are in listen-only mode. Hello, and welcome to our monthly HCC Intelligence webinar and virtual office hours. Today's webinar is presented in collaboration with the American Academy of Home Care Medicine, and is entitled COVID-19 Updates, Advanced Care Planning, Self-Care, Team Care, and Centers for Medicine and Medicaid Services Telehealth Changes. My name is Danielle Feinberg, HCCI's coordinator for education and research. I will be your moderator for this event. Before we begin, I would like to cover a few housekeeping items with you. All participants are muted, but please use the chat or the questions boxes located on your screen to submit comments and questions. Questions that are submitted will be answered when we transition into the virtual office hours portion of the webinar. The recording of the webinar, slide presentation, and transcribed Q&A will be made available on HCC Intelligence page no later than Monday, April 20th. Today, we are joined by Dr. Rachel Miller, Associate Professor of Clinical Medicine, Director of Education, Division of Geriatrics, University of Pennsylvania. Dr. Matan Shukman, Assistant Professor of Medicine, Gerontology, Medical Director for Johns Hopkins Home-Based Medicine, J-Home Program, Johns Hopkins Medicine. Dr. Mariah Robertson, Clinical Fellow, Geriatric Medicine and Gerontology, Johns Hopkins Medicine. Dr. Paul Chang, Senior Medical and Practice Advisor, HCCI, and Medical Director of Northwestern Medicine, Home Care Physicians. And Ms. Brianna Plensner, CPC, CPMA, Manager, Practice Improvement, HCCI. The objectives for today's webinar are explain how to conduct effective advanced care planning conversations through telehealth in the setting of COVID-19. Discuss how to apply the Bridges Transition Model to your work environment in order to anticipate and address psychological distresses in the context of the COVID-19 pandemic. Understand the Centers for Medicare and Medicaid Services telehealth waiver flexibilities as a result of the new interim final rule. And to discuss challenges and solutions to providing virtual care to complex patients. Without further ado, I would like to turn it over to Dr. Rachel Miller and Dr. Mariah Robertson. Thank you so much. This is Dr. Robertson speaking. It's such an honor to get to talk with everyone today. We're gonna talk a little bit about advanced care planning in the COVID era, specifically focusing on telemedicine and connecting homebound patients, connecting with homebound patients. I have experience in public health prior to medicine and have a passion for the homebound older adult patients. So this has been particularly important in the last couple of weeks as I've thought about our practice. So recently you might have noticed that advanced care planning has gotten a lot of attention. And for those of us in home care medicine, this is something we've been thinking about for a long time, but it's pretty amazing to see how many news articles and even journal articles like this viewpoint piece in JAMA have been focusing on the importance of advanced care planning. Something we've been thinking about for a long time, but we're recognizing that the need is there to readdress this and be certain that we're having these conversations as preemptively as we can right now in the setting of this pandemic. I think while there's a call to action in all settings of medicine right now, that we in home care medicine are best suited to have these conversations. So I view this as a call to action for us. This is mainly because we are uniquely situated in that we're caring for the most vulnerable patients in our population right now, the patients who are at the highest risk for mortality from coronavirus. Additionally, we know how to do advanced care planning or we've thought a lot about it. And in that setting, we have a critical role in having these conversations with the most vulnerable patients in the population. And probably most importantly, we know our patients best. It's best to have these conversations when you have the background and you know the patient's story rather than when the patient's an extremist in the hospital with somebody in PPE trying to have a conversation under the least ideal circumstances. And finally, I think something else that we must notice that we have the opportunity to have these conversations over time. And so this doesn't mean that we're calling and making decisions the first time we call about the advanced care planning, but rather that this is an ongoing conversation that we have the ability to have. Next slide. So when we think about who we're gonna target, I think we all have read the news and are seeing the news coming in still about the patients most affected. I think the first top three tables were summarized in a wonderful article on the Jerry Powell blog that was looking at all of the data we have thus far. On the far left is the CDC data for the whole of the United States through March 16th, which in the red box, you can see the highest risk for mortality, the highest case fatality rate is in our oldest old and patients over 70, I'm sorry, over 85, although even those over 75 are at high risk. When we look at Washington State's data, even though only 10% of the cases were in patients over 80, we see that the percent of deaths were much higher in our 80 and older population at 55%. And this is very consistent with what we see on the far right table, which is the case fatality rate for China and Italy both. And so we see that age is certainly a factor. And part of that is also related to the comorbidities that we see patients getting as they get older. And we know that patients with chronic lung disease, renal disease, heart disease in an immunocompromised state are all at much higher risk. So it's not surprising that our older patients who have more of these comorbidities are also at higher risk. The bottom link is an article, excuse me, go back, about a game plan for the most vulnerable. And I think another thing we cannot neglect, and this was an article written by Lisa Cooper at Hopkins, but there've been many others, including Dr. Fauci who wrote about the importance of recognizing that just like we see disparities in all health conditions, we're seeing that there are significant disparities in who's affected by coronavirus, including racial disparities with African-American populations being at higher risk, mostly because we're also seeing that those are, that is a population that often is subject to many more disparities than other racial groups. Additionally, patients living in lower income communities in housing that's much more crowded or patients whose family members have to work in order to maintain their financial status or essential workers are all at higher risk. So we need to think about those patients as well. So that leaves us all wondering, how do we find or how do we figure out who we pick because all of our patients are high risk? One suggestion as presenters that we have is that you think about focusing on the highest high risk patients first, rather than thinking about trying to tackle an entire panel of patients. Think about your oldest old, the ones over the age of 80. Think about the patients we talked about who might be living in situations where there's multiple people in the home or people coming in and out of the home in lower income communities, and also patients who have more comorbid conditions. I think about our patients on dialysis, our patients who have severe lung disease or severe heart disease as people we should focus on first. So quickly, we'll just walk through telehealth tips. I think you've probably all seen different derivations or versions of this. This is off of the Center to Advance Palliative Care website or some of this is derived from that. But the most important thing I think is to really take the approach that this is just like any other visit. I know we're not in the home physically, but we do have the opportunity if the video is working to be in the home virtually. And so starting with the same greetings and introductions and small talk that you might have in a visit, but maybe focusing it on the challenges of setting up the video call or the phone call that day. If you are doing a video, adjusting some of the barriers. So being sure that you match your body size to your patients. And that may mean having your patient move the screen away from their face so that you see more than their nose and their eyes, which has been a challenge for some of my patients. And so having them set it a little bit further away so you can see them a little better. Making sure the volume's okay. I found hearing impairment to be a little bit challenging and so ensuring that they could hear you okay. And also making sure on your end that you're dressed professionally as you would when you came in their home and that there's nothing distracting in the background that might make it hard to have a visit. As you begin the visit, it kind of depends. Some of these may be that you're already calling to do regular follow-up and some may be just to have an advanced care planning conversation. And that's the whole point of the visit, but making sure that you're touching based on how they're doing overall with the coronavirus and how you can support them. And setting up an agenda so that you're not surprised by anything as you're trying to have an advanced care planning conversation and they have multiple other things that they're concerned about. In the clinical encounter, you conduct the visit as you would minus the physical exam if you're doing a full visit. But if not and you're just speaking about advanced care planning, then you can transition to that pretty quickly and Dr. Miller will give us her pearls and teaching around that in just a moment. And finally, perhaps one of the more important things is to summarize what you talked about and set an action plan. Very much it may include having follow-up visits to discuss further advanced care planning because it's often not possible to get all the answers at that visit, but to maybe have started the conversation and then think about how we can incorporate other family members into the discussion later. So thank you, Dr. Robertson. Hi, I'm Rachel Miller. I'm a home care physician and I'm here to talk specifically about some of the language that we can use to discuss advanced care planning with our patients either on the phone or through a virtual visit. First, I wanna say a lot of this, there's been a lot of information that has come out and a lot of frameworks and we do reference them in the middle and at the end of the slides. So I definitely encourage you to take a look at these slides, but also to some of the links we've provided as well that have come out from some of our geriatric and palliative care resources. So I think we've set up the visit here. We're talking with the folks. A lot of times I think we know that it's not only going to be discussing advanced care planning because they do have other concerns, but as we transition to that part of the visit, I think it's really important to normalize the conversation and get the perspective of the patient's goals and story. So one of the things I like to start out with is really just saying one thing that we're trying to do is have a conversation with all our patients to better understand their medical preferences and goals of care at this time of COVID. And a lot of times I've say, you know, this is something I know that we've already talked about and this is a time for us to review that again. So I might say, I want to take a moment to talk a bit about the big picture. Would that be okay, getting their agreement? What do you understand to be the risks surrounding COVID-19? And I think this question really helps because it gets me to kind of know, where are they? How much do they know? I'm finding my patients tend to know a lot and they might already have specific questions or specific things that they're worried about. And I may even follow up with a question here. Is there something you're particularly worried about? Because that might frame some of the further conversation that we're going to be having. Next. So one of the next things I'll do is, we'll give, I'll give our medical perspective and concerns I've heard from them. And now I want to tell them where I'm coming from and what our team is thinking about. So I'll start out by saying, you know, first of all, actually, I usually say, I hope that COVID-19 is not an issue for you, but that for most, but if it does happen, we're here to support you. For most people, COVID-19 is mild to moderate, but for some it can be severe and even life-threatening. And I'll mention that I'm worried about their particular risks because of their age, comorbidities, immunocompromised state, whatever it is that is particular for that patient. Again, to help them frame why we're having this conversation. I will often at this time also mention that our goal is to treat mild to moderate symptoms at home. And this is something I'll come up with later again. I think because a lot of our folks are not necessarily aware that this is our intention, that we're really talking about what happens if it becomes more severe. Next. So then we'll go similar to how we would have any advanced care planning conversation, shared decision-making. So I'll say, is it okay if we talk about what you would and wouldn't want it to happen if you got seriously ill? And then if they say, yes, that we can talk about this, then I'll review their healthcare decision-maker. So I might say something like, first, I know that you're making decisions now for yourself, or maybe I'm talking to the caregiver, but I wanna review who would make decisions for you if you were unable to. Do they know? And I might even ask here at this time, is there anybody else supporting them, anybody else around that they wanna have this conversation or that we can have in the future with them as well? Next. And so I'll get a little bit more in the details here. If you were to become seriously ill, would your priority be quantity of life at any cost, or would it be more important to focus on quality and comfort? And this may come back to some of those conversations we've had before, where we've talked specifically about code status, whether they wanted to go to the hospital or not, whether they wanted to die naturally. A lot of the different conversations that we may or may not have had with them. I think one of the things that we've been talking about a lot here is that I think it's important to be broad, but also to add some specific language here. And I think it's okay to give some of your own specific recommendations. You know the patients well. Often you've had some of these conversations with them before, and I think they really wanna hear from you as well. And another important conversation, I think, especially for our homebound folks, is to talk about whether if they did get seriously ill, if they would wanna be taken care of at home or in the hospital. You know, this differs from some of us that are also taking care of clinic or folks in other settings. A lot of our patients have already really thought about that they want to be at home, but they may wanna know how they're going to be supported at home, or some may still wanna go to the hospital. And I think it's important for us to sort of, to lay that out and to start that conversation now. I put this slide in here because, you know, this can be very emotional to have these conversations. It can be emotional for us, and it also can be emotional for our patients and for their caregivers as well. And I'm not gonna read through this entire slide, but I think this is a good reminder of some different techniques that can help us as we're having these conversations. All the language here doesn't necessarily apply to this particular situation, but the idea of naming, acknowledging what they're feeling, discussing, understanding, certainly respecting and supporting. And I think probably the most important here is exploring. A lot of different emotions may come up, a lot of different questions may come up here, and we really wanna pause and take the opportunity to answer these questions, to ask if they have these questions, and move down that avenue if that's what's important to the patient. In this idea of exploring and reassuring patients, I also think it's really important to remind them that you're working with them to prepare for any medical issues, non-COVID or COVID. And despite being remotely connected, that might be different for you, that you are still there, your office is still up and running, you're still able to answer questions for them, you're still talking with them virtually, you're still going out if needed, obviously depending on their practice. And from a practice point of view, and for the patients, it's important for them to know that they're gonna have their medications, for folks that you know have that CHF flare every few months, or that COPD flare, that urinary tract infection, thinking about making sure they have medications in the home and reminding them to call early. Again, just a reminder that you are there for them and reassuring them. And getting back to thinking about treating if they are COVID positive, the mild to moderate COVID, reminding them that you also are there and you'll be able to discuss symptom control and options in the home as well. I think that's really important because while we're talking about advanced care planning here, they're also thinking about what's gonna happen now. I know a lot of my patients when I talk to them are thinking this isn't gonna happen to me, or I don't wanna think about that. So they're willing to start to have these conversations, but they also really are focused on their current medical issues as well. And again, reassuring them about frequent check-ins, the use of telemedicine, and the options for hospice when appropriate. Some of the other things that can come up, and I just put this out there, so these are some questions that have come up for me. I don't have all the answers right now for you, but I think it's really important that you know what your program is doing, what protocols that you may have, and really what's available in your community as well. So these are some questions that I've seen. What will you do to support me in the home? And this really goes back to the last slide that I just discussed. Should I be tested? Obviously that varies per community and access. Will I have all the medications that I need? I know a lot of folks are working to make sure our patients have enough medications in the house now, and working to see what medications they'll be able to get them if they end up having COVID. Who will help my mom? There's a lot of concerns about home health aides and caregivers, and what about hospice? And we're not gonna talk specifically about that today, but I think it's important to know what are the options in your community? What will your program be involved in end of life as well? And finally, like Dr. Robinson mentioned before, it's important to wrap up and to end the visit by really thanking them for this discussion, knowing that this is hard and this is not an easy conversation to have, reminding them that this isn't a one-time only conversation that you can continue to have this, and reviewing the plan. So this might include, you're gonna have a follow-up phone call with them or maybe another caregiver. We can think about this and talk about this again later next week. Next time we can talk with so-and-so if that would help. Perhaps you're gonna review the goals and plans. If you did come to a more concrete point or conversation, you might say that you're gonna discuss and you'll document the conversation and goals in the chart. And again, something for you to think about before, this is site-dependent, consider how you are gonna document it. I know some folks have different phrases and templates that they're using. I think whatever you can do to make it easiest for your practice, because you're gonna have a lot of these conversations, will help you. And if you're able to give a patient a copy, again, thinking about what's gonna work best for your practice and for your state. And then finally, reminding the patient and caregiver that you are available to talk more and that they shouldn't hesitate to call. And finally, just a reminder here, we talked specifically about some techniques and language for advanced care planning. Like I said, in the beginning, there are some websites and links that we put in the beginning of the slides. And here are a few others, particularly from Patsy and from Vital Talk. I think they're really great. We kind of put them together during these slides, but they're even more expanded here. And I know that a lot of you might have also specific questions about symptom management protocols. I know we didn't address that today, but there are some great resources on the CAHPSI website as well. So I definitely encourage you to take a look at them too. And I think most importantly, being open to having these conversations, being prepared for the questions that are gonna happen, and also knowing what resources your team has and what's in your community can really help you move along in these conversations. Thank you. Thank you very much, Dr. Miller and Dr. Robertson. We will now hear from Dr. Matan Shukman. Thank you very much. This is Bridges Over Troubled Water, self-care and team care in the time of the COVID pandemic. So I wanna start with a clinical case. This is a story of a 36-year-old geriatrician, knows significant past medical history. He had appendicitis when he was 19, no tobacco, occasionally enjoys a micro brew, only medication is a vitamin D when he remembers. Next slide. He presented to me with three weeks of symptoms. The symptoms were disrupted sleep, mostly early awakening, intermittent bitemporal headache and irritable mood. And now this is somebody who's usually described as calm and cheerful, and now is really quick to anger and reactive. And on further evaluation, when I asked if there was anything else going on in this patient's life, he revealed to me that at work, he recently had to shift his practice of medicine and also start leading a team through a COVID-19 pandemic. And I thought, aha, this might be the problem. Next slide. This is a patient who is going through transitions. And I find the Bridges model to be very useful for describing and understanding transitions. William Bridges is a preeminent authority on managing change in the workplace. And as an aside to some geriatricians out there, he died in 2013 from a Lewy body disease. So Bridges says that change is something that's external and transition is how we respond to change. And in his model, he said transition has three phases, ending, the neutral zone and the new beginning. And now the border or boundary between these phases might be hazy. You might have one foot in one phase and one foot in another phase or be in multiple parts at once. Next slide. However, the important thing for a change to be successful is that each individual goes through each of the three phases. If one of the phases is bypassed, repercussions will be felt later on. New beginnings can't occur without passing through the endings and the neutral zone. So I'm gonna talk for the next 10 minutes or so about just what each of the zones are and what to expect in each one and how you can lead a team through these transitions. So the first zone is ending. Every beginning starts with an end or letting go. If a person or team doesn't fully and adequately experience an ending, they can't fully start a new beginning. This starts with acknowledging that there's been an ending and honoring what's been lost. So take, for example, you're moving to a new house. Even if that's a good change, you still have old patterns that you have to let go of. You don't have that neighbor who will watch your cat and get your mail. Your favorite restaurants or walks are no longer right around the corner. You have to let go of feeling comfortable and settled so you can start getting used to your new place. For this clinical case, the change was moving to telemedicine. Boundaries between work and home are no longer there. There's no more face-to-face interaction with patients, that sense of connection with colleagues, and really importantly, a sense of competency, a sense of knowing what you're doing every day when you go to work, and a sense of identity as a house call doctor. No longer a house call doctor, but a sort of hybrid house call telemedicine doctor. What is that? And I developed this sense of just not doing enough. And I just realized that I revealed, in case you didn't already know, that I am, in fact, the patient in this case, but I think that since HIPAA has been kind of relaxed during this COVID pandemic, that that's okay. Next slide. So the ending was not only happening for me, but at the same time, it was happening for our whole home-based medicine team. And one thing that's important for leaders to do during the ending is to identify what is actually ending. Who is losing what? And you can bring this up with your team by saying things like, you know, what have you missed since we've changed, or what feelings have these losses brought up? I'd encourage you not to be afraid to talk about feelings at work. Often, in fact, not talking about feelings that stirs up trouble. In this ending phase of transition, expect that there are going to be signs of grieving and loss, depression, anger, confusion, and you should honor everyone's subjective reality. One way to assuage this anxiety is to provide more information. Give people information and do it again and again. I would avoid phrases like, oh, we don't know all the details yet, so there's no point in telling the team things until the details are decided, or, you know, they don't need to know yet. We'll tell them when the time comes. Because I can assure you, your team already is aware and quite anxious about what's going on. I would clearly explain what processes are ending and which are continuing, and clarify how this protects the continuity of your team's mission. Because if you're like me, you have a tendency to throw the baby out with the bathwater. Everything is changing. We're just going to start fresh. But in fact, that's not true. We're still providing care for older adults in their homes. That's our mission. It's just that in these times, that might not mean doing house calls. That might mean doing telemedicine. Next slide. We're all going through a lot of change and adjusting to new realities of COVID-19 in our personal and work lives. Here's a quote that I felt really captured this early phase well. It's by Ayesha Ahmed, who's a faculty of political science at the University of Toronto and specializes in conflict. Your first few days and weeks in a crisis are crucial, and you should make ample room to allow for a mental adjustment. It is perfectly normal and appropriate to feel bad and lost during this initial transition. Consider it a good thing you're not in denial and that you're allowing yourself to work through the anxiety. No sane person feels good during a global disaster, so be grateful for the discomfort of your sanity. At this stage, I would focus on food, family, friends, and maybe fitness. You'll not become an Olympic athlete in the next two weeks, so don't put ridiculous expectations on your body. Next is the neutral zone. And the neutral zone was most confusing to me when I first learned about this framework because it sounds so nondescript. It's the limbo between an old sense of identity and the new. The old ways are gone, but the new ways don't feel comfortable yet. The psychological state is still catching up. And it's appropriate that we're talking about this on the last day of Passover, because that's a story where, you know, the biblical Jews were packing up and getting out of Egypt and that was a real quick ending, but then we had 40 years of wandering in the desert. That's the neutral zone. Next slide. It's important to understand and expect the neutral zone because it can't be rushed and it can't be bypassed. You might think that the confusion and frustration felt here is a sign that something is wrong with you. You might feel anxious. Old weaknesses are often accentuated. However, this is also the best time to be creative and innovative. The neutral zone is when re-patterning takes place. Old and maladaptive patterns can be replaced with new ones. You might be feeling things like nothing is a given anymore. No one knows the answers or there are multiple and conflicting sources of information. Productivity often drops. I know that on my team, communication was always not a strong, was never really a strong point for us. And we started instituting twice a day huddles in the last month to deal with all the changes that were coming out with the COVID pandemic. And even just over the last month, we've already iterated that with changing the times of the meetings, changing their length, their agenda, and adding personal check-ins. Next slide. When you're leading a team through the neutral zone, you know, one of the things that comes up is that you should assure your team that what they're feeling, those emotions that they come up are normal. Having the personal check-in has allowed me to disclose what's happening to me and that in turn made a space for my team to connect. By sharing my fears of treating patients with COVID while living with somebody who is on immunosuppressive medications made me feel less isolated and made my team, helped my team understand why I was doing tele-visits while other providers were still out seeing patients. Our team is very much in the neutral zone and we're collectively and creatively coming up with new policy to respond to situations as it emerges. We're creating these temporary systems with more frequent communication and stronger intergroup connection, because the neutral zone is a really lonely time. It's also a time that we should encourage our team members to be creative, experiment. It's not a time when I would reprimand anybody for doing something that maybe had poor results because we want to encourage this experimentation and growth. On a final note about the neutral zone, I would just be aware of the language you choose to use. We often use metaphors to characterize what we're doing in the neutral zone. And I've noticed that around the country and in my institution, we use a lot of metaphors like redeployment and battle and other war-like metaphors. I would just wonder if that's appropriate or really productive for our cause. Next slide. The last phase of transition is the beginning. Beginning is still a very nervous period. We're not really sure of our new identity. Think about starting a new relationship with somebody. You've gone on a date or two, but you haven't had that conversation yet about what's going on. You're not allowed to post about this on Facebook or tell your friends. It's still, you're feeling like you're breaking in a new pair of shoes. Now there's also a difference between beginning and starts. We've certainly started dealing with COVID-19, but at least on my team, we certainly haven't reached the beginning phase. Now some of you might be saying, how can, you know, Matan, everything you said is nice, but this is a crisis. We don't have a plan. It's emerging day by day. Okay. I hear you. Next slide. Keep in mind that all the changes that we're dealing with are linked together. The point of the change is to preserve that which does not change. It's like a bicycle that we have to make adjustments to our steering and to the pedaling in order to keep that forward momentum going. Emotions and interpersonal problems that emerge are really expected. You know, at my home-based practice, J-Home, you know, the goals might not be the same as they were last week. Our methods are changing, but the purpose, still the same, still to provide excellent healthcare to people in their homes. So foresee as much as you can. Think of worst case scenarios, build in contingency clauses, but also emotionally prepare for change to be the new norm. Even teaching this framework provides a shared language for your team and a way for them to connect around change. Next slide. You might still be thinking, great, Matan, I like all of this, but I'm a healthcare provider. The world is on fire. How can I make time for this? Next slide. So I have an offering, you know, we might be in the ending and neutral phases of transition for quite a long time. In fact, there might not be a promised land after all of this ending and neutral zone. And if we're holding our breaths with the hope that things will return to normal without emotionally committing to something new, a new normal, we'll be holding our breaths for a long time, which will make it hard for us to take care of ourselves and to treat each other with compassion. So I'll leave you with this final quote, also from Aisha Ahmed. Understand that this is a marathon. If you sprint in the beginning, you'll vomit on your shoes by the end of the month. Emotionally prepare for this crisis to continue for 12 to 18 months, followed by a slow recovery. If it ends sooner, be pleasantly surprised. Right now, work towards establishing your serenity, productivity, and wellness under sustained disaster conditions. And on my final slide, I just leave you with three references, one with more information about the BRIDGES model. The second is a link to the article where the two quotes came from. And the third is a really fantastic list put out by the World Health Organization that has some concrete steps that you can take for yourself and your team for your mental health. So thank you very much. Thank you, Dr. Schuchman. We will now hear from Dr. Paul Chang and Brianna Plansner. Thank you, Danielle. So we want to provide an update on the ever-changing regulatory and CMS telehealth billing and coding regulations, largely which are most significantly impacted out of our March 30th interim final rule from CMS. I do have a couple slides to start off with on advanced care planning. You heard from Dr. Miller and our colleagues speak about this earlier and want to make sure you know the billing requirements for that if you can advance, Danielle. So advanced care planning is on the approved list of services for CMS. You can provide and bill for these services via telehealth. Remember that they are time-based, so you do have to spend a minimum of 16 minutes on that two-way audio and video call with the patient and or caregiver in order to bill for it. And it does need to be just that 16 minutes has to be solely dedicated to that goals of care, you know, documenting and talking about preferences and all of those things. It's not for the other portions of your E&M. If you do have that separate time and work documented, you can still bill for your, you know, home telehealth visit and advanced care planning, although you would need a modifier 25 in those situations. And if you really are just, you know, having that televisit, just talking about advanced care planning, then just bill for advanced care planning. Here's an example of what the documentation might look like. I know that's always appreciated. Just remember that you do need to document and obtain patient consent. Start and stop times are always recommended for time-based services. And you know, you just need to briefly describe the nature of the, you know, what you provided, what were the patient's preferences, what did you advise and discuss. If you documented, you know, in a post form, although that would obviously be hard to do in the current times, but here's an example that you can reference and compare to your own documentation. Next slide. So it does pay about $86. And then moving on to the more significant changes that we've seen come out of CMS, they really are embracing telehealth during this time of crisis, and we're continuing to see more and more flexibilities each day. Next slide. So as of March 30th, although they did retroactively make it effective as of March 1st, home and domiciliary visits as well as 85 other services were added so that you can provide these services. There's been a lot of confusion about audio only or audio and video. Again, for your home and domiciliary visits that you're providing to patients via telehealth, you do still need to have that two-way real-time communication between the patient or the caregiver and you. We did, I know we mentioned on the last webinar, but because of the relaxed HIPAA requirements, it can't be public facing, but it could be, you know, a non-secure platform such as FaceTime, but through the patient's smartphone, but there are a lot of HIPAA compliant platforms as well. Some of the ones that I know practices are using are Doximity or Doxy.me. Zoom even has a healthcare module where they'll sign a HIPAA BAA. These are certainly not the only ones, not recommending one or the other, but do your research and what's out there. There are other applications as well, like VC and Updox. The other big change that we had as of the interim final rule is the modifier in place of service. So, you should no longer be reporting place of service 02 for telehealth. In order to build the non-facility rate or be reimbursed, I'm sorry, you're going to want to just build a place of service where you would have normally seen the patient, so POS 12 for home. And then you're going to attach modifier 95 and that's going to identify it as a telehealth service. I have seen a lot of communications out of the MAC that they're denying if you don't have that modifier 95 on there, so make sure you're doing that. And then not noted on this slide, but you may have heard about the CS modifier and that's only needed if you're providing a professional service that results in the need for testing. So, you actually order or you administer a COVID test, which not all regions are, but if you did, you would use the CS modifier to waive cost sharing on the plan level. But also remember that during this public health emergency, providers and practices have been given the flexibility to waive cost sharing for all telehealth services. That's not a requirement. That's a choice on the practice. So, you know, you're going to bill for your telehealth services like you normally would, co-pays and deductibles still applied, but due to the relaxed stark law and other requirements, you could waive that cost sharing if you choose to do so for the patient. Another area that I've been getting a lot of questions on is how to document the consent. So, here is just an example macro or smart phrase that you create that I created on, you know, each of these E&M visits, so your home and domiciliary visits that you're doing via telehealth. They do require service-specific consent. Also keep in mind that this doesn't have to be the provider. You can use your other staff to obtain and document that consent for services. If you're using that non-HIPAA compliant platform, they are recommending you make the patient aware of privacy risks. And I've also seen organizations that are recommending to note the location of the patient and the provider. So, even though the originating and distant site requirements are waived, some practices are choosing to include that in their smart phrase as well. Next slide. So for telephone services, so what if your patient doesn't have internet, they can't use the smart device, you haven't figured out a solution for that just yet and you really just want to bill for that audio-only phone call. CMS did make an active payment status for the telephone E&M codes. You'll notice the reimbursement is low, but they are available. And also a point of confusion, these are not telehealth, so these are not services that were typically provided, you know, face-to-face with the patient. They're just a telephone E&M code, and you do not need modifier 95 for that reason, and you would just report the place of service where you rendered the service itself. And we also have on the next slide telephone services for other qualified healthcare professionals. So if you employ licensed clinical social workers, they also have availability to bill for their services. When we're talking about phone calls and practices getting creative on how they can run long before COVID, reimbursement in those telephone E&M codes, and I've given you just a couple examples of what that might look like. So in 2020, we got a new G-code for a traditional CCM. So if throughout the month you and your staff spent 60 minutes, that would be about $118. And if you as the provider are spending 30 minutes and it's all just your time as the billing practitioner, then you could use 99491 instead for about $84. So keep that in mind, all other requirements for CCM still do need to be met. And I reviewed the CCM requirements in a past HCC Intelligence webinar on 2020 coding changes, which is available on our website if you need to refresh your memory. So the other kind of option that we've heard about for virtual care is what CMS refers to as communication technology-based services. And again, this is not CMS's definition of telehealth. These are actually services they made payable before the public health emergency, and they include G2012. That's that virtual check-in, which could just be a phone call. There's no difference between this and 99441, their first telephone E&M on the other slide. So for Medicare patients, if it's just a five-minute phone call, you would use this. If the patient sent you a secure photo or video, whether that's via a patient portal or a secure text message or email, there is a code to bill for that. You may have also heard of e-visits, which are also called online digital E&M services. And these are patient portal communications that occur over a seven-day period. So this isn't real-time audio or visual connection with the patient, but over seven days, if you're doing an evaluative service, you're documenting the time, the dates, the nature of it, what's the patient's concern or problem, what is you as the clinician, your clinical judgment or recommendations to that patient. There are services that are billable for that, as well as other healthcare professionals that can bill with the G codes. And then again, just a reminder, if you are in a position where you're looking into remote patient monitoring, the difference with all of these services is because they're not telehealth, they're not subject to all those requirements. And as a result of the 2020 final rule, yearly consent, excuse me, is acceptable rather than service-specific consent. And it can be during the public health emergency for new and established patients. So with that, I want to pass it to Dr. Cheng. Well, thank you, everybody. Great information. I'm aware of the time and I'm going to, because I want to leave as much time as possible for Q&A. As I look, as I listened to the presentation, as I look back over the last three weeks in terms of my practice and the challenges in terms of deploying telemedicine, which we have not done before prior to COVID, I think the challenge just comes down to four categories. One would be hardware, two would be software, third would be patient, and the last is provider. Hardware, some of our patients simply don't have smart devices. They don't have laptop computers. And that's a challenge for us to do audio and video visits as Brianna has described, if we want to appropriately bill. Number two, software. Whenever we mentioned, now, you know, you need to go to the Apple Store or the Google Play and download an app and install and create an account, I think we lost the patient. Many of them are challenged enough as it is to use their phone, their smartphone, and to go through that process, it's an additional barrier. From the patient side, as Dr. Miller and others have mentioned, sometimes it's just hard for them to get the computer pointing the right direction, the volume setting. Some of them have vision impairments. Some of them have cognition issues or arthritis issues that makes using a smart device or computer difficult. And the last comment I'll make is on the provider side and an office flow. It's very different for our office in terms of maintaining the previous flow that we had when we were doing face-to-face visits. Now the flow is different. The scripting is different. The outbound calls are different. And how we interact with our patients, also very different. How do I stay engaged on screen, paying attention, and extend empathy over a screen rather than a face-to-face visit? So those are some of the challenges that I think my practice has faced over the last three weeks of addressing COVID and using telemedicine. And with that, next slide. Yeah, again, just I won't read all of it in terms of utilizing your clinical staff to educate your patients and setting up for video visits and scripting and asking your patient and family if they have telehealth readiness. Check with your EHR if your EHR has video capabilities. We've talked about technologies, different vendors to use in terms of video platforms. You can see that listed there. And think about, you know, is there a need for actual face-to-face visits? Some of our patients are so sick and they're so afraid of going back to the hospital. And there's a crisis situation that really needs to be addressed and better addressed face-to-face encounter. And that's a decision that has to be made on an individual basis. Think about an opportunity for a grant or other funding dollars to help you deploy telehealth into the homes of these patients. And I think with that, I'll move on to the next slide. And here are just some additional resources to guide the listeners regarding some of the regulatory requirements and offer advice from CMS on how we can engage our patients during this crisis. Next slide. Okay. So, as we transition into our virtual office hours, our presenters will now address your questions that were submitted ahead of time, as well as those that have been submitted to the questions and or chat box today throughout the presentation. We will do our best to make sure that if we do not get to your questions today for the sake of time, that we provide answers to those questions through the available uploads, also through our HCC intelligence page, as well as through our LinkedIn COVID resources. First question, any tips for experienced providers versus new providers? I am seeing vast differences in the two groups. It is actually easier with the younger providers because they will share more. I worry more about the very seasoned providers. Any tips you can provide? Yeah, thank you for that question. This is Matan. I think that with, you know, more seasoned providers, like anything, who are experiencing a big change, the change might be even more dramatic for them because, you know, you're going from somebody who's used to knowing everything, being the one who other people turn to for help, to really being on the same playing field as everybody else in this new environment that's confusing. So it might be a bigger change and a bigger loss for more experienced providers, not to mention possibly less comfort with the technology or different changes that might need to be implemented. So I think that the same overall strategy still applies, though, of, you know, making room for them to respond and expecting that kind of difficulty and emotions that it might bring up for them. But ultimately, I think that all the providers will be able to, you know, work through the different phases. It just may take some people longer than others. For most of my patients, they are on Medicare. Many do not have technology and will require virtual telephone encounter. Can you use G2012 plus advanced care planning billing codes together? This is Brianna. So, yes. So G2012, the nice thing about that virtual check-in, which can be a phone call, is there's no frequency limitations, and advanced care planning in general is not bundled with a lot of services. So you could bill those together, although you probably would need the Okay, I think her sound may have cut out, but we will definitely circle back to that question. We are using GT modifier for telehealth visits. Is 95 the correct code to use? And then we'll circle to another question. Excuse me just one moment here. We work with older populations. Many clients are in assisted living, living, excuse me, memory care communities and are under quarantine. Anxiety, fear of the unknown, isolation from social activities, family, friends, et cetera, and are dying alone. These are some really big concerns. Any insights? Thank you. This is Paul Chang from Home Care Physicians. We have quite a few patients who reside in an assisted living and essentially all of them are on lockdown and certainly can be very frightening for them and confusing for them in terms of, why can I leave my room, for example, and how come I have to eat in my room instead of the common dining room area? We try to support them as best as we can and coming up with creative ways to deliver our care to these patients during uncertain times. Again, work with your team and your assisted living facility leaders in terms of how you can best engage them in helping them, helping the nurses as well during this difficult crisis. For example, several of our assisted living facilities, there's a designated person that I can send out an email invite to using a particular platform, doxy.me, and the provider will click on the link and we can literally make rounds at the assisted living place and there are opportunities for us to engage with our patients, to look at them face-to-face and talk with them and share with them our willingness to help and support them and listen to their concerns and address whether it's a medical issue or anxiety or depression that might be related to their underlying illness that's just exacerbated by COVID. So that's one approach that our practice have taken in terms of finding a designated person who has a smart device and making rounds at the assisted living facility. Thank you, Dr. Cheng. Okay, so a question, best options for patients that don't have visual capabilities. How do virtual check-ins and e-visits work? What needs to be documented? This is Brianna, sorry about that. In the world of technology, seemed to have lost my connection there for a minute. But so for the e-visits, again, those are the patient portal communications and then the virtual check-ins and the telephone E&Ms are for phone calls. But you're gonna wanna think about the date and the time. What was the patient's concern or the problem that they are reaching out to the patient on? And then you as the provider, what's your clinical judgment? What recommendations did you make? What was the treatment plan? And I referenced earlier, but for those e-visits and those telephone E&Ms, they cannot be filled if it's related to an E&M or a telehealth visit for your home and domiciliary visit that you did via telehealth within the past seven days. And it cannot result in the need for that telehealth visit. So those are really when you're addressing things in between the need for that actual, in today's world, audio, video visit, kind of acute concerns that come up in between for your patients. Thank you, Brianna. Another question, are practices getting verbal consent only or actual paper as well? This is Brianna, I can speak to a little bit of what I've been hearing from practices. I think the majority, given that these patients are home limited and we're all new to technology are doing verbal consent. In a perfect world, you would have a formal written consent for telehealth services. But right now, as long as you're obtaining and document verbal consent, you would be doing it appropriately. Yeah, Paul Chang from Home Care Physicians. We are getting verbal consents for visits. And one learner typed in, I think I misheard. Is CT just for COVID testing or for waiving all cost sharing? So it's the CS modifier, so S as in Sam. And that's only if you are ordering or administrating a COVID test. So that would waive, that's under the CARES Act or waiving the cost for the actual testing itself. You can still choose to as the provider, you don't need a modifier for cost sharing for you. You can just choose to waive that for the patient during this time. But CS is only if it's actually a COVID test. If your region is testing and you either order the patient to be tested during the visit or you administer it, then that's when you would use that CS modifier. I have noticed that I can't bill CCM if it is less than 10 days after the last home visit. Does the same hold true for telehealth? That's an interesting problem. And you might wanna connect with me offline at the health at HCC Institute email. You shouldn't really be running into that problem. So telehealth and visits and CCM, so telehealth and visits and CCM can be built together as long as the separate time, you're not duplicating time and efforts and all of that. So let me look into that a little further. And if you wouldn't mind connecting with me to try and get more information on what might be going on with you. Okay, and we will take one last question because I do wanna be respectful of time. And then again, we will make all of this available to everyone with regards to the presentation, with the questions and answers, as well as a link to the archive recording no later than Monday, April 20th. Our final question is for telephone encounters that take more than 30 minutes, are we better off using 99443 or G2012 minus 21 plus minutes phone call or 99358 prolonged services non-face-to-face? So the telephone E&M codes only go up to that 31 minutes. In general, I think you're better off using CCM if your practice is equipped and set up to do that because the reimbursement is much higher. If you were gonna use prolonged services, it would still have to be related to a face-to-face or a telehealth visit for that 99358. So it would depend on the scenario. You wouldn't go backwards with G2012, that's just a five minute phone call. And again, I guess if you had subsequent phone calls, you could continue using those telephone E&M codes, but CCM, honestly, if you're doing that much telephone time is probably your best reimbursement option. Excellent, thank you. And then Danielle, just before we close, there was a little bit of a confusion about the 95 modifier. So all telehealth E&M visits, so your home and domiciliary visits, you should be using the 95 modifier in a place of service where you would have typically seen the patient like 12 for home. Perfect, thank you for clarifying that. I know that question did come in. We want to thank all of our presenters today from taking time out of your very busy schedules to provide with us your expertise and knowledge and answering our questions as you can see, they came in very quickly. We want to refer all of our learners as well to the HCC Intelligence Resource Center, which provides you with various outlets to connect with our subject matter experts. In addition to our monthly webinars and virtual office hours, you can contact us via our hotline as well as download valuable tools and tip sheets. Every third Wednesday of the month, you can join us for our HCC Intelligence webinars. Join us on May 20th at four o'clock p.m. central time for our next scheduled HCC Intelligence webinar of putting person-centered decision-making into practice. Our guest presenter will be Dr. Carol Montgomery, Director of Physician Development and Program Improvement, Respecting Choices. Please visit our HCC Intelligence Resource Center and we will also be sending out a short survey after today's presentation and the link to register for that will also be available in there. If you do have any questions, please feel free to reach out to us and thank you everyone for your attendance today.

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