Telemedicine Considerations During the COVID-19 Pandemic

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At this challenging time for patients and providers, telemedicine represents a unique opportunity to ensure continuity of care for our cancer patients while minimizing risk of exposure to infection. On March 17, 2020, the Centers for Medicare and Medicaid Services (CMS) agreed to pay providers to care for Medicare beneficiaries for office and hospital visits via telehealth anywhere in the United States. This went into effect retroactively on March 6, 2020, and will continue throughout the COVID-19 pandemic.

• Real-time audiovisual interaction is required (as of March 29, 2020).
• No reduction in rates; payment is the same as in-person visits.
• Normal co-pays and deductibles may still apply.
• Department of Health and Human Services will not be conducting audits to ensure that a prior relationship existed for claims submitted during the public health emergency.
• During the COVID-19 health crisis, CMS will not require the previously mandated business association agreement (BAA) for video technology for Health Insurance Portability and Accountability Act (HIPAA); HIPAA-compliant encrypted video technology should be used as soon as is feasible.

CMS has categorized three encounter types that do not require in-person visits:

1. Telemedicine visit – real-time audiovisual communication
2. Virtual check-ins are meant to be five- to ten-minute phone calls to serve as a brief communication with the patient that is not related to a visit within the past week or in anticipation of an office visit within 24 hours ahead
3. E-visits are interactions/requests initiated by a patient through an electronic medical record portal

Source: Medicare Telemedicine Health Care Provider Fact Sheet (CMS, March 17, 2020)

Considerations as You Get Started:

• Basics of what you need: EHR access, phone line, video, ensure adequate broadband connectivity.
• Have a secure quiet place to conduct the telehealth visit.
• The patient must give consent to participate in a telemedicine appointment (example below).
• Verify your patient’s identity when you start the encounter if the patient is not logging in through a secure patient portal.
• Investigate what technology is in place for your EMR at your hospital (i.e., computer stations in hospital, phone/iPad or other handheld technology based secure platform in your EHR such as Haiku or Canto for EPIC or other electronic medical record programs like Cerner, Allscripts).
• If you are in private practice, reach out to state and county medical associations for resources (e.g., the California Medical Association) on telemedicine pertinent to your practice.
• Self-standing platforms exist outside of EHR systems (see resources at bottom of document for information on these). BAA requirement for vendors has been waived by CMS during the COVID-19 pandemic however all insurance companies may not reimburse for vendors where a BAA does not exist to take responsibility for data breaches.
• If using basic videoconferencing tools such as FaceTime, Google Hangout, Skype, these platforms were not considered HIPAA compliant, but given the COVID-19 pandemic are able to be used for telemedicine encounters. Similar BAA considerations exist for these platforms and insurance reimbursement.
• Schedule carefully: Train your staff to enter telehealth appointments and consider scheduling any in person or urgent visits in one segment of the day and your telehealth visits grouped before or after this.

Example Statements for the Encounter:

• Scheduling notification: “Please join at least 5 minutes beforehand. Your provider will make every effort to join on time but please stay connected if they are not on exactly at your scheduled time. If they have not joined within 10 minutes of the appointment, please feel free to call their office for an update. From the ‘Epic MyChart’ mobile app or user application, please test your device’s video connection prior to your visit by selecting ‘test video’ when prompted. Please note: You may be liable for any relevant copays or coinsurance depending on your insurance plan.”
• Consent to include in note that patient signs electronically or verbally agrees to:
  Patient Consent to Telehealth Questionnaire
  (Name of patient) – I agree to be treated via a video visit and acknowledge that I may be liable for any relevant copays or coinsurance depending on my insurance plan. I understand that this video visit is offered for my convenience and I am able to cancel and reschedule for an in-person appointment if I desire. I also acknowledge that sensitive medical information may be discussed during this video visit appointment and that it is my responsibility to locate myself in a location that ensures privacy to my own level of comfort. I also acknowledge that I should not be participating in a video visit in a way that could cause danger to myself or to those around me (such as driving or walking). If my provider is concerned about my safety, I understand that they have the right to terminate the visit.

Billing Considerations:

• Telemedicine is not universally covered, is regulated by the state you practice in, and is dictated by individual insurers; check for reciprocity of licensing with your board before providing care to patients who live in a state that you are not licensed in.
• Document the time spent speaking with the patient in your note.
• Visits with real-time, two-way audiovisual are encouraged and better reimbursed, but CMS will pay for telephone only services at a reduced rate during the COVID-19 crisis.
• Medicare Advantage has better reimbursement and will give a Part B payment to physician and a facility fee to the health care site hosting the patient if the physician is connecting from a healthcare site.
• Most Medicaid programs pay the same rate as face-to-face services.
• Payments by commercial insurance are not required to be equal to those for face-to-face visits and coverage may be limited to certain providers according to the insurance company.

Which Gynecologic Oncology Patients Are Best Suited for Telehealth Visits:

• Identify which patients have active issues that can be addressed through telemedicine:
  o Chemotherapy, immunotherapy, maintenance drug surveillance visit
  o Postoperative check for incision after minimally invasive procedure
  o Progression of disease requiring change in drug, but medically stable
  o Goals of care discussion with someone who is at high risk of infection
  o Select new patient consultations
• Patients for whom telemedicine is not a good option:
  o Routine cancer surveillance visits for patients in remission greater than one year; recommend delay in visit two to three months
  o Endometrial cancer routine surveillance
  o Symptomatic disease burden requiring in-person evaluation
  o Concern for postoperative wound infection/complication, vaginal bleeding
• Remote collection of vital signs is evolving, blood tests can be done offsite at private laboratories if patients want to avoid coming to the hospital or medical center.

Troubleshooting:

• What to do with a failed telehealth visit.
  If the technology does not work or provider/patient is not able to login, one can list the interaction as a failed telehealth visit, and document a telephone encounter as a virtual check in. Reimbursement may be less, but a provider can still provide a code for the interaction.
• Older patients or patients in resource poor settings may not have access to or may have trouble using technology for telehealth visit. Consider this when booking the patient. Identify an office staff member/medical assistant to reach out to the patient prior to the encounter to walk them through logging in.
• Coding/reimbursement guidelines continue to evolve. SGO, ACOG, AMA, ACOG, and other organizations will update recommendations.

Resources

• SGO Coding Corner with David Holtz, MD
• Medicare Telehealth Frequently Asked Questions
• Medicare Telemedicine Health Care Provider Fact Sheet
• From Shitanshu Uppal, MD, MBBS: FaceTime or WhatsApp: How to implement video calls using FaceTime
• AMA Quick Guide for Telemedicine