Telehealth Group Therapy: Reimbursement Clinical Issues

As group therapists work to respond during the COVID-19 crisis, online telehealth group therapy sessions are replacing in-person groups. During this time of social isolation, group meetings add a greater protective factor. In addition, telehealth group sessions give therapists an effective and efficient method to support patient mental health during the COVID-19 crisis.

Telehealth Group Therapy Treatments and Billing Codes

Two code sets for telehealth group therapy treatments fall under the emergency COVID-19 guidelines for Medicare:

• CPT Code 90853 Group Psychotherapy by Telehealth (Added March 30, 2020)
• 96164 and 96165 Health Behavior Assessment and Intervention Group codes

Ethical Practice for Telehealth Group Therapy

Competency in both group therapy and telehealth services are the basis for offering online group therapy sessions. Telehealth group therapy has seldom been implemented by most therapists, so the legal and ethical frameworks are still evolving.

Emerging literature suggests:

Review your ethics code

Review evidence-base about telehealth group therapy for your type of group and population

Greater risks than in-person

Documentation is essential

Privacy & Confidentiality

While session leaders are under an imperative to maintain confidentiality, telehealth group therapy members (in most states) are under no ethical or legal obligation.

Privacy is the individual’s legal right to control dissemination of information

Confidentiality is professional’s legal duty to protect an individual’s privacy

Privacy can be violated by the professional and/or by other group members

So, video platforms are potentially beneficial, especially during the current isolation. Yet, online systems have some hazards that do not exist for in-person group sessions. As a result, each patient’s confidentiality is at greater risk.

Potential Breaches to Confidentiality May Include:

Member connects from an unsecured location where a third party can see or heard

Member records or takes a screenshot, picture or records the group or an individual member

Member uses such material to threaten or harm another group member

Privacy violations can be significant to member and/or family

Compromising a group member’s privacy could affect them individually and potentially impact the benefits of telehealth group therapy. So, group psychologists should alert members to the increased risks associated with telehealth in a group setting.

Options can be discussed considering risks/benefits of each of these and other precautions:

Wear disguise or block face with pre-approved masks that do not interfere with voice

Use nickname, fictitious name or initials on screen

Choose to not participate

Seek alternative treatment

If patients block the video feed of their face, this form of contact may be considered telephone therapy, which is reimbursable outside of the video group session codes. See MEDICARE APPROVES TELEPHONE SERVICE FOR COVID-19 for more information.

Group leaders should outline potential benefits for each member of the group and compare that to any potential for concern.

Telehealth sessions should never begin before patients read and sign the informed consent forms for group telehealth. A discussion with the therapist before the initial session makes sure they are aware of the benefits, risks, and any concerns about confidentiality. The group leader is always responsible to uphold and adhere to the most stringent privacy standards that are possible for each group.

HIPAA Compliant Video Platforms

Clinicians remain encouraged to use HIPAA compliant platforms for the highest possible levels of confidentiality and security for telehealth group sessions whenever possible. While the privacy guidelines have relaxed during the COVID-19 pandemic, and though HIPAA requirements are not a guarantee of confidentiality, privacy continues to be a central legal and ethical concern when providing telehealth group therapy sessions.

Our federal government waived provider penalties for HIPAA violations with a “good faith” proviso for telehealth services during the COVID-19 national public health emergency.

Screening Appointments Before Group Sessions

Group screening appointments remain a best practice for group leaders before telehealth group therapy sessions, just as with in-person group sessions.

Conduct pre-screening appointments to:

Review informed consent

Review group guidelines

No WIFI – need secure network

Conduct “tech check” after giving telehealth platform specifications to make sure the connection and technology is adequate

Set expectations to reduce group dropouts, clarify goals and maintain the integrity within the telehealth group therapy sessions.

Telehealth Technology Preparation Suggestions

Consider these available settings, as per your group’s needs:

Choose a multi-point video system with digital waiting room

Consider these available settings, as per your group’s needs:

Members can be seen simultaneously

Simulated backgrounds

Member(s) can be removed from meeting

Digital waiting room where you post group rules

Disable chat to prevent distracting side conversations

Allow private question feature but advise members to only use for technical difficulties

Disable recording of sessions (recording is discouraged by telehealth research and consensus documents)

Conduct a “tech check” before allowing a prospective member to join the group.

Ask them to learn/demonstrate that they know:

How to arrange adequate lighting for their face to be completely visible, even in the evening

Where/how to mute the sound from their microphone

Shut off the sound from their speakers if needed (prevents feedback)

Be in the same location they passed a tech check for every meeting

Use earbuds or a headset available at every meeting

Respect how sensitive the microphone can be

Prevent disruptions and intruders

Telehealth Group Therapy Practical & Clinical Suggestions

Distraction-free, private space

No recording of sessions in any way

No use of WIFI

Prevent anyone in environment from hearing or seeing group interactions

Log in with own ID – legal name, pre-agreed nickname, initials, etc.

Do NOT use anyone else’s ID upon entry or during interactions

Alone & able to speak freely

Do not disturb sign on door

Seated but not on bed or with bed in view

Sit close enough to camera to have their face be seen clearly (if facial expression is important to tx model)

Clear background from distractions

Turn off text-messaging and/or email

Wear appropriate clothing

Secure their device’s position

Camera at eye level

Phones/devices on airplane mode

Wear earbuds or headphones

Keep microphone close to their mouth

Keep speakers low enough so sound doesn’t come back through their microphone to create feedback

Dial in by telephone if Internet signal degrades but keep video connection alive.

Turn sound from computer off when using telephone to replace audio signal.

If video platform fails and connection is lost, exit and return to the virtual meeting room if possible. Stay off your telephone, and wait for directions by [email, text or telephone].

Start sessions by asking if everyone:

• Can hear you
• Can see each other
• Agrees to abide by posted group rules
• Is on a landline
• Has sign on the handle of a locked door to their space

Legal Issues for Telehealth Group Therapy Services

Across state lines

Clinicians not licensed in the state from where telehealth group therapy members attend must watch federal and state guidelines. Always consult state licensing board interstate practice policies.

For more information about practicing across state lines see COVID-19: TELEHEALTH ACROSS STATE LINES AND INTERNATIONAL BORDERS

Telephone vs Video Connections

Telephone-based care is approved by Medicare.

For applicable codes see MEDICARE APPROVES TELEPHONE SERVICE FOR COVID-19. State-based insurance companies may or may not all follow suit.

Check your insurance commissioner websites for your states, and get guidance from third party carriers as applicable. CCHP (Center for Connected Health Policy) maintains an up-to-date portal for information on state law reimbursement policies HERE.

In Summary

As policies change quickly, and each state responds differently to the COVID-19 pandemic crisis, clinicians are encouraged to be extra diligent. The hassle involved in checking current policy and dealing with companies that don’t all comply with state law, reduces the chances that you bill incorrectly and not get paid, or fail to bill at all.

For additional information on the COVID-19 Crisis and how it impacts telehealth services as a whole, see our primer HERE for a complete overview.

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 41,000 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 TBHI 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).