).