COVID-19 Practice Operations Discussion Forum: Telehealth - Q&A

What percentage office encounters are you seeing now via telehealth vs face-to-face pre-COVID?

100%, after just a couple of days mid March with mix of services. However with all the conversions, moving procedures around, cancellations, and people refusing to convert, efficiency of filling blocks of time is about 30-50%. This should ramp up. Don't forget to reach out to your May and June new patients and bring them into unused slots NOW. Make liberal use of short followup e-visits to fill upcoming open space.

In my city, the hospital has converted the space where endoscopy is normally done to a COVID-19 space. Now hospital-based endoscopy must be done in the OR with the patient on a vent. Not optimal. Is there a possibility HOPD rates will be allowed for ASC's that must be activated to accommodate endoscopy patients normally done in the hospital?

If the hospital is taking over ASC space they will be billing as HOPD. The question is how the ASC gets paid out of hospital revenue and when, what? That would need to be worked out locally.

Will our telehealth visits be subject to the MIPS calculations? is this the same kind of documentation in our notes required?

MIPS is essentially suspended or will be exempt, just like places knocked out by floods in recent years. CMS stated you don't have specific requirements of history, physical to document telehealth visits; if you're billing based on medical decision making or total time the day of the encounter.


We are using Zoom for telehealth, I'm not aware of their security issues, could you tells us more about it? Should we switch to something else?

There may be security issues if the platform used does not comply with HIPPA rules. Platforms like Zoom have stated they are attempting to correct to their security problems. Make sure you are using the latest version. Tip for the GI Team: Some GI teams find it efficient to use Microsoft Teams for communication between teams of staff, particularly when everyone is off-site. For example, the Medical Assistant can interview the patient, admit to the virtual waiting room, and signal the provider to enter the encounter. Other such solutions may be available.

There has been reluctance on the patient part to use telehealth as they don’t want to be charged and want the advice free? Any suggestions regarding how to improve the acceptability?

Try to encourage them to have some kind of visit, letting the patient know that it is a covered service taking the place of an office visit and that is how it will be charged. Assure them that the co-pay is not more than what you normally would have for an office visit. If the patient is still reluctant, conduct a telephone service. Medicare will cover this telephone service, but the rate is not as high. If the patient is still reluctant you may explain that the practice cannot povide free care because of state of the office staff and to maintain the finances of the practice. You are being flexible, they should be flexible.

My practice has learned that private insurers such as have relaxed the stringent requirement that telehealth visits are audio and video, and are allowing audio only. Are these private insurers allowing the SAME payment or do the telphone only codes over this?

"Audio only" is essentially by telephone and is now billed by telephone visits codes 99441-43. There is a set of codes for non-physician providers. Payments are at a lower level than office visit equivalent and the 'maximum' time of service in the codes is 30 minutes. There are a few private payers paying for telephone service as if they were telehealth, i.e. at office visit rates and via office visit CODES. Check the websites and bulletin alerts of your payers for this information.

Do you envision physicians using telehealth (video) visits in lieu of basic phone calls when handling after-hours calls or phone inquiries on weekends?

Phone calls on weekends could indefinitely convert to telehealth visits. Triage type situations could be moved to conducting via telehealth and collecting a charge. This is an pportunity that was not done previous to COVID-19.

Do you inform your physician referral base about your capability for patient telehealth? How did they respond?

We have not formally done so. In our community and in many areas across the country, the majority of physicians, including referring physicians, are doing telehealth in most areas and have to adhere to orders that have been put in place locally.

Is time use for E/M coding not just face-to-face time? Can you include time to review documents etc?

For Medicare, retroactive to March 1st, the entire day's time needed for the encounter can be the basis of code selection, which is what was planned for 2021 for office/outpatient visits. So, this will include the face-to-face time, time to do your note, prescriptions, labs, pre-authorizations, pre- or post- visit record review same day, and that total time can determine the code for that visit. See the Encounter Time document posted in GI Leap to understand what times link to these codes.

If you work from home, do you have suggestions for "website manner" (similar to bedside manner). What should home office look like? How should providers dress, behave, etc.

It may be beneficial to have two monitors or two computers - one with EMR up and the other on which your patient can see you. Another option would be to use a split screen where you have your chart on one side and video up to communicate with the patient on the other side while having the ability to can write note and look up thngs on the chart. You can also create a background, either white sheet background, digital logo or a conduct visit in your home office/den. There are a couple lines of thought on the dress code. Dress as if you were going to the office to see a patient, e.g., wearing labcoat. Another perspective would be that patients may not have an objection with seeing provider in more informal dress, knowing you too may be homebound. This could provide an intimacy with patients in the COVID era that they would not otherwise experience.

Please address ASC conversion to a COVID hospital and receiving hospital reimbursement.

Some organizations are being contacted by hospitals to expand their service umbrella. If your organization is set up to accommodate the conditions of the hospitals you may be required to assist. However, many endoscopic ASCs may not provide for an efficient use of space. For example, a pure Ambulatory Endoscopy Center is a nonsterile environment with limited space. Organizations in larger multispecialty ASCs with sterile and nonsterile environments may have a higher degree usable space for the needs of HOPD services.

What date are you scheduling screening colonoscopies again? Do you schedule a follow up visit in 6 months as virtual visit? Will the reimbursement rules change then?

It is unsure whether the liberal rules will apply once the emergency restrictions are no longer in effect. Telehealth visits can be scheduled and then converted into an in-person one if the restrictions are lifted. In the future, there may be flexibility to choose either modality.You can also assess required procedures and setup reminders for these procedures to determine if they should be done or if a telehealth visit is appropriate.

I have found two cancers in the COVID era method. How can we treat patients with while there are restrictive policies over the next?

For serious clinical diagnoses make sure endoscopy center is doing its best to perform cases that are appropriate to do based on the seriousness of the situation. You would be able to justify the choice without the liability for cases appropriate to do. Regulatory and legislative avenues may be adopted which shield physician liability for situations where delayed diagnosis is unavoidable or missing 'physical findings' of importance was unavoidable. Given the restrictions on nonemergent proecedures though, patients who might not have 'needed' the procedure NOW who have the procedure and suffer complications or wind up in hospital may increase liability exposure, both professional liability and even threats to medical licensure.

There seems to be a difference of opinion among clinic physicians on how to properly document the physicial exam portion of the note. Some say to list no physicial exam was performed. Others state interaction with patient regarding last recorded temp, SOB, mental state and list patient answers as part of the record. Please provide guidance.

Since the CMS Interim Rule of March 30, 2020, but made retroactive to March 1, Medicare does not require any specific amount of history or physical exam in patient notes. We use a telehealth template that simply describes general appearance. If you can or SHOULD do more of a virtual exam, document what's medically necessary. Focus on medical decision making or length of time spent during the entire day to provide the encounter as the basis for code choice. Private payers may not accept these rules however. For new patients in this situation, stick with 1995 or 1997 guidelines and document for example that cranial nerves appear intact, psychiatric status is good, there is no mood disorder and some other systems (eg no visible goiter) need very few 'systems' to get to a level 3 new patient.

Can providers use “phone only” to provide services? How are you billing for new patient visits for telehealth?

Telehealth refers to the 'audio/visual' realtime communications and not face-to-face. Pre- Covid-19, this was not covered by Medicare. Telephone services are opened up now for services on new and follow-up patients. This can be confused with quick check-ins or virutual check-ins, which are five to ten minutes services. Virtual check-in should be viewed as having the patient follow-up in a week or two on how they are doing following some type of visit with them. This G2012 service can be reported without a frequency limit if medically necessary and documented (time, details, medium used). Practices should refer to rules of private payers to see if how they cover telehealth and related services. Billing for telephone services uses existing CPT codes (99441-99443, different codes for other non physician qualified healthcare providers). Place of service should be used for where you would have typically taken care of the patient. For the telehealth visit, it was approved to use office visits codes for physicians or APPs and a wide variety of others. Refer to ASGE FAQ or CMS FAQ on recently passed interim rule that is retroactive to March. In summary, telehealth visits are billed as if you were in the office and telehealth for established office patient would be the existing office patient codes, using new patient and established patient codes (99201-99215). Almost the entire set of E/M codes are accepted for Medicare for telehealth during this emergency. You will need to check with private payers. Another liberalization Medicare has established is that for documentation, you can base your coding decision on either the medical decision making complexity or the time you spend the entire day of the encounter. (Next year's rules).

How has provider time scheduled for a new consult or follow-up visit changed using telehealth?

Telehealth is new for some practices and evolves and improves each week. Regarding scheduling, some practices currently schedule 30 minutes for both recurring and new patients. The first 5-7 minutes involve ensuring the patient is able to log on. The Medical Assistant may also join the visit. The patient is reminded of the visit the day before and 15 minutes prior to the visit. Returning patients may not need the full 30 minutes. Catchup time is built in because some visits do not take the full 30 minutes. Each week scheduled telehealth visits increase as staff and patients acclimate to the new normal.

Are your schedulers working in the office or at home? What are you hearing from your schedulers relative to the patient experience with telehealth?

Some states are in a shelter in place situation while other states still have limited patient contact at the practice level. Many groups have moved scheduling off-site. Things to consider: Transition is easier if you have a phone system that is capable of allocating inbound calls to various phone numbers in a balanced way. The other point to consider is the challenge of staff that do not have landlines and their cell contracts may not have unlimited minutes. Moving practice calls to these staff may have a financial impact on their private cell phone bills. Practices may wish to consider compensating staff for minutes used or provide “business only” cell phones. Practices have stated that patients have had a positive experience, often not realizing the staff member is at home and not in the office. An ongoing challenge will be the ability to measure productivity for staff working from home.

What are the top two things your practice has done to prepare for a telehealth visit?

Pre-calls are important so both the patient and provider are prepared for the telehealth visit. Pre-calls should be completed before the provider engages the patient. Training of staff is also important. Create an infrastructurre with staff for services and train staaff such as administrative assistants and front desk receptionists to schedule telehealth visits. Practices should identify allies in the industry like labs that provide phlebotomies, stand alone radiology companies, home infusion services and places that pick up and drop off stool sample kits. In addition, creating instructions and other publications for patients is important to get done and distributed. Acquiring apps that can easily connect with patients and utilize caller ID features that routes the number office number is helpful for staff working remotely as well. agents are prepped. The goal is to run like clinics as best as you can and to keep patients out of the emergency room.

Does the provider need to be in the office for the telehealth visit?

No. Practices are primarily conducting telehealth visits in a home location. Most staff is working from home

How can patients prepare for the telehealth visit? How are provider orders communicated to the patient?

See ASGE Telehealth FAQs on preparing for patients. Provider orders: Communicate plan and send hard copy of visit in the usual information sheets. Scheduling is immediate. Assess the risk with timeframe. semi emergent endoscopy suite..

What are the successes you have experienced providing telehealth services?

The health of patients is the priority and patients are grateful that you providing and guiding them in a way to receive the best care. Staff and Providers are closer, incorporating things such as early morning staff meetings before going on to their respective roles. There is more of a comraderie to iron out kinks and to create a different positive culture in these critical times.