Hello, and welcome to a special COVID-19 webinar entitled Navigating COVID-19 Challenges with Telehealth that will be presented in collaboration with West Health Institute and Northwell Health. My name is Danielle Feinberg, HCCI's Coordinator, Education and Research, and I will be your moderator for this event. Before we begin, I'd like to cover a few housekeeping items with you. All participants are muted, but please use the questions box located on your screen to submit comments and questions. Questions that are submitted will be answered when we transition to the Q&A portion of the webinar. The recording of the webinar, slide presentation, and transcribed Q&A will be made available on the HCCI COVID-19 Information Hub within the next few days following today's webinar. Today, we are joined by Dr. Karen Abrashkin, Medical Director, House Calls Program, Northwell Health, and Medical Director, Clinical Call Center, Northwell Health. Rachel Lynn Spooner, Vice President for Clinical Transformation at Northwell Health. Jill Slaboda, Principal Investigator, Gary and Mary West Health Institute, and Brianna Plensner, Manager, Practice Improvement, HCCI. The objectives for today's webinar are discuss strategies and practical tips for implementing a direct-to-patient telehealth model for each, for home-based primary care. Share insights and recommendations on how to continue providing telehealth post-COVID-19. Review documentation and coding requirements for telehealth and reimbursement options for different practice models. Without further ado, I would like to turn it over to Jill Slaboda. Great. Thanks, Danielle. So, why telehealth? Why now? Next slide. So, at this time, it is probably clear to everyone on this call why telehealth has become the right tool for right now, as it can help contain the community spread of COVID-19 by limiting travel and reducing exposure. Additionally, many of the components of the in-person visit can be completed via telehealth. And today, we're going to discuss how Northwell's House Calls was able to use telehealth to address their patient needs. The expansion of telehealth through the 1135 waiver has broadened access and payment for telehealth services for Medicare beneficiaries. We'll have more information on payment presented later in this presentation. Next slide. Understanding your starting place, what exists and what can be easily implemented for the delivery of telehealth can be valuable first steps. To tell you about our initial starting place, the Northwell House Calls team and the Gary Mary West Health Institute have been working on implementing telehealth for a few years through a research collaboration that aimed to lower the cost of care delivery while maintaining quality. We began the telehealth journey with a direct-to-consumer video visit model that connected social worker care managers with patients. We initially had trouble gaining traction with this model. During the pilot, patients had to use their own devices and could not be assisted by paid home care aides. We struggled with patients having the right internet speed, up-to-date devices, and overall their willingness or unwillingness to participate in the study. After careful consideration of the practice needs, we revised the model to a facilitated or telehealth presenter model. This facilitated model used emergency medical technicians or EMTs as physician or provider extenders, with the EMT able to perform a physical exam, vitals, as well as operating the technology to address acute non-emergent needs of the patient. This program has been successful and completed over 200 visits before having to pause due to the COVID-19 pandemic. Both of these experiences have helped inform care during the pandemic. And as restrictions for telehealth were relaxed, Northwell House Calls teams were able to use the lessons learned during the pilots to implement a telehealth program. We knew the limitations of the direct-to-consumer model, and thus were able to define a strategy, often using the home care aides as a facilitator to use telehealth during the pandemic. Additionally, patients were more eager to participate in a telehealth visit. During this presentation, we will describe the experience of implementing and conducting video visits, and I've broken the presentation into three phases, before the visit, during the visit, and after the visit. I'll turn it over to Rachel now to discuss how to prepare during the visit, or before the visit, excuse me. Thanks, Jill. So, as we look to what we should do before the visit, you can advance the slides. One of the first things is to train in practice. We will ask that our patients do this for us to improve their experience. But one of the first things that we need to do as providers and staff supporting these visits is to train and practice ourselves, because this is a process that is new to all of us. For Northwell, we actually ensured that everyone practiced logging in and out and initiating calls. This helped us to ensure that everyone knew what their password was, because nobody wants to forget their password at the critical moment of trying to log in before a visit. And also, it allowed us to understand if we had a workflow that was conducive to the way we continued to practice in-house calls. Also, it was very important for our providers to understand what needed to be documented and where that documentation was located in the EMR. One of the things that we asked our providers to do was to conduct mock calls among each other and to provide feedback on camera presence, as well as things that maybe were not necessarily obvious, including workflow challenges, like how do you access notes quickly? What are things that you can do to improve the video experience for the patients? Next slide, please. Also, before we got started, we did have a little bit of luxury of time with this. We made sure to coordinate with our friends in billing and coding and our revenue cycle team. This allowed us to have advanced opportunities of incorporating the billing into our EMR. What we were able to do is include certain flags and allowed for the appropriate documentation in places that could be searched for. Not all locations in our EMR are able to be searchable. And so, we were able to input that in the beginning. We also made sure that our templates had all of the required communications that we would be speaking with the patients, so that they could be documented appropriately. And on the following two slides, you will see some examples of that. We can move up to our first example. This was a macro that we used, and we pulled into our note template that allowed us to say that consent was given for a telehealth encounter. So, this was our first iteration when we were newly in the process. Can move to the second version. And now, we've been able to have enough time where we are able to build it into our EMR. It is now a reportable field and actively searchable, so that we can flag if a patient has consented or not to the telehealth visit. All right, we can keep going. One of the things that you want to make sure to take care of prior to the visit is to work with the patients to ensure that they have a device that is functional, that it meets all the technical specifications. And if you are using specific types of technology, that the application or software is compatible with that technology. At house calls, you'll see a checklist on the right, which allowed our office staff to conduct a pre-visit checklist to ensure that we had devices being used by patients that would meet the technical specifications for an effective telehealth call. Also, because our office staff is doing this prior to the visit, we are not wasting clinical time to attempt to remedy and troubleshoot any issues. Move to the next slide. So, one of the opportunities during this call confirmation is to have the administrative office staff consent the patient for telehealth, especially if it is not currently built into the EMR. So, as we discussed before, you want to make sure that this is documented according to your facility or practices guidelines. Sometimes that means it's documented at every visit. Other times it means that it's documented once a year or only when updated. So, this can be something that the office staff can absolutely help with. Next slide, please. When we first started, we were iterating on our telehealth consent, and we would actually have our office staff read the consent, have the patient verbally agree to it, and then a blank version of the consent would be scanned into the chart so that we had a record of what the patient had verbally agreed to. So, that was our phase one, and then our phase two was actually to build it into the EMR. So, it doesn't need to be perfect to start, and oftentimes, waiting for it to be perfect is not that helpful. Go ahead and move on to the next slide. This is one of our favorite pieces. We need to validate that the device they have is functional, and the connection they have is also working. We need to practice with our patients, and this is something that the administrative office staff was incredibly helpful with. We made sure that our administrative staff were able to get on a mock call with the patient when they confirmed the clinical video visit for later. They offered the patient some tips for camera presence, including to keep your phone, tablet, or computer on a stable surface so that we are not all getting seasick as we watch you move around your room. To be in a comfortable place so that the patient themselves wouldn't feel that they needed to move around a lot if that was possible. But also, you want to have a safe distance from the camera. Karen will share some stories later of what that can do to a clinical call if the camera distance is not really appropriate. And then also, you know, making sure that all of the technical components are available. The software we were using was sending emails to patients that could be trapped in the spam folder. And so, we wanted to ensure that that was not going to happen on the day of the visit. If patients were using their telephones or a tablet with a cellular connection, that they were in an optimal place in their home so that they weren't experiencing dead spots or loss of signal. And then also, there was an app that was part of our software platform. And some people did have trouble launching it. So, this did give our office staff time to work with the patients, which the patients very much appreciated and felt cared for. And also, the office staff was able to remedy a lot of issues that could have created a significant challenge or problem at the time of the scheduled clinical visit. Next slide, please. So, as we've discussed this pre-visit, you can see that most of the pre-visit is conducted by administrative staff or office personnel while the visit is reserved for the clinical care provider. This was a separation of work that worked for the House Calls Program and also allowed the administrative staff to take some of the burden or perceived burden off the providers so that they could focus on clinical care delivery. Next, please. One of the things that may not be immediately obvious, but if anybody has ever been on a call and had it drop, knows having a backup plan is incredibly important. AMWELL is the software of choice for Northwell, but there also needs to be some type of backup plan. As I will say for right now, the HIPAA compliance requirement has been lifted during the crisis, but those are things that if you are using them and your practitioners get used to using non-HIPAA compliant systems, it may be challenging to roll that back after the pandemic crisis has been lifted. The other piece of caution I will offer you is that if you use a personal phone number or any type of personal login to access your patients in video format, your patient now is likely to have that number saved in their phone, and you may or may not receive multiple phone calls at times when you are either not on call or not able to answer them. One of the questions that had come up for setting up a telehealth program was how Northwell came to make some of their decisions. We did not separate our telehealth platform from our other clinical care delivery policies. This was something that we made a choice that telehealth was a way to practice clinical care delivery, not an entirely separate entity. And so for Northwell's selection, we ensured that the software was HIPAA compliant, that we had a business associates agreement in place so that we knew how and when data would be moving around, and our security team had access to review all of these different servers beforehand. And we just included this as part of our clinical practice policy, including scope of practice and all other items that would be relevant here. So this was something that as a system we chose, and we continue to refine the methodology and workflows along our different practice areas. So I will turn it over to Dr. Obrashkin so she can walk you through what a visit looks like. All right. Thank you, Rachel. So during the visit, there's a lot of questions that come up about what can and cannot be done by telehealth, especially around the physical exam. So I'm going to walk you through a physical exam. But before we get to that, if you want to advance to the next slide. Let's just talk about a couple of things to keep in mind during the telehealth visit. So, of course, I think it goes without saying that you need to be in a quiet environment, of course. Start the call by introducing yourself. This is especially true if it's a patient who you're not familiar with, maybe one of your colleagues, patients or even a new patient. And one of the things that I do to build familiarity is that I actually show my ID badge into the computer, into the video when I start the visit, especially for me, I have a particularly long last name. And that can also help break the ice as patients try to figure out how to say my name and they feel more comfortable once they have that association. I also tell the patient what to do if they get disconnected. And that's something as simple as if you get disconnected, I'll stay in the room, please rejoin. And I also start the visit by letting the patient know that this is going to be similar to a regular structured visit. That way, they're not surprised when we do things like medication reconciliation and go through some of the physical exam. You can advance the slide, please. So let's talk about the clinical evaluation during a telehealth visit. So when I was first starting out, I wasn't really sure what could be done over a video. And since I've done a number of these visits, I'm hoping to just share some practical information for what you can do during your visits. So in terms of the vitals, you can have the patient or the caregiver and in home-based primary care, it's often the caregiver, check the patient's vitals during the visit. I ask them if they have a home blood pressure cuff, a home pulse oximeter, and most of them have a thermometer. And so we just pause during the visit and allow them to check it and you record it in the EMR. It's very important that you make a notation somewhere in your note, depending on what your EMR looks like, that the vitals during that visit were checked on the patient's home devices. So what I do is because the EMR that I use is set up in a slightly restrictive way, I can't notate that where I write the vitals, I actually put that in part of the physical exam under the general appearance section. I'll just make a notation, vitals during today's visit were checked using patient's home machines. You can certainly comment on the patient's general appearance. You can do an HEENT exam and often I will have the caregiver actually hold the video up and show me the different parts of the head and the neck. I'll have the patient open his or her mouth. I can open his or her mouth to look at the mucous membranes, which especially in a patient who's not able to communicate can tell a lot about what's going on. And I can also, you know, just comment on the external aspects of the HEENT exam. I can comment on whether the neck is supple. I have tried to examine the patient for JVD during the exam, but that is very hard by video, I will admit. And in terms of the respiratory status, you can comment on whether the patient is speaking in complete sentences, whether they're in any distress, and certainly whether they're using accessory muscles. Next slide, please. The cardiac exam is difficult by video, unless you have a patient who has some fancier Bluetooth devices that might be connecting to your visit. Generally, what you can comment on is whether the patient has edema. In terms of the abdominal exam, I actually have the patient or caregiver aim the camera at the patient's abdomen, lift up the shirt, and then I actually ask them to palpate all around the abdomen. And I comment on, gee, is it soft? Does that hurt when somebody is pressing on your abdomen? And I have them, I make sure that they do all four quadrants of the abdomen. The skin exam, of course, video is great in terms of seeing if patients have any rashes. And for patients who are bedbound, I actually have the caregiver roll them and, you know, look at the video, have them pull down the pants and undergarments and see if there's any bedsores. And in terms of the neurological exam, you can comment on cranial nerves, the patient's speech, and the patient's word finding. I do often have patients stand up, have the caregiver or whomever is with them hold the camera and observe their gait. And then in terms of the psychiatric exam, you certainly can comment on the mood and the affect, as well as the orientation. Next slide, please. A couple of tips I just wanted to share were around etiquette. So keep the lag time in mind. That's both when you send the invite out. For us, it can take up to five minutes for the patient to get the invitation. So I wait before I call and start asking them why they haven't logged on yet. When you're speaking, there can be a lag. And also if, and we're not able to do this, but if you're sharing a screen, there can be a lag as well. Keep in mind that your clothing and your backdrop should, you should try to have a solid color clothing and backdrop and try to avoid things that have patterns or stripes. It can be very distracting on the screen. Prepare what you need before the visit to limit movement during the visit. And so for me, I always have a pad of paper at my side and I have the EMR open. But since most of us are working remotely at this time, it's very hard to see what's It's very hard to have a video screen open and be looking at your electronic medical record on the same screen at the same time. If you're in an office with a larger screen or multiple screens, that would definitely be more feasible. But for me, I find that I, I'll tell the patient that I'm actually looking over if I need to look at their medication list. Okay, I'm going to look over to the side now to check your medications. And for much of the visit, I'm actually making notes on paper, which isn't what I do in a face-to-face visit. I do my documentation after the telehealth visit, whereas in a face-to-face visit, I'm able to document more in real time. Make sure that your camera is set at eye level and make sure that you're making every effort to make eye contact with the patient or the caregiver. And in home-based primary care, a lot of the interaction that you're going to have is going to be with the caregiver and not with the patient. So make sure that they have your full and undivided attention and that you're demonstrating that by making eye contact. This is the only body language you have to show empathy. Of course, you're not patting anyone on the shoulder or anything that we typically do. And as I said before, this can impact your real-time documentation. And I'm also very careful to explain if I need to look away so that they don't think that I'm distracted by something else. And lastly, in terms of the tips, I would just caution you to speak in a normal level voice. You don't need to raise your voice excessively. And that makes it seem more conversational with the patient or the caregiver. Next slide, please. I just wanted to include a couple of lessons from the field as our practice has done about 600 telehealth visits at this time. We all have our own stories, but I happen to just pick a couple that happened to me recently. So the lesson one, I know everybody is on mute, so we can't necessarily comment, but just take a moment to see what you think is going on in that picture. So you can see me up in the screen. That is that's me actually doing the visit and I'm just holding up the phone to take a little screenshot of what's going on in order to educate others. This is actually the patient's ear with her finger over the camera and the camera up to her ear. And this patient was very hard of hearing. And typically she uses her adapted telephone to communicate. But when we were on her caregiver's iPad, she couldn't hear anything I was saying. So she actually compensated by holding it up to her ear and therefore we weren't able to do the telehealth visit. This is very common. And I just thought this was a nice picture to illustrate what we typically do in these situations. And as I said, it's very common. Call the patient on their home phone, have them mute or their caregiver mute the video, the video feed. You can conduct the visit by the video feed and then the patient's home phone. The other thing that I found is in some of our older adult population, they're not as comfortable using the camera as younger people are. So in one of my visits, this was actually a new patient visit who I hadn't met previously and was just being admitted to the program. I actually asked the patient to lift up the shirt so that I could do a skin exam. I was met with this incredibly puzzled look about why I would be kind of asking somebody to lift up their shirt on a video visit. And the patient just said that they weren't comfortable and they basically just said, no, I'm not going to do it. So, of course, never going to force somebody to do something that they're not comfortable with. And so, of course, I'll just do that aspect of the visit once I make a regular house call after the pandemic is lifted. But a couple of lessons. All right, you can go to the next slide. And I'm going to turn it over to Jill to talk about after the visit. Great, thanks, Karen. You can go to the next slide. So let's talk about evaluation. Considering develop an evaluation plan for your telehealth program that can help identify what is working and what improvements may be needed. So you can define metrics that assess the quality of the telehealth visit from both a technology aspect and an operations aspect. And you might want to start with measures that are easily accessible from the technology platform. So, for example, you can consider collecting the number of successful connections with the technology, the number of failed connections. And then for failed connections, how many attempts were there to reconnect after the failure? You can report these as an absolute number or you can use it as a percent divided by the total number of attempts of telehealth connections. On the operation side, you might want to collect the number of visits, the length of the visits and the levels of billing to help you understand how well you and your staff are using the program and what opportunities might exist for improvement. So, for instance, for the level of billing, if before telehealth you were billing at E&M levels four and five, but after billing or after using telehealth, you notice that your most frequent visits are at the level one or two for E&M, it's definitely an opportunity to understand the gaps in the care delivery when using telehealth and to think about how you can start understanding what is going on and what changes can be made. Finally, you want to keep monitoring your typical quality metrics. This is a new way to deliver care and there could be gaps in documentation or visit components being missed even by seasoned clinicians. So could you do next slide? I think there's two pop ups. There we go. Next one. So just to note, we also realize that you may not be able to measure all of these metrics from the inception of the telehealth program during a pandemic, but these might be a good starting point as your telehealth program matures. Next slide, please. So user experience is another valuable component to your evaluation plan. Surveys are a great way to easily identify the user experience. We use two different surveys in our pilot, a patient survey and a care team survey. These surveys were easy to fill out, required minimal amount of time and provide some useful data on impressions and perceptions of the telehealth program. And they're helpful because they can serve as initial data points for improvement projects. We adapted our surveys from the paper reference below. Next slide. So creating a culture of everyday improvement will be important for your telehealth program. You can plan a rollout of new technology and workflows, but really have to acknowledge that adjustments will probably be made almost daily to these workflows and technologies. So setting those expectations with staff of continual adjustments may be helpful for motivation. Similarly, having daily huddles may help staff share success, challenges and tips as they're learning for a new way to deliver care. I know Karen has told me that the House Calls team has found that starting or ending the huddle with sharing of a telehealth patient success story has really helped staff feel connected to their patients during this time when they cannot go and see them. Sharing data is always useful, such as the number of visits to provide encouragement that the technology is connecting, particularly if staff feel like they can't connect or are having trouble with the technology and that patients are being seen and their needs are being met. Encourage peer learning and urge staff to ask questions. You can also leverage some of your partners to help answer these questions if you have a billing and coding team or HCCI, as well as some of the telehealth team or company representatives that may be helpful for to answer your questions around the technology. Be clear about the benefits and dependencies of change and how these changes are connected. Focus on the bigger picture and leverage wins to advocate your telehealth program. Review notes, billings on the back end to provide group or individual feedback. Next slide. So what's next? Next slide. So what what does telehealth look like post pandemic? We really aren't sure, but expect that the regulatory changes may be lasting their health systems. Providers practices have spent considerable amount of time and effort and money to rapidly expand the use and access to telehealth. And we believe that this may that the telehealth may continue post pandemic to deliver seamless care across the continuum, particularly as vulnerable populations may remain at home or want to continue to shelter in place and social distancing. There may be a patient demand for the telehealth services. The relaxed restrictions have really created an opportunity to demonstrate what is possible with telehealth, with the home as the origin originating site, and really believe this is a game changer for addressing patient needs while protecting them from potential exposure to the virus. We believe that telehealth could be the silver lining to the COVID-19 pandemic. And one of the key components to even expanding telehealth is really to get patients and providers comfortable when they when patients are feeling well to help facilitate better care when the patient becomes sick. Next slide. Okay, over to Danielle and Brianna. Thank you so much. We'll now turn it over to Brianna Plentsner, HCCI's Manager for Practice Improvement. Thank you. So I'm going to speak with you all about documentation and coding during the pandemic. Clearly, we know that we've got not one, but two interim final rules from CMS. So what that means for telehealth billing. So what E&M services can you go for. So here's a high level list of what's applicable to home based providers and we know that now we can build for these services, regardless of the patient's location and from any setting of care. So the home and domiciliary visits that was added after the first interim final rule, you do need to use interactive two-way audio and video technology still for these. That requirement did not go away. So you can still go for your home and dom visits if you have that video visit capability, but they are reimbursed at the same rate of in person, which is really helpful to help your practices be sustainable. Also, don't forget that transitional care management is on the Medicare telehealth list. So if you're seeing patients post discharge, the reimbursement was raised for those in 2020 so that's a great opportunity. And then the other change that just happened on April 30 is Medicare came out and said, okay, there's some services we realize we have to pay for audio only if it's just a phone call. If your patients really don't have access and they're mostly education counseling services, but of significant note, advanced care planning and annual wellness visits. Both of those you can do via telehealth from just a phone call and go ahead and bill for it. Now you still have to meet all the other requirements. So don't forget advanced care planning is 16 minutes of that discussing end of life preferences and advanced directives. But that's a great opportunity that those can be phone calls now. And if you look at the link that was included on the slide for you, Medicare has actually updated that list that has a column. So it clearly tells you, yes, if it can be an audio only telehealth service. So that's a great opportunity for you to go ahead and bill for it. So, for place of service, I've been getting a lot of questions on billing. So, for your home and domiciliary visits, if you're doing two-way audio and video, you're going to report the place of service that you would have seen the patient in person. So, that's POS-12 for the home. And then you're going to use modifier 95, and that's going to allow them to reimburse you at the same non-facility rate as you were seeing the patient. The caveat to place of service is if you're billing a non-face-to-face code, like the telephone E&M services that we're going to talk about later, that's not a service that you would be doing in person. So, you're going to bill the place of service where you rendered the service, just like you would, you know, chronic care management or any other non-face-to-face service. And typically, that might be POS-11 for office. So, again, if you're home and dom, where would you have been seeing the patient? That's the place of service you use. If you're doing a non-face-to-face service, the place of service is where you rendered the service. And then the CF modifier, that's only needed if it either, you know, the service or the visit that you're doing either leads to an order or you're administrating an actual COVID test. And that's because under the CARES Act, there's no cost sharing for the actual testing of COVID-19. So, just another consideration for you to keep in mind. And then, again, just a reminder, I know I referenced this, but even though there are certain services that can be audio and video or audio only, the majority of these Medicare telehealth services are still requiring that audio and video. They need to have that real-time interaction. So, I want to take a moment to talk about documentation and also just use this as a friendly reminder about how important compliance is. We know that during the public health emergency, we've been giving a lot of flexibility for our team so that we can, you know, continue to just do what's best for the patients and remove this red tape regulatory barrier. And while there's not auditing going on right now, and they're not going to go back and audit the new and, you know, the new patient relationship or pre-existing relationship, none of that is a concern, that doesn't mean that when this is over, they're not going to go back and audit your telehealth visits. So, keep compliance in mind. It's really important that you're providing the care you need so that you're doing it in a correct and compliant way so that you're not putting your practice at risk afterward. And when we talk about billing for home visits via telehealth, that means that you still need to document the same you would a face-to-face visit. You know, you still need to have that chief complaint, your HPI, you know, past family or social history, the physical exam, review of systems, medical decision-making. And don't forget to take the time with your assessment and plan like you normally would documenting your clinical impression. Really, you know, take the time to comment on what makes this care so complex for this particular patient, even if there's psychosocial barriers that you're addressing and facing. All of that's going to support medical necessity. And then, of course, the kind of added documentation that we need is the verbal consent. And a way for you to kind of, you know, best practice, if you will, so that there's never any question on what kind of telehealth visit you did is when you're documenting that consent, you can not only note the location of you as the provider and that patient, so they know the patient's at home or maybe you're in the office, that there's, you know, they're in different places, and what kind of technology you use. So, if you're commenting that you obtained the patient's verbal consent, the patient was at home while you were in the office, and you used two-way audio and video, that can never be questioned when this pandemic is over. Next slide. So, here's just an example. And I know Northwell and West Health were kind enough to share theirs as well, but what that macro might look like. And then, also, I just want to echo what my colleague said earlier. This doesn't need to be your provider. Your provider should just worry about verifying that the consent is on file, but use your administrative or your other support staff to actually set up the video visit and get this consent, and then pass it off to the clinician. Next slide. So, if we can actually advance one more, what I did for everyone to hopefully help is, you may have had some E&M cheat sheets before. But if we go to the next one that says established home visits, just a reminder of what the history exam and MDM components really are. So, if we look at that level three established home visit, you need either, you know, for a detailed history, that means you have four HPI elements or the status of three chronic conditions. Don't forget that the status of three always gets you to an extended HPI. Only two to nine review of systems, and only one past family or social history element. That's going to get you to a detailed history. If we think about the exam using the 95 guidelines, you only need two to seven body areas or systems. You do have to have expanded details, so not just that positive or negative, a little bit of what's going on with that. But that's reasonable, and you heard Dr. Obrashkin comment on how physical exams is possible. And then moderate MDM, and we know these patients are complex. So, fill appropriately, but keep in mind this is obtainable. And if we go to, I included the slides for domiciliary as well, just for your reference to go back to. But let's go ahead and skip to the slide that says telehealth physical exam. So, I'm not going to spend too much time on this, but also remember for established patients, only two out of the three E&M elements, so history, exam, or medical decision making, if you meet the level of service for at least just two of those and that's supported by medical necessity, then you can bill for the service appropriately. So, it's a little easier with established patients than new. And you also want to keep in mind, when is it appropriate to bill on time? So, it should not be an every time, every encounter scenario that you're using time, but especially for a telehealth visit where you might be doing a lot of counseling. If the visit is dominated by counseling and coordination of care, then that's a great opportunity for you to just bill for the visit on time and not be measured by those E&M elements. And the top part, again, I think Dr. Brushden spoke very well on what kind of exams you can do via telehealth. Next slide. So, the other options that we have from CMS, and I do want to say everything that I'm going over right now is federal Medicare guidelines. So, this is for traditional Medicare billing. You will need to check with your Medicare advantage if you have any commercial or payors if they have any sort of different policies. But again, what I'm talking about is traditional Medicare, the federal guidelines we have out of CMS. So, we know the past couple years, they have been looking at how we can be reimbursed for virtual care and giving us opportunities that they call communication technology-based services that are not on Medicare's telehealth list, therefore they're not subject to the same requirements. And during the public health emergency, they did clarify, again, they want all patients new or established to have access, and the other change that we got recently is for this G2012, this could just be a phone call, though the telephone E&Ms, which we'll talk about later, have higher reimbursement. But actually, only during the public health emergency, this could be filled for by your licensed clinical social workers if you have those on your team. And the same with G2010, that would be if they're reviewing a photo or a video image, but keep that in mind. And the other opportunities we have are what we're called e-visits. And so, I talked about these in a previous webinar, but high level what they are is a digital communication. So, either a patient portal or some sort of other platform. So, it's not a phone call, it's not a video visit, it's digital communication over a seven-day period. So, maybe the patient reaches out with an acute concern, you are communicating back and forth throughout the week, and then you can bill for that on the seventh day. And I've also been hearing from practices a lot more interest in remote patient monitoring, especially during a pandemic. And I should have put a caveat on here. Yearly consent is acceptable for these other communication technology-based services, but for RPM, you do need to get consent. Typically, they're like 30-day service periods, so you need to get at each service period at the start when you're providing that service. But especially now, this is a great way to think about what does your clinical care delivery model look like, and would your practice benefit from remote patient monitoring? Next slide. So, these are the telephone E&M services that I referenced earlier, and the teams that we got on April 30th, CMS said, we heard you, we know you need some sort of other way for audio-only phone calls payments. And so, what they did is they actually added these services to their approved list of telehealth services, and they increased the reimbursement. These were only starting at about $15 prior to the April 30th rule, and now they pay the same as the established office visits. So, it's still less than a health call. So, keep in mind, if you can do a video visit, you know, you're still best doing your E&M home visit as a telehealth visit. If you are doing phone calls, here's another option for you with the increased reimbursement. And now that they're on Medicare's telehealth list, they're going to want modifier 95. Keep in mind that for your MACs, your local Medicare Administrative Contractors, any policy guidance, typically 95 is only on video visits. But right now, we know that CMS is telling us we need modifier 95 to pay for all telehealth services, and these are not telehealth services. You also still need to obtain and document patient consent, verbal consent for these services. So, just there are another set for your other qualified healthcare professionals. So, keep that in mind. The reimbursement was not increased for these, as these type of providers can't bill for E&M. But, you know, just another consideration depending on your practice model. Next slide. The only other thing to keep in mind, so with the telephone E&M services, this is only for these telephone phone call visits that we just spoke about. CPT does require that they're patient initiated. Now, don't let that scare you away too much because the bar is pretty low. But CMS did clarify right now they're still maintaining. This could change. We know that they're continuing to change. health guidelines very frequently, but as of right now, they're maintaining the patient-initiated requirement, but they are saying, we expect that providers might need to educate patients on the availability of these services. So if you think about what that might look like, let's say you know you have a couple patients next week that don't have access to video technology and you want to check in with them, but it's just going to be a phone call. Maybe you ask your support staff to call the patient, check in with them, don't just call to confirm an appointment, ask them how they're doing, educate them that video, or I'm sorry, phone visits are now available and would they like to schedule that next week, and then also ask them, you know, how are you doing? Are there any concerns? If you had that kind of documentation, you could support that the visit was patient-initiated. You do have to keep in mind for telephone encounters and telephone E&M, they cannot be related to a visit within the past seven days, whether that's an in-person visit or a telehealth visit, and it also cannot result in the need for kind of that more formal face-to-face or telehealth visit within 24 hours in the next available appointment. I'm going to give you a CCM reimbursement example. CCM is a better business model. It's higher reimbursement to use telephone E&M services. AQ practice is set up to do that, but I wanted to lay out all the options, but keep in mind that telephone E&M and CCM cannot be built together. They are bundled and they will be denied if you bill for both services within the same calendar month. So, here's just an example of what CCM might look like if your practice is set up for it. It's a great way to get paid for not only your provider's time, but your clinical staff, and we also don't have to worry about that patient initiation requirement. This is any and all time from your clinical staff and providers that is medical in nature and you're managing the patient. We got a new G code in 2020, so that allows us to bill up to 60 minutes per month, and if you were doing that, that would be about $118. So, for any of the independent providers or if your patients are on CCM and you're having extended phone calls and it's just the billing provider, you as the physician or nurse practitioner or physician assistant, it's just your time, not your clinical staff, 30 minutes per month. Don't forget there's a CCM code for just provider time that is 99491 and is $84. Or if you didn't need 60 minutes, just another example of what 40 minutes per month would look like. So, with CCM, as it being a care management service and a great way for you to get extra reimbursement per patient per month, it does have restrictions. So, just a reminder of what services are bundled with CCM. You cannot bill any of these within the same 30 days as you do CCM. And with that, I would like to save a little bit of time for Q&A, I believe, Danielle. Yep. Thank you so much, Breanna, and to all of our presenters. We are actually going to transition now into our question and answer period. We will answer any questions that were submitted ahead of time, as well as those that have been submitted into the presentation today itself. So, the first question is, how do you decide which patient to visit at home face-to-face versus a televisit? I'm happy to answer that question. This is Karen. So, one thing that we didn't mention about Northwell is that it's located in downstate New York, so the area that's hardest hit by the COVID pandemic. So, in our practice, we have converted the vast majority of the practice into a telehealth delivery practice, and we are only seeing patients face-to-face, using proper PPE, of course, when that face-to-face visit is going to change clinical management. This has been very hard on our staff because we love making our house calls, and so everybody is chomping at the bit for when it's going to be safe to go back into the home. I think in the future iterations of this telehealth, you know, once the pandemic has declined a bit, hopefully, we're going to be using it as an adjunct to our face-to-face visits. So, in some cases, we have very long drive times between patients, and we're evaluating skin rashes. That would be a perfect use case. We'll start shaping the use cases for telehealth really to the clinical need, but as of now, we're doing about 95 plus percent of our visits by telehealth. Thank you. Another question. When you are conducting family meeting and patient is not involved, can you use 99358? So, I can speak to that. This is Brianna. So, CPT code 99358 is for prolonged services, non-face-to-face. It does have to be directly related to a face-to-face, or it could be a telehealth visit. So, if you were talking with a family in follow-up to a telehealth visit that you had with the patient, and you spent at least 31 minutes, that's the requirement for 99358, discussing whatever follow-up matters it was with the family, that could potentially be an opportunity. But keep in mind, if you're doing CCM, that's bundled with prolonged services, and you just have to make sure it wasn't captured in your EM a lot of times. But potentially, yes, that could be an opportunity, only if it was related to a recent visit, which could be a telehealth visit. Thank you. What checklists are available for providers and family caregivers to help improve experience and assure that important information is covered? This is Karen again. So, I'm happy to answer in terms of what we do in downstate New York in our telehealth program. Part of the reason why I set up the visit at the very beginning with the patient and the caregiver to say that this is going to be similar to how we would do a regular face-to-face visit is so that I can also mentally prepare that I'm going to go through all the regular steps. I am using my EMR, and so I use that kind of as a cheat sheet to make sure that I'm not missing the med reconciliation, you know, the review of systems, and all of the different components that I would do in a face-to-face visit. We don't give the patient any type of checklist because I don't want that to be on the patient to need to have to remember or navigate various components of the telehealth visit. But as the provider, as the person doing the visit, I need to make them feel comfortable. I need to follow the flow of a regular visit so that we don't leave anything out. And, of course, at the end, ask me if there's any questions or anything else that we need to address before ending the visit is really important. Are there any special considerations when doing telehealth visits for patients with Alzheimer's or dementia diagnoses? We do definitely have to take, you know, it's much different doing a telehealth visit for a patient who has advanced dementia from somebody who's, you know, able to participate in the video visit themselves. Often a lot of the face-to-face time on the visit is done with the caregiver. And I think that's just like in a regular house call that you might be doing with those patients who aren't, maybe they're not verbal, not able to communicate. And it's just as important that we make the caregivers and family members feel comfortable with the telehealth component of the visit. I would say that it can be a little bit more awkward also because the caregiver does need to bring the phone or the iPad or the tablet that they're using over to the patient and actually really facilitate the physical exam by moving the camera since the patient isn't able to do the movement him or herself. And so, you know, I think it's more challenging and it doesn't feel as personal with the patient as when you have a patient who can actually participate in the video visit. But certainly we can still get a lot of the physical exam done and we can help provide that reassurance to the family or the caregiver that we're still there to help whenever they need it. For the virtual check-ins and e-visits, how are we billing since they are already technology-based codes, POS02 or same as telehealth with POS11 and modifier 95? This is Brianna. So that's a good question. So keep in mind that the virtual check-ins, those communication technology-based services, those are not telehealth. So you do not need modifier 95. That's only for Medicare telehealth services. And you don't need POS02. CMS is actually not using that anymore. So you could use, you know, the POS11 and no modifier. What are some good platforms? I'd like information on how to construct a telehealth policy. So this is Rachel. I can share a little bit about the journey that Northwell took. We investigated several different software and app platforms. One of the things that our executive team decided was important was that there were a variety of ways to connect using the particular platform. So we did not want our providers and by happenstance our patients to be locked into only computers, only smartphones. And so we wanted to have something that was flexible. And then I will say at Northwell, our security bar is quite high. And so that was obviously a hurdle that many of our vendors really needed to meet in a very significant way. I think that as you think about what your patients need, we've explored several different platforms. And I think, and please add to this, Karen, having the flexibility to be on a computer or on a phone or a tablet has been helpful given that not all of our patients have or know that they have wireless internet in their homes. And so making sure that they can connect on a phone has been quite helpful. And then from a thought of how do we construct a telehealth policy, the avenue that Northwell took was to really structure it as using telehealth as a way to provide clinical care rather than a care delivery model in its own right. And so just adding an addendum to the clinical care policy to include telehealth as a virtual visit was really how we approached making the policy for our clinical care providers. And then on the back end, again, it was very security-based to ensure that we knew our patients' information would be safe, both during the visit and anything that was saved after the visit. Thank you. As the president for geriatric medicine PAs, it would be great to hear additional pearls for technology troubleshooting with the geriatric population. Even general observations are welcome. For example, are iPads better or more tolerated for the patient than a smaller smartphone? I've found pluses and minuses to using a smartphone. One of the things, you know, I can even refer back to a visit that I had today, I was trying to connect to a patient through an iPad for exactly that reason. But when I connected to them through the iPad, I had to send an email to initiate them joining the visit, and they weren't getting the email, probably for some of the reasons that Rachel pointed out. So I had to send an email to some of the reasons that Rachel pointed out. Maybe it was going in the spam folder, there was a delay in the email. And so we ended up using the smartphone because I could send an invite by a text message. I think in our practice, we found that anything that can be sent by a text message that has a link in it, and that's true for Doximity Dialer as well, is the easiest to use for patients and for caregivers. Something that has to be opened by an email is much more difficult to use. I will just say also, smartphones and tablets are much more advantageous, especially for patients with limited mobility, because the device itself can be moved. So I wouldn't want my patient or the caregiver of a patient who's bedbound to be opening up this telehealth visit on their desktop, not have a mobile camera, and then I take a physical exam on the patient. So anything that's mobile is much better. Thank you. CPT E&M codes 99347 to 99350 can be billed using just phone services, or is it really needed two-way video and audio? This is Brianna. So you have to have the two-way audio and video for all of the home and the domiciliary E&M codes. I apologize if that wasn't clear. So if you're billing the home visit E&M, which is 99347 to 99350, Medicare still requires two-way audio and video. They're only playing for phone calls. So if you're doing audio only, your options are the telephone E&M codes or advanced care planning and annual wellness visits are two others of significant note that could just be a phone call. But all of those other services, your home visits, your domiciliary visits, those have to be two-way audio and video unless you're doing, you know, chronic care management would be another option just for phone calls. Perfect. Are there specialists using your telephone platform in the care of these patients, for example, psychiatry psychologists? I think everywhere is going to be different. In downstate New York, there's a huge variety of practices that have switched to telehealth during the pandemic just because of how hard we've been hit here. So I've had patients who've had new hemog visits via telehealth, certainly dermatology visits. There's a lot of behavioral health being done here and psychiatry visits through telehealth. So we've just seen an explosion of, and of course, many regular office-based primary care visits are being done by telehealth. We've seen an explosion down here in terms of adoption of telehealth models. Probably places that are not as hard hit will have different experiences though, but in downstate New York, we have many options for telehealth visits. I will say just one other small piece of information is that for some of my patients who are completely homebound and who really did need to see specialists but have never been able to, the telehealth visits have actually increased their access to care because they can have their telehealth visit with a specialist who they were never able to get out and see. So in that sense, it's been beneficial for them. Excellent. Thank you so much. And as we are wrapping up, because I do want to be cognizant of everybody's time, we want to remind everyone that on the HCCI COVID-19 hub, there will be resources, including those from West Health and Northwell. So please, by all means, feel free to go in and click on those resources. A very special thanks to our co-presenters today from West Health and Northwell for providing their insight and expertise on this valuable topic, as well as Brianna for her great insight onto all of the coding and answering those questions. Our upcoming events, we do have an upcoming HCC Intelligent webinar on Wednesday, May 20th, Putting Person-Centered Decision-Making into Practice. This will be presented by Dr. Carol Montgomery. We will make the registration link available to everybody. Additionally, right after this presentation is over, you will be receiving an email. We ask for your input on this particular presentation today. You'll be receiving a link to a survey. Please take a couple of minutes to fill out the survey. We greatly value your insight, and we use that to help build on future topics. So thank you so much to everyone. Thank you to all of our panelists today for joining us, and we wish you all very best, and please stay safe.

telehealth

COVID-19

pandemic

training

billing

documentation

devices

geriatric patients

reimbursement

patient care