Written by Farzad Mostashari and Emily Maxson

Telehealth Parity

Here at Aledade, we have been anticipating the financial challenges wrought by reduced office visit volume in the time of COVID-19. A key way to reduce that volume is by adopting telehealth (read more about Aledade’s efforts to promote telehealth here).

Traditionally, CMS payment for telehealth has been at the facility rate, which has meant that it brought in about 30 percent less revenue than an office visit. We have been advocating fiercely for telehealth payment parity with regular office visits.

On March 30th, CMS issued an interim final rule with a comment that creates true parity for practices between an in-office visit and a telehealth visit. Under this rule, any approved telehealth service will now net the same payment that your office would have been paid had you performed that visit in person.

How To Receive Parity for a Telehealth Visit

To receive parity for a telehealth visit that would have otherwise been performed in the office, CMS now instructs (pg15) practices to:

• Bill the place of service code had the service been performed in person (POS 11 for most of independent practices)

(Note that this is a departure from previous CMS guidance, which instructed practices to use the POS code 02. If you continue to use POS 02, you will be paid at facility rates.)

• Include new modifier -95

**Again, it is important to note that if a practice bills using place of service 02 it will continue to pay the lower, “facility” rate. To get parity a practice must bill the POS code of the service in person and use the new modifier -95.**

This is a real victory for primary care and we hope this policy change will ease the strain many practices are already experiencing. For Aledade ACO practices, we will update all Aledade Telehealth Toolkit materials accordingly.

Telephone-Only Visit Update:

On March 30th, CMS also added a series of telephone only codes to accommodate longer time periods. Physicians, NPs and PAs can bill:

• 99441 (5-10 minutes, $15.99)
• 99442 (11-20 minutes, $31.13)
• 99443 (21+ minutes, $45.37)

You do not need a modifier for these visits, as these CPT codes are for telephonic visits by definition, and you should use the usual place of service.

We have received a lot of questions about the ability to provide telehealth services without the video component. Though CMS did expand the number of services that practices can bill over the telephone only as above, it did not relax the telehealth video requirement for performing and billing other telehealth visits at parity.  

The expansion of the number of telephonic services is great news, but practices should be aware that if they elect to perform a visit with phone only and without video enablement, they should use the telephone specific billing codes and the visits will be paid at the corresponding rates.

We are humbled at how quickly practices have pivoted to adopt new technology to serve their patients and keep them safely at home. We hope that this new billing guidance encourages practices who are still considering the transition to go ahead and take the plunge.  

UPDATE (March 23, 2020)

We have reached a turning point in many of our communities, in which questions on health care personnel exposure and self-quarantine protocols have become more prevalent. This update will explore this topic.

Before we discuss the CDC guidelines on risk assessment after exposure, a few pertinent updates:

• We are thrilled to see the enthusiasm among our practices for our new collaboration with Updox to provide telehealth enablement below cost as we respond to this crisis. To those practices who are still considering it, we highly encourage you to take advantage of it. 
• The App Team has made quick adjustments to the COVID-19 App Home Page so Aledade ACO practices can access the telehealth information, patient resources, and COVID-19 library in the Aledade Learning Center. 
• We have changed the questions on the Practice Needs Assessment to help us better tailor our support to our ACO practices’ needs and concerns. We encourage all of our practices to respond fully, so that we can fully meet their needs in this rapidly-evolving situation.

How do I assess my risk (or my staff member’s risk) after potential exposure to COVID-19?   

SOURCE: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

The CDC interim guidance identifies several data points that go into your determination of the risk of contracting COVID-19 after potential exposure: 

1) whether you were wearing PPE at the time of exposure; 

2) whether the person of interest with possible COVID-19 was wearing a mask at the time of exposure; and 

3) whether you had prolonged contact with this person.  

While the first two are relatively straightforward, the third is not. This is how the CDC explains “prolonged, close contact:”

Close contact for healthcare exposures is defined as follows: a) being within approximately 6 feet (2 meters), of a person with COVID-19 for a prolonged period of time (such as caring for or visiting the patient; or sitting within 6 feet of the patient in a healthcare waiting area or room); or b) having unprotected direct contact with infectious secretions or excretions of the patient (e.g., being coughed on, touching used tissues with a bare hand).

Data are limited for definitions of close contact.  Factors for consideration include the duration of exposure (e.g., longer exposure time likely increases exposure risk), clinical symptoms of the patient (e.g., coughing likely increases exposure risk), and whether the patient was wearing a facemask (which can efficiently block respiratory secretions from contaminating others and the environment), PPE used by personnel, and whether aerosol-generating procedures were performed.

Data are insufficient to precisely define the duration of time that constitutes a prolonged exposure.  However, until more is known about transmission risks, it is reasonable to consider an exposure greater than a few minutes as a prolonged exposure.  Brief interactions are less likely to result in transmission; however, clinical symptoms of the patient and type of interaction (e.g., did the patient cough directly into the face of the HCP) remain important.  Recommendations will be updated as more information becomes available.

Armed with these definitions, you need to classify the health care personnel’s (HCP) exposure as high, medium, or low risk.

• High risk: “prolonged close contact with patients with COVID-19 who were not wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19”; OR present for aerosolizing procedure or event WITHOUT wearing PPE
• Medium risk: “prolonged close contact with patients with COVID-19 who were wearing a facemask while HCP nose and mouth were exposed to material potentially infectious with the virus causing COVID-19”; OR present for aerosolizing procedure or event while wearing PPE
• Low risk: “brief interactions with patients with COVID-19 or prolonged close contact with patients who were wearing a facemask for source control while HCP were wearing a facemask or respirator.”  Note that eye protection further lowers risk.

After classifying your risk of exposure, you can use the following table to find out what to do.  Note that active monitoring implies that the health department or other delegate is recommended to monitor the exposed HCP.

The other nuance worth noting is that the above guidance is for those who are caring for a confirmed case.  In the majority of concerning events in our outpatient community, we might assume that the person’s COVID-19 status is still unknown.  In the event of unknown COVID-19 status (testing sought or pending), monitoring and work restrictions listed here could still be applied if the test results for the patient are not expected to return within 48-72 hours:  “If the results will be delayed more than 72 hours or the patient is positive for COVID-19, then the monitoring and work restrictions described in this document should be followed.”

Here’s a helpful explanatory chart from the CDC:

We are so thankful for all our health care workforce is doing for our communities.

UPDATE (March 18, 2020)

Yesterday, Medicare released their eagerly anticipated telehealth guidance. (You can find our detailed analysis of it here) Today’s update focuses on the most pertinent details of the telehealth guidance, highlights our telehealth strategy moving forward, and then progresses to patient messaging.

Personal Protective Equipment Update

First, great news – we may be able to procure masks, hand sanitizer, and gowns much sooner than 6-8 weeks. Aledade partner practices should refer to our Practice Needs Assessment and stay in touch with their Practice Transformation Specialist for more details. If you need a refresher on recommended PPE in different situations, please see the CDC’s guidelines here.

Medicare Telehealth Guidance

FaceTime and other consumer technology are now explicitly allowed under HIPAA for the duration of the declared national emergency related to the COVID-19 virus. The guidance expressly permits the use of non-public facing consumer platforms to conduct telehealth encounters.

Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. 

Two Important Notes:

1. Visits will still be subject to State-specific laws and regulations governing the provision of telehealth as well as state-specific privacy regulations. Among other things, these laws address how a patient may consent to telehealth, which providers may conduct telehealth encounters, and the type of equipment that can be used. Aledade’s legal counsel is in the process of preparing State by State summaries, which will be ready for distribution by Friday.
2. Purpose-built telehealth tools have many features such as consent management, waiting rooms, etc. that are not available in consumer technologies. If you use consumer technology, you need to ensure all requirements are met. The only thing the waiver does is waive enforcement of the privacy and security requirements around the technology itself. Aledade’s legal team is preparing a template consent-to-telehealth-treatment document that you can tailor to reflect your practice’s name, location, and type of equipment.

• Rural health centers and federally qualified health centers were not excluded from this guidance, which means that their qualified professionals (physician, NP, PA, CNM, clinical psychologist, clinical social worker) can bill for these services where such practice is authorized by state law.  
• Medicare will pay the facility rate for the service. Facility rates can be found in the physician fee schedule lookup tool. The list of services available through telehealth is here.   
• “How do I bill for these visits as telemedicine visits? Do they require additional documentation?” Traditional physician offices bill the CPT code with site of service code -02. Federally Qualified Health Centers and Rural Health Centers bill the CPT code with the GT modifier. The documentation is the standard documentation needed to support the CPT code plus patient consent to the service.
• “What about patient co-pays?”  Practices can charge a co-pay, however, HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
• “What about tele-enabled Annual Wellness Visits” As you know, AWVs require blood pressure and BMI measurements. The CMS guidance does not contain any special provisions to exempt telehealth AWVs from these vital sign requirements. In lieu of forgoing these important visits altogether, Aledade’s recommendation is to provide a virtual E&M with time-based coding and complete as many of the typical AWV components as feasible. Please note that for an E&M visit, you must comprehensively document your assessment, decision making, and plan in order to link a diagnosis code to the bill, which has implications for providers’ accurate risk coding efforts.

Commercial Telehealth Guidance

Our commercial team at Aledade is gathering and maintaining an ever-changing assessment of commercial insurers’ approaches to telehealth during this emergency. We will post this information externally as soon as feasible. 

Aledade Telehealth Strategy

We are considering telehealth enablement a company-wide imperative. This technology will provide a means for vulnerable patients to stay at home and avoid exposure while still receiving necessary healthcare, and we expect telehealth billing to serve as an essential avenue for practices with COVID-19 related staffing challenges to continue to serve their patients.  

We are in final negotiations with a telehealth vendor that will be able to work with us to get interesting practices engaging patients quickly with a fairly lightweight, intuitive solution.  

We are wrapping up work on our Telehealth Toolkit, which will include workflows for FaceTime telehealth enablement, generalized telehealth guidance, and patient messaging.

This Friday morning at 9 AM EST, we’ll hold a special Aledade Rounds devoted to telehealth enablement during this public health emergency. Aledade CEO Farzad Mostashari will be joining us as a special guest. This will be recorded and made available as soon as possible for others to digest asynchronously.

Patient Messaging

For all interested Aledade ACO practices, Aledade will be mailing postcards to all Medicare patients at no cost to the practice. These postcards remind patients to call the practice with any health care concerns, educate patients on COVID-19 typical and emergency symptoms, and provide a few useful social distancing reminders. 

This week for interested Aledade ACO practices, we will deploy a third-party service to contact Medicare patients by phone to emphasize what they can do to stay healthy and avoid exposure, and to educate patients on typical and emergency symptoms of COVID-19. We will encourage patients to call your practice with questions. 

If you are an Aledade ACO practice interested in Aledade contacting your patients directly by phone, text, or postcard with the messages above, please reach out to your Practice Transformation Specialist (PTS)

There are two unique messages that I think patients particularly need to hear:

• It is essential that patients with chronic disease take their medications during this time, in which COVID-19’s effects on patients’ access to the practice is unpredictable. We encourage you to enable mail order pharmacy for vulnerable patients and/or take other measures to ensure your patients have a 3 month supply on hand.
• Vulnerable patients should stay out of healthcare settings whenever prudent.  In addition to enabling telehealth visits if possible in your practice, it may be wise to advise patients to postpone elective surgical procedures and visits and touch base with specialists virtually when possible.

Please stay tuned for additional support.  We remain open to thinking creatively about practices’ needs.

UPDATE (March 15, 2020)

As health care workers across the nation and the globe respond to the outbreak of COVID-19, we have turned to practices to understand what their top concerns are at this moment. A recurring theme is the need for more information and resources around testing patients for COVID-19, availability of Personal Protective Equipment (PPEs), and transition to tele-visits to protect vulnerable patients and staff.

Our Latest Research on Testing Protocols and Procedures

Over the last few days, our team has done a deep dive into available testing protocols and procedures and discussed with private lab companies the testing shortage issues that a number of practices have reported to us. We hope that today’s update on our best understanding of appropriate testing procedures for COVID-19 will help practices keep their staff safe, while enabling them to serve as stewards of scarce testing resources. For Aledade-affiliated practices and staff, these updates and additional information are available on the Aledade Learning Center.

Notes on Limited Supply of Tests for Commercial Labs

According to one private lab company that we have been in close contact with, the lack of supply combined with providers’ initial enthusiasm in screening large numbers of patients has depleted the supply of testing kits. Because of that, practices might find companies rationing tests in many areas. We are working to connect practices with some of these companies directly to help them gain access to tests when supplies are critically low.

Protective Equipment

Our internal Practice Needs Survey has identified N95s, regular facemasks, and hand sanitizer as the top needs among practices. As we work to support practices, we are running into reports of a 6-8 week delivery time frame for N95 masks in particular. While other channels may have different timelines, we recommend practices prepare with these delays in mind.

Televisits

Televisits are an essential tool to protect our health care system’s capacity during this outbreak. Not only do they allow patients and their physicians to communicate quickly and efficiently, but they also protect physicians and their staff from being exposed to the spread of COVID-19 and thus reduce the need for quarantine and the risk of contracting the illness themselves. We are working hard to support tele-visit enablement (including vetting telemedicine vendors and EHR integrated platforms and monitoring for the release of CMS’s initial guidance after the passage of the telemedicine regulation). We will continue to update practices on those efforts and expect to share more publicly in the next week.

UPDATE (Wednesday, March 11): The Federal Government Temporarily Permits the Use of Facemasks for Health Care Workers Caring for COVID-19 Patients

SUMMARY: If you are having difficulty finding N95 respirators due to a shortage, the federal government is temporarily allowing you to use facemasks when caring for patients with known or suspected cases of COVID-19.

Late last evening, CMS, the CDC, and the FDA came together to put out new guidance expanding the types of face protection that are recommended for working with patients with suspected cases of COVID-19. Because the CDC has determined that early reports of COVID-19 “suggest person-to-person transmission most commonly happens during close exposure to a person infected with COVID-19, primarily via respiratory droplets produced when the infected person coughs or sneezes”, the federal government is permitting the use of facemasks rather than respirators when respirators are in short supply. (Facemasks protect the wearer from splashes and sprays. Respirators filter air and provide the wearer with respiratory protection.)

At Aledade, we applaud the federal government for taking this step, as we have been advocating for measures like these to ease the resource constraints that many primary care practices face. We look forward to similar, proactive measures as the outbreak of COVID-19 develops.

The memorandum states:

Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable temporary alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to Health Care Providers (HCP).

CMS recommends that “when the supply chain is restored” practices with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Those practices that don’t have a respiratory protection program, but care for patients infected with pathogens for which a respirator is recommended, should implement a respiratory protection program.

The federal government continues to recommend eye protection, medical gown, and gloves for practices caring for patients with COVID-19.

Original Post (Monday, March 9)

As the world navigates increasing public health concern from the outbreak of a new coronavirus (COVID-19), we have been in steady contact with our practices across the country. On top of their day-to-day work to keep their communities healthy, they’re preparing for this outbreak, answering questions from patients and families, and checking in on their high-risk patients.

We wanted to share some of the information we’ve provided to them, in case it can be helpful for other providers or anyone looking for more information on how this outbreak can affect primary care practices.

But first, as this is a new virus and public health experts are learning more about it each day, we recommend staying tuned to CDC’s virtual “Situation Room”, where you can remain up to date on US cases and general emerging information. Johns Hopkins Center for Systems Science and Engineering has also created a dashboard of the latest cases and trends in the disease. 

With high infectivity of the virus and cases mounting daily, it seems likely that sustained transmission will eventually occur in most communities. The goal of mitigation will be to use common-sense measures to slow the spread of the virus, thereby reducing stress on health care systems and buying time for development of effective treatment and vaccines. (For further reading on how businesses, communities, and individuals can practice preventive behaviors, see: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3549276)

Figure 1: Intended impact of enhanced hygiene and social distancing measures on the COVID-19 pandemic adapted from Fong.

What should I tell my patients about COVID-19?

The CDC has boiled down what the general public needs to know in patient-friendly language. Patient Friendly handouts in English, Spanish, and Chinese are located here. The top 5 facts from the CDC are:

1. Diseases can make anyone sick regardless of their race or ethnicity. (People of Asian descent, including Chinese Americans, are not more likely to get COVID-19 than any other American.)
2. Some people are at increased risk of getting COVID-19. (including people who have been in close contact with a person known to have COVID-19 or people who live in or have recently been in an area with ongoing spread).
3. Someone who has completed quarantine or has been released from isolation does not pose a risk of infection to other people.
4. You can help stop COVID-19 by knowing the signs and symptoms (including fever, cough, and shortness of breath).
5. There are simple things you can do to help keep yourself and others healthy:

• Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food.
• Avoid touching your eyes, nose, and mouth with unwashed hands.
• Stay home when you are sick.
• Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

As COVID-19 is a relatively new pathogen, and information about the disease is changing as we learn more, we recommend staying attuned to the most up-to-date clinical criteria, which can be found here: Evaluating and Reporting PUI Guidance (CDC 2/27/2020)

Who is most at-risk for COVID-19?

A vital part of value-based health care is keeping a focus on the highest risk patients. With COVID-19, there are a few different aspects that put patients at higher risk:

• Age, comorbid hypertension, and cardiovascular disease are associated with worse outcomes (more so than diabetes or cancer)
• Smoking is associated with worse outcomes.
• On the opposite end, young children are often associated with both fewer symptomatic cases and better outcomes

Two of the most prevalent symptoms in confirmed cases have been fever and a dry cough, and the most common avenue of spread, at least in China, was family spread.

You can find out more in this detailed interview with an expert from WHO, “China’s cases of Covid-19 are finally declining.”

How can a practice screen for COVID-19?

The public and private sector have been collaborating on a number of different ways to support screening for COVID-19.

• America’s Health Insurance Plans have said they are working to ensure out-of-pocket costs don’t stop patients with private coverage from being a barrier to testing
• Individual private payers are taking steps. For example, Blue Cross Blue Shield of North Carolina will cover doctor visits to screen for COVID-19 the same as any other doctor visit, based on a member’s health plan.
• Medicare has specified that screenings are free to Medicare beneficiaries, and that, starting in April, laboratories performing the test can bill Medicare and other health insurers for tests that occurred after February 4.

Likewise, private labs including Lab Corp. and Quest Diagnostics have begun offering testing for COVID-19. Labcorp has announced that they will provide the necessary supplies at no charge and insurance will be billed for testing. Sample collection instructions can be found here.