The relationship between quality of care and cost of care is complex. Less care does not always mean better care-- nor does more care. I'm not sure I would call this stewardship as much as necessary shifting in a crisis. In many cases, I think that we will see that outcomes appear comparable with telemedicine, with a lower cost. Nonetheless, the outcomes of the current shifts are unknown and will be important to study. There are bound to be some adverse events in the mix.

I guess the reward is reimbursement for delivering the service, or do you mean other kind of reward?

I am not sure what you might mean by this. If someone is a physician and bills for a telemedicine visit for medical care, it should not matter if they believe in or practice naturopathy or any other alternative modality.

If the clinician is a naturopathic physician; licensed in some states, but not all.

Currently Annual Wellness Visits are not on the list of services that Medicare covers via telehealth. The AMA is expecting a new regulation on COVID-19 to be issued by CMS soon and that regulation may expand the telehealth list.

Hi Sandy,

In FAQ #4 of this latest article from Medical Economics, Annual Wellness Visits (specifically G0438 and G0439) are included covered services that can be delivered via telehealth under the COVID-19-related changes to the program.

medicaleconomics.com/news/coro...

This is also consistent with the list of services included in the recent CMS fact sheet on the topic released earlier this month (note: you have to manually enter the URL listed in the table at the bottom to get to the link with the XLS):
cms.gov/newsroom/fact-sheets/m...

On the list of covered telehealth services Go439 is listed:
G0425 Inpt/ed teleconsult30
G0426 Inpt/ed teleconsult50
G0427 Inpt/ed teleconsult70
G0436 Tobacco-use counsel 3-10 min
G0437 Tobacco-use counsel>10min
G0438 Ppps, initial visit
G0439 Ppps, subseq visit
G0442 Annual alcohol screen 15 min
G0443 Brief alcohol misuse counsel
G0444 Depression screen annual
G0445 High inten beh couns std 30m
G0446 Intens behave ther cardio dx
G0447 Behavior counsel obesity 15m

Ms. Marks, can you kindly comment on this? Thank you

Yes, these codes are on the CMS list of telemedicine codes. The AMA has published the CMS list, updated to include the codes added yesterday. The list may be viewed at: ama-assn.org/system/files/2020...

when doing G0438 and G0439 via telemedicine - are the vital signs still a required piece?

I think I heard this asked on a CMS call and my recollection is that you are supposed to ask the patient about them, for example, if they monitor their weight and blood pressure at home. Sorry I do not have more definitive answer.

Hi Kimberly, I am curious if you've explored using RPM devices to get actual from your patients during the AWV. We're looking to pilot something with some practices around this solution that incorporates the actual telehealth visit along with live data actually collected in realtime from the patient devices. Have you seen anything like that, or have you explored adding in device connectivity to supplement the visit?

We anticipate that CMS will issue a new rule soon with additional COVID-19 policies and flexibilities. This rule may include changes to EMTALA such as allowing EMTALA screening via telehealth.

I know of Rural hospitals that are using telemedicine to staff their ED's. Bryan Health is doing it as staffing some of those facilities are challenging otherwise. Brochure attached here. As far as EMTALA, on call services are currently being used to satisfy requirements under EMTALA and CMS supports it (go.cms.gov/3apUM9U), but I haven't seen anything yet on telemedicine as the sole source for a medical screening exam. Would love to know if others have know otherwise.

Using Telemedicine as the sole source for the initial medical screening exam should be covered to satisfy the requirements under EMTALA, correct? Otherwise how is Bryan Health proceeding past the telemedicine step?

For rural applications where no other physician is available:

If no onsite physician is needed, the Telemedicine Physician performs the complete encounter. Telemedicine carts used in this environment are equipped with a stethoscope and examination cameras for the exam.

If an onsite physician is needed (for a procedural need), the Telemedicine Physician can start labs and/or Radiology orders while the physician is en route. This model exceeds the level of care with the on-call only ER coverage model that many rural hospitals use.

As noted earlier, telemedicine encompasses many modalities, including portals (including secure messaging), which are already a part of every major EHR system. Telephone care is telemedicine, as is "video care", and so on. Although some patients do not want or require these forms of care, many patients benefit, and perhaps nearly everyone has used a phone to call a medical office about a symptom. Thus, yes, not only *should* we enable and financially account for the uses of these various technologies, but we *must* do it to provide what I would consider to be the standard of care. There are lots of questions to be answered, regarding insurance, coding, security, and coordination-- not to mention medical indications for telecare-- but we're not in a position to retreat into the dark ages. As bad as COVID-19 is, perhaps a bright spot is the increased recognition of the value of telehealth care. Although we know a lot about the digital divide, that divide has narrowed quickly with mobile devices, cellular service, and the expansion of wifi, such that telecare can now decrease disparities and improve access. The physical distance can be a plus in a pandemic! I hope we don't have to realize that benefit as frequently as the others.

Telehealth is a great platform for medical student and resident education. It is like an OSCE but the student/resident does not perceive it as such. I always ask patient's permission to involve trainees, which should take care of the privacy concerns. For asynchronous exchanges, it is more about transparency; letting the patient know that a student is involved in the care and being specific about what roles people have as they touch the communication thread.

It is a novel educational opportunity but will likely be a baseline part of their professional future. I do not know if there are an guidelines and it might be something we start to develop. I think it can expand access to mentoring and can be done remotely, ie 3 way. Yes, it is important to have disclosure and permission. A new frontier!

Thank you for raising this question, Sherry. I know you and the AMA's CPT / policy / clinical experts were involved in the below document. It is an excellent summary of clinical scenarios and appropriate coding/reporting.

I assume this is a living document, so others on this PIN discussion should share additional scenarios which they are seeing in their communities but are perhaps not captured in the document. The AMA, I am confident, would be pleased to construct those additional scenarios.

Likewise, as we are all learning, share any corrections, additions or alternatives which may be pertinent.

ama-assn.org/system/files/2020...

I saw 10 patients yesterday on my own video app (ListenMD doctor) and called in medication renewals etc. A basic note created from voice to text said what the patient felt and what I did and was auto faxed from the app to document virtual patient visit. I still went to my emr, created encounter but felt odd detailing all the problems in the plan. So, if a basic call is made to renew meds, what codes to use and if a full review of EHR and review of labs, CT scans is made (short of physical exam), how best lo code especially now with COVID crisis?

New guidance from the AMA provides special coding advice during the COVID-19 public health emergency. One resource outlines coding scenarios designed to help health care professionals apply best coding practices. The scenarios include telehealth services for all patients. Examples specifically related to COVID-19 testing include coding for when a patient: comes to office for E/M visit, and is tested for COVID-19 during the visit; receives a telehealth visit re: COVID-19, and is directed to come to physician office or physician’s group practice site for testing; receives a virtual check-in/online visit re: COVID-19 (not related to E/M visit), and is directed to come to physician office for testing; and more. There is also a quick-reference flowchart that outlines CPT reporting for COVID-19 testing. A new web page on the AMA site also outlines CMS payment policies and regulatory flexibilities related to COVID-19.

Check the AMA COVID-19 resource center to stay up to date and for additional resources

ama-assn.org/system/files/2020...

ama-assn.org/delivering-care/p...

ama-assn.org/delivering-care/p...

Things keep evolving (in a positive way). We are bringing 11,000 providers up to speed on how to do virtual care. Options range from video, to asynchronous, to phone calls. The provider makes the decision which modality works best for the clinical scenario and in MA, all of our payers have promised to pay at parity with f2f. The big question in my mind is whether patients will ever want to go back to the old way once the dust settles.

We are finding that many patients, and not just seniors, have relatively little experience with audio-visual platforms like Skype or Zoom. This is certainly understandable – many of us are comfortable with these interfaces because our professional responsibilities demand it. Those whose jobs do not have less reason to be well versed.

Which gets us back to the original question? Will audio only (aka telephone) be covered?

There are a couple of options here. One is simply to allow payment parody with face to face service such as office-based E/M. There also is a set of telephone consultation codes, 99441-3, which are differentiated by time. The challenge with these telephone codes is that CMS does not cover them.
Either of these two solutions would help in the short-term. Thank you to the AMA for working on this on all of our behalfs.

CMS convened a public conference call "Lessons from The Front Lines: COVID-19" this morning. In a response to a question, CMS Administrator Seema Verma noted that an Interim Final Rule announcing additional Medicare policy related to the COVID-19 crisis is expected to be released within days. We are hopeful that CMS will address payment policy related to phone calls and other services. I will circle back to your question once the Rule is released.

Ms. Smith,
Thank you very much for your response. I appreciate the time you are all putting into this site.
Chris

Thanks Sherry. I'd like to know the answer to this as well. What about the uninsured? I am curious to know if you are aware of anyone discussing to how make telehealth available to this group as it relates to COVID-19?

The interim final rule released yesterday indicates that CMS will pay for services by telephone during the emergency. Those codes (98966-68; 99441-3) were not previously covered. The payment amounts are not as high as comparable E/M codes but it is a start. And the right thing to do.

Thank you Dr. Silva! Can you please clarify how the 98966-8 codes should be used vs the 99441-3? I have read the CPT definitions but can't figure out the difference. Many thanks for what you are doing.

99441-3 reside in the Evaluation and Management section of CPT. Many payors, including Medicare, will only pay claims related to the E/M to physicians and certain other qualified health care professionals. To ensure that other health care professionals may report their telephone services, CPT created a set of mirrored codes, 98966-8. Example of health care professionals who may report 98966-8 include physical therapists, occupational therapists and speech pathologists.

Again, thank you for your response. Have a good week.