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How to "See" Patients during a Pandemic—and Get Paid for It

How to "See" Patients during a Pandemic—and Get Paid for It

SR Health's text-first platform enables nationally top-ranked Boston Children's Hospital to affect more meaningful conversations and interaction with the families it serves.


LEA CHATHAM: Hello, everyone. Thank you so much for joining us today. I'm really excited to have you all on today's webinar. We are going to be talking about how to "see patients" during this pandemic time, and make sure that you're getting paid for that. I'm really excited to have Elizabeth Woodcock with us today to talk to you about that. I'm going to hit a couple of quick housekeeping items first, and then we will jump into today's content, which I know you're all going to find really useful.

We do still have people coming on. So, hopefully by the time we sort of get through these housekeeping things, everybody will be here. The first thing I wanted to mention was, for those of you who are not already connected with Solutionreach on social media, this is a great way to stay up on these kinds of events, the latest information, resources, best practices around patient communication, practice marketing, patient engagement, especially right now, as things are changing so rapidly, we are producing a lot of content and information to help support practices and healthcare organizations during this time, and that is a great place to stay on top of all of that.

If you haven't connected with us, please do. Also, I do really want to encourage everyone to ask questions as we are going along today. You can do that by clicking on the arrow next to questions that opens that bar, and you can put your questions in. This is the place to put if you're having any questions or issues behind the scenes, technical questions or issues, let us know. We'll try to help you there. But also, any questions you have for Elizabeth. We will have time at the end to answer questions. A couple of common things that come up. One is regarding audio. If you're having choppy audio or any issues with your audio, I would suggest going to the audio option on your toolbar, click on the little arrow and open it up, change from computer to phone audio.

Often, the computer audio is more choppy if you don't have the bandwidth, and the phone audio can be better. You can dial in. Also, if you're having any issues downloading the handouts today, we will be also sending those out to you. So, you'll get those via email as well, which brings me to the next one, which is the slides and the recordings. You will get an email later with a link back to the recording and a copy of the slides, as well as, like I said, the handout. You'll have that to share with other employees or colleagues or whoever you want.

I am just quickly want to gather a little bit of information from those of you who are with us today about where you are in your telehealth journey before we kick off. I'm going to push out a couple of quick polls, and the first one is just about whether or not you are already currently conducting telehealth visits of any kind. I'm going to give everyone just couple of minutes here to let us know about that. We did conduct a survey actually of our own customers asking about that. About 50% to 60% were currently conducting visits, and 90% of those were people who had started since February.

We are seeing a pretty big shift here. Okay, let's see. I'm just going to give you a couple more seconds here. It looks like the voting has slowed down, so I'm going to go ahead and close that. It looks like almost 80%. I'm going to share that out so everyone can see. It looks like almost 80% are using something, which brings me to my next question actually, which is, what types of visits? I'm going to watch that. I know some people already had something in place for two-way video. Some people have managed to implement something like FaceTime, even to be able to do that. But I've talked to a lot of practices that are largely doing everything over the phone or some combination of phone, portal, and text.

Obviously, the ideal scenario is you're able to do a little bit of everything to meet the needs of all your patients, but it's really challenging right now. This just gives us a sense of kind of where everybody is. All right. Looks like voting is still moving along at a bit of a pace. We'll just give you guys a few more seconds. Wow. It looks like ... Okay, so I'm going to push this out. It looks like almost 50 or yeah, about 50% are doing a little bit of everything, which is awesome. That's very exciting to hear. Great. Some people are just doing some kind of two-way video or just doing phone. That's great.

That's very exciting. Okay. I'm going to hide that. I think towards the end, we may push out one more little poll but we'll get moving here. Okay. For those of you who don't already know who Elizabeth is, I'm just going to introduce you to her. I'm thrilled to have her here. I've worked with Elizabeth in the past. She's an amazing presenter and really knowledgeable when it comes to billing and coding. Just great to have her here talking about something that, for a lot of you, is fairly new. She is a speaker, author, and trainer, and has obviously the education to really back that up. You can see here that she's, in addition to being a certified professional coder and the founder at Woodcock & Associates, she also now is the founder and executive director of the Patient Access Collaborative.

She's been a consultant with MGMA. She has worked with many different organizations across the country. She has her MBA from the Wharton School and is currently getting her PhD at the Bloomberg School of Public Health. I just cannot say enough about what a great presenter she is and how knowledgeable she is on the topics about which she speaks. If you have not seen her before, you're in for a treat. I would also recommend certainly checking out some of the other work that she's done. I'm going to be your facilitator today, and my name is Lea. I have been doing this for about 20 years.

I've spent 15 of that or so doing education for providers and their staff on all kinds of topics around patient engagement, practice management, practice marketing, and do quite a bit of writing and presenting myself. But I also did five years as the person responsible for patient engagement, marketing, communications for 20 physician integrated health group, that really had just about every service under the sun. I do have some experience being in your shoes, and hopefully, if needed, can provide some additional insights as well. I'm going to go ahead and hand this over to Elizabeth, and then we will come back at the end, like I said, for questions.

If you are having questions, please throw them in there and we'll make sure we get back to them. I am going to shift this over now. Elizabeth, you should be getting that little pop up there, and then you'll be able to show your screen and pull up your slides. Looking good. I can see you getting your ...

ELIZABETH WOODCOCK: Awesome. Fantastic. Well, I'm super excited about the opportunity to present. Lea, thank you so much, and thank you to Solutionreach for sponsoring the webinar today. Most of all, thanks to all of y'all for joining me within this new normal. My kids and I were talking about it this morning. We feel like it's Groundhog Day, and yet I want to kind of approach our topic today thinking about literally, the years of dreaming about the government relaxing regulations, dreaming about the day where, maybe we could get reimbursed outside of seeing patients in this traditional bricks and mortar setting.

Indeed, thinking about this, from an optimistic perspective, I know none of us would have wished the pandemic on any of us, or of course, the world. However, how can we think about this as really the beginning of what may be, particularly in the ambulatory care setting, truly a new normal? We're going to talk about an overview and then dive into some reimbursement issues. I want to talk about regulations that have been relaxed in the last as six weeks. Then we're going to talk about actually both billing and collecting, because those of course, are two very different things. Then a little word about FQHCs and RHCs, our friends at community health centers, federally qualified community health centers and rural health clinics.

We want to spend a few minutes talking about workflow best practices, because we all had, as we've seen from the polls, moved into this, most of you very, very quickly. What probably should have taken two to three years, we did in two weeks. So, stepping back and thinking about this really, what is likely going to be for the next 12 to 18 months, and perhaps even thinking about the fact that there's no way, no way and ambulatory care and physician offices and practice management, we are going to go back to where we were in mid January.

What does that mean? How can we start thinking about best practices and this workflow? Indeed, we talk a lot about telemedicine, but as lay as Paul shared, actually, there are multiple ways to provide non-face-to-face services or remote care. One of the, I think really central challenges that we've had in the last four to six weeks after the pandemic really hit, is thinking about telemedicine in kind of the old way. It helps to step back just a little bit, and like, why weren't we doing this before? What was the deal?

The deal was that Medicare, which I know you're dealing with Medicaid and Blue Cross Blue Shield, etc, but we often think about Medicare and I think the agency that controls it. Of course, the Centers for Medicare & Medicaid Services, CMS, is like the bellwether for physician reimbursement. What they had said is telemedicine fine, you can do it, but only if, only if you have a very specific set of technology in order to do it with, and they didn't define vendors, but they gave us a pretty distinctive definition.

Then, even more importantly, oh my gosh, the patient actually has to be in a HPSA, a healthcare professional shortage area. So, you're like, okay, well, how are we going to get this going? Really, do we have enough volume to even make this happen? We all know the statistics. Basically, pre-COVID, it was about 1%. 1% of all physician office visits. Obviously very minimal. The pandemic and really the public health emergency that was declared, and most of the regulations stretch back to March 1st in terms of when they began the relaxation of these regulations to include the patient could be anywhere.

Whoa, that's a game changer. The patient could be anywhere, and as we'll talk about in just a few minutes, in addition to that, this whole sophisticated technology that we were requiring you to use, yep, we've thrown that out the window too. So, we still have telemedicine, but in a very evolved form. Now, in addition to that, we're picking up on what opportunities actually we have seen from a coding perspective related to remote patient monitoring, related to virtual visits, eVisits, and indeed telephones.

These are non-face-to-face services, collectively the items in the blue, you will see a referred to by CMS as communication based technology services, CTBS, communication based technology services. It was their way of distinguishing that from telemedicine, which had these ... It had lots of rules, but kind of two basic rules that really didn't allow that to elevate into any sort of volume. We need to think about this really, from a coding and billing perspective, but I actually would encourage us to start thinking about this from the patient's perspective.

I've kind of re aligned all of those billing and coding terms to think about what the patient has. The patient has interactive two way audio, video capabilities. What does that mean to us in our practice? Aha, that means we can do telemedicine. Again, let's think about reimbursement based on what the patient has, what their communication technique is, and let the reimbursement fall into line instead of vice versa. I think we could be really framing this from a coding perspective if this was like a six weeks and we were out, we were done, everything was going back to normal. But gosh, it doesn't look like that.

In the next 12 to 18 months, let's think about this from the patient's perspective, and as we'll talk about from a workflow best practices, this is actually really, really important to drive what is largely these coding and billing challenges to the front end of our practice and actually scheduling based on the communication device. Let me just give you an example. If I have a patient who only has the phone, that's all they have available, maybe we find out they have a flip phone.

I've got a 78 year old patient. When I'm talking to the patient about scheduling, we're going to do a telehealth visit. I can't do a telehealth visit because I have a patient who does not have an interactive two-way audio-video device. What I'm saying is, if I can figure that out and put that in the appointment template, then goodness gracious, think about that information then flows to the MA who's rooming the patient, who is not going to do it by video, because there is no video. It flows to the doctor who's coding that. There's a different set of codes I would need to use. And then of course, the code or the biller.

Again, thinking about these technologies from the very, very get-go is going to allow all of this to flow so much smoother and for you to get paid what you deserve. Our five devices, we have audio, video, interactive two way, we have telephones, we have a mobile health device, some sort of a pulse-ox machine, etc. The patient has a patient portal. Then last but not least, the patient has a mixture of these things. That is kind of defining again, seeing patients in a pandemic, but from the patient's perspective, not the coding and reimbursement perspective.

The coding and reimbursement perspective falls from that. If the patient has an interactive two-way audio, video, then we have an ability to go ahead and "see" the patient via telemedicine. Now, I would argue this is really our best bet. The reason this is our best bet, and we'll delve into this in just a few minutes, is that basically, we can code and bill for services just as we would have if the patient had been seen in our bricks and mortar. From a reimbursement perspective, just purely from a dollars perspective, this is going to be your best bet, telemedicine.

So, patient doesn't have it. They've got the phone. We do have a set of codes now we can use through the phone that are actually payable. These codes have actually existed for many, many years in fact, but they really haven't been payable, and so we've got now, these six codes that we'll talk about in just a minute that we could bill for. Then, a patient may have some sort of mobile health device. We've got all of these services that we could be thinking about from a remote patient monitoring perspective, and then goodness gracious, great workflow best practice. Definitely want to put this on your tip sheet that you take away from this webinar, is to make absolutely sure that at every single touch point with your patient, you ask them to sign up for your patient portal.

Because of course, what we want to do is drive as much communication through this asynchronous format that is definitely more efficient than trying to chase down patient on the phone. The patient portal, I think becomes even more important. We've got to let it go, all of the horrors of our memories for meaningful use, when we had to get all of these portals up and running. Now think about, okay, in this norm new normal, this is a great communication channel for us to use, and we need to make sure that our team members, when they're scheduling patients, are really pushing the portal and making sure that we have our patients enrolled.

Then last but not least, really that plethora of services or techniques that the patient had, and that's going to drive our ability to be coding those virtual visits. Now, one of the challenges that we have with this is that we almost have to do this lineup based on payer. I know this is incredibly frustrating and it's been incredibly frustrating for me. One of the follow-ups that we have for our attendees today for our webinar is a fact sheet that I've created that you can actually go through and have all of the sources of all these changes and regulations, and all of the links to all of the payers.

Because each one of our payers varies in policy. Just giving you an example, the phone only, as an example, for some payers allows you to bill telemedicine. As we'll see in just a minute, basically telemedicine is the same thing you were doing back in January, seeing patients in your bricks and mortar setting. I would encourage you to create a grid. You may not like this, but again, I like to think about this from the patient's perspective instead of just the coder's perspective, is to create a grid where you have all of your major payers.

This is really going to help, not just for your coders and billers, but again, I would encourage you to think about this for your schedulers, your medical assistants, and your doctors, so that you're not having to go back and forth recoding all these services based on the payer's rules that you introduce upfront if the patient has a phone and the patient is, for example, a certain commercial payer, that, that is a "telemedicine visit" because that's what the payer allows. Again, a best practice is to drive these rules into our scheduling process.

Let's take a look at telemedicine. From a relaxation perspective, the Centers for Medicare & Medicaid services did go ahead and stick with this definition of audio and video and two-way interactive. So, you'll see those terms throughout all of the CMS communication, but what they did relax is, okay, listen, we know, guys, that we still need you to have this basic construct. However, you can basically use a multimedia communication equipment that includes this at a minimum.

That was a really important relaxation that we didn't have to have, these fancy million dollar telemedicine machinery that actually our patients could use FaceTime. They could use Skype. They could use Zoom. This is actually super important as you think about looking at telemedicine. Now, you might ask, okay, cool, that's really nice, but what can I do over telemedicine? Here is your go-to website for Medicare part B, and you will find actually dozens. If not, I looked at yesterday, there's a little bit more than a hundred services.

This is just like a screenshot from them. Medicare part B will accept as a telemedicine visit, and importantly pay you what you would have received had you done these services in the office. It also includes the services and the hospital, and even in the emergency department. This is really a go-to list of what you can be doing via telemedicine. Again, let me just remind you that this is where I would say this is your best bet, because the rates here are the same as you would have seen in mid January for these services.

You can see patient focus health risk assessment, health behavior inventory, physical therapy. The only kind of crazy thing with physical therapy is that unfortunately, as CMS, they're hopefully making this change, but physical therapists actually are not a provider who can be rendering services via telemedicine. So, you do have to cross-reference. That's kind of the big one, RPT and OT, but basically, all of our provider types with that exception can bill for these services under telemedicine.

Again, we can get into some Q&A here, but what I'm saying here in summary is there's a list, definitely want to reference that list for Medicare part B. Then you also want to look at your individual payers to determine what they are offering as reimbursed via telemedicine. Going back to a Medicare part B, you can see these rates 99213, of course, the most billed and utilize code within the United States. It's paying on a national rate, $76.15. I'm talking about a national rate, of course, because there are approximately 80 different Medicare rates for each one of the 7,500 CPT codes, because Medicare does indeed take into account a geographic kind of index. They call it a GPCI, a geographic practice cost index, and they take that into account when actually paying you.

This is a national rate, but think about this plus or minus $5. The important news here is that these are the same rates that you were getting paid in your office pre-COVID '19. Again, you can code and bill these out for Medicare part B using that two-way interactive audio-visual device, and for some payers, even using a telephone. Now, speaking of telephone, interestingly enough, just about a week and a half ago, Medicare CMS, excuse me, did come out and said, "Listen, we know a lot of patients just have the phone, and so for Medicare part B, we are going to go ahead and recognize the CPT codes as payable codes."

Again, recognize, because these codes have been around forever in a day. It's not that they're new, but they just have never been paid. As you can see, the telephone E&M service provided by a physician to an established patient, and I do want to make sure I make a footnote that Medicare is allowing all of these services to be performed, not just with established patients, but also new patients as well, so new and established. That's changing up again, the reimbursement rules just a little bit. The only kind of challenge with this is, it's really needs to be distinct from an E&M service. So, it in and of itself needs to be an E&M service. My kind of decision tree is best bet telemedicine. Oh, patient only has a phone.

Okay, I'm moving to these set of codes, because as you can clearly see, the reimbursement isn't as high. This is really driven up by the device. Now, again, I can have a physician or a qualified healthcare profession or a qualified non-physician healthcare professional use these codes. For Medicare part B, it's giving us a little bit extra kind of swath of who actually can be using, who actually can be rendering services over the phone. Again, we've got telemedicine, phone. Now, let's go to our next level. Our patient has some sort of a device.

I say some sort, because as you can see from these CPT definitions, it actually is a fairly broad kinds of devices, pulse-ox, blood pressure cuff. You can see physiologic parameters. Remote patient monitoring, in my opinion, is very compelling from a service perspective in terms of allowing physicians to be able to use these codes to get paid for something that you're likely already doing, and I should mention not getting paid for. Again, stepping back and thinking about remote patient monitoring, maybe this is not like your big new service line, certainly could be, but to look at these and say, oh my gosh, I actually had no idea that I could be getting paid for these services, which is what, when I showed these to physicians, many physicians say.

You can see the line up here. These codes have actually been around for now about almost 18 months. Again, they're not really new, but under COVID, I think they're very compelling here because they're non-face-to-face services. You can see the first one is like your initial setup here, patient education. The second one is, okay, I'm going ahead and supplying this device. As you can see, it is billable every 30 days. Then these next couple of codes, 99458 is actually new in 2020. You can see these are basically for 20 minutes of, oh, let me just point this out, it's not just the doctor, but clinical staff. Aha, I really like that. Physician or other qualified healthcare professional.

If I'm actually communicating with the patient, look at that, I can actually can bill for that 20 minutes. That initial billing is about $50, and then if I spend more than 20 minutes during that month, I've got these additional 20 minutes, which Medicare part B is capping at two units for these additional 20 minutes. Ah, now things are starting to add up. Again, I wanted to linger for just a minute on these remote patient monitoring, because I think these offer a lot of wonderful opportunities for you to be looking at these services for ... Services you may be performing, but hadn't even realized you could get paid for. It's interesting because this is kind of new for me.

CMS is now offering YouTube videos. So, what's interesting is that remote patient monitoring is really something that the agency is pushing. If you haven't had a chance, I mean, it's not really a compelling information or entertaining, I should mention, but it is compelling to look at, maybe this YouTube video by CMS. CMS has offered a number of them, helping us walking through some of these relaxation of rules. Just making sure, as you can see, CMS, we're making it clear that you can provide remote physiologic monitoring services to patients with acute and chronic conditions. This can be provided for patients with one disease and oh, by the way, it can be COVID.

Again, just again, some little bit of resources, a little bit of advice about how to be thinking about these remote non-face-to-face services, and what is likely our new normal. Our eVisits. This is a patient who might have a portal. As you can see, it's really for online digital E&M services. This is kind of accumulative. Again, think about this. The patient is like giving you questions via the portal and you or your staff is getting back to the patient. At the end of the week, we look at this and we go, oh my gosh, I've actually spent some time. Now, if I spent less than five minutes, I really cannot code and bill for that.

But you know what? I'm up to 27, 28 minutes. Oh, okay. I'm the physician, I'm the advanced practice professional. I can bill out a 99423. As you can see, at least for Medicare part B, which these again, are reflecting the national payment rates, that is $50 and some change. Again, eVisits, I like to tie those pretty directly to the patient having a portal. Now, we have our virtual check-in codes. These are my least favorite because as you can see, they're basically, I don't know, $12, $15 here, but we've had our G2012 and our G2010 for a while now. Under COVID, they may represent some opportunities because this really is that check-in.

The 2012, again, you can see about $15 communication, is technology-based service. That's really giving you a fairly broad swath in terms of what device the patient is giving to you or has for you, but it is that check-in. If that is, oh gosh, patient, you really need to have a telemedicine visit this afternoon or we need to "see you" maybe in the office, if you've gone back, or considering going back to office based services again, a best practice there, especially if you're in primary care seeing patients with COVID related symptoms is to kind of bifurcate your in-person clinics to hot clinics.

That is what I would refer to as your COVID-19 related clinics and your non hot clinics, your non-COVID related clinics, but this virtual check-in, if you do that and it leads to a visit, you can bill for that, but otherwise that G 2012 might be applicable in your situation, whether it's on a phone, on FaceTime, or portal, etc. Again, this is the set of codes that kind of allows you a little bit more broad swath of technology devices. That gives you a good sense. Again, I was trying to look at this from the patient's perspective about what type of non-face-to-face remote care options you have, knowing that each payer is doing this a little bit differently. Ideally, you build out that grid and consider my recommendation.

Again, extracted really from folks like you who are doing this well to really think about this at the scheduling phase, so that we're scheduling with what device the patient has and letting our coding and reimbursement fallout from that. So, what can we do? We talked about the device and the fact that we didn't have to have this kind of technologically fancy telemedicine component that we actually can have a patient use a phone. Interestingly enough, as you can see from the URL, this is Congress actually stepping in and saying, okay, it's okay for doctors to be able to see patients via a telephone, but they do have to have an audio and video capability, at least for Medicare, to be able to use for a two-way real time interactive communication.

Now, of course, we were all terrified about HIPAA, and so very quickly, health and human services stepped in and said, for this public health emergency, HIPAA basically goes out the door. Now, as you think about the next 12 to 18 months in your journey with non-face-to-face care, and really kind of rethinking about how you're delivering services, I'm going to suggest that you not just throw this out completely, but that your staff is still checking, for example, confirming the patient's name, date of birth, and/or perhaps one additional variable, or at least making sure you're confirming that the right patient is on the line.

However, technically, as you can see, and again, you'd want to talk to your attorney about this if you have any questions, HIPAA privacy regulations have in essence, been thrown out the window, at least for the time of the public health emergency. I was talking to a physician about this, this morning. Many of our payers have kind of given dates about when they're stopping reimbursement for telemedicine. I would encourage you to put that on your tracking sheet, your grid that you can build. However, please know that there is no end date from a federal government perspective for the public health emergency, at least as of the moment that we are in today.

We do know that, basically your physicians can be rendering care from anywhere. This is important, because we do know that there was a web of regulations related to licensure in terms of physician as location and their performing telemedicine services. Again, much like HIPAA, this has basically been thrown out the window. I should mention, because there's a little bit of confusion about this, that CMS was requiring for about a week or so you to enroll physicians in their home locations, but they quickly realized that that was unsustainable and changed their mind.

If you do have that in your background or a little bit confusing, that definitely was in the ethernet. It was part of the regulations. But again, after about a week of sitting on that, CMS did change its mind. Now, I should mention that licensure, even though we've seen these relaxations at the federal level, licensure is controlled by each state. So, my go-to website for this is the Federation of State Medical Boards, and you'll see, right on their homepage, they actually have updates for all 50 states, as well as US territories in terms of licensure.

I'd certainly encourage you to go to this website just to double-check, particularly if your physicians are working out of their homes and they are located across state borders. Again, just a nice double check for you, that Federation of State Medical Boards. Now, we do know that telemedicine was not allowed for patients, at least at the Medicare part B who had no relationships. So, our communication based technology services, you really couldn't see new patients on a non-face-to-face setting, again, thrown out the window. We do know that CMS has said over and over again in communications that you can see, not only established, but also new patients.

To the best of my knowledge, all payers have adopted this. You may find something different as you build out your grid. But again, to the best of my knowledge, we are able to see new patients as well as existing through any of these remote non-face-to-face services that I have described. But again, it pays to double-check your private payers. Now, I think one of the big things that we've seen question marks about relates to the consent. Okay. Wow. We can basically see patients on pretty much any device, although the government said not TikTok. I don't know how you would see patients on TikTok, but they expressly said do not use TikTok. So, indeed all of these things have been thrown out, HIPAA just established patients, licensure.

Okay. We're starting with a clean slate. What about consents? Consents, at least according to the government, are indeed required. However, you can obtain these annually, and furthermore, they can be obtained at the same time that a service is furnished. Furthermore, they can be obtained by, not just the doctor, but auxiliary staff. Again, when we start thinking about this from a workflow perspective, I think it's a great idea, if you can, to build, in your consent process, into scheduling. If you don't feel comfortable about that, confident about that, or if your legal advisor is indicating something different, then consider perhaps building that into the MA or the nurse rooming process so that we do not have to tie up the physician's precious time by dealing with consents.

Of course, this is a great opportunity for you to be thinking about not pen and paper, but how we can have the patient's virtual signature, but please, also note that, for the federal government, simply documenting the patient's verbal consent is adequate under this public health emergency. Let's talk for a few minutes about billing. For billing, there was a lot of confusion from a federal perspective about payment. Soon after the pandemic began, CMS did start releasing regulations about payment for telehealth services, and those a release of communications indicated that they would be paying for services, but they would be at the facility payment rate.

Of course, a lot of physicians and administrators called CMS and participated on their, almost daily web calls saying, hey, listen, oh my goodness, we can't get paid at the facility rate because it is much lower than our professional services rate. You can see, I've just given you the example of a level five established patient visits. I mean, it's $35. That's a lot of money when you're thinking about seeing patients 15, 20, 25, 30, 35 a day, this is going to start to add up very quickly. Soon after that, CMS actually said, oh, huh, this whole modifier and place of service that we've been telling you to use, we've actually got to throw that out the window.

The reason we have to throw that out the window is because that is what is triggering the lower facility rate. Let me stop here and say, if you bill your services using telehealth place of service modifier 02 for Medicare, Medicare is going to pay you at the lower facility rate, because that's how their claims systems are set up. That's what created this whole chaos for about two weeks. We were like, oh my gosh. If we use this modifier you've been telling us to use, we're going to get paid at this lower rate. Oh my gosh. We've got to throw that out, and we've got to report the place of service code that would have been reported had the service been furnished in person.

Why? Because that's what CMS tells us to do, because CMS, to their credit, and I don't say this very often, wants you, as physicians, to get paid appropriately, and appropriately is at that higher rate. Our place of service 11, if that is what you normally use as a physician's office, and of course that contrast to an outpatient hospital clinic, which would be using 19 or 22, and of course, those automatically get paid at the facility rate because that's how you get paid. If you are a place of service 11, a physician's office, then big takeaway here from this webinar is please, please, please, for Medicare part B, use place of service 11, and the way you know to get paid at a telehealth or to get to signal to Medicare that you're rendering the service as a telehealth is not by your place of service code, but rather by modifier 95.

So, our other payers, unfortunately, vary in policy. Some of them do want the 02 for telehealth, but I'm telling y'all, please do watch your services in terms of reimbursement. Because if that is triggering that lower facility rate that would be going to hospital outpatient clinics, I would strongly suggest that you advocate with your payers or you look for that payment, what Medicare is doing, which is saying, hey, listen, cutting through our claims adjudication system to get to that higher rate, the way you do it doctors is by billing place of service 11 and modifier 95.

Let's talk about collections payments, cause we know that's different than billing. We do know that the, not just CMS, but the office of the inspector general, doesn't like you going around waiving co-payments, waiving co-insurance, waiving deductibles. Why? Why do we even have deductibles, co-insurance, all these cost sharing? Well, of course the reason we have them is because from an economics perspective, we're trying to control utilization. If we got rid of all patient cost sharing, we'd all be flooded with patients trying to get in to be seen. So, we have this kind of aha like, oh goodness gracious, we actually cannot waive cost sharing.

What's interesting is that, under the Public Health Emergency, the Office of the Inspector General, as well as you can see from the upper quote, CMS has said, yeah, you can do it. You can waive cost sharing. But folks, this is important to know, they're giving us the flexibility to do it, but they're not paying you at the full allowable. So, they're saying, oh right, if you want to, you don't have to charge the patient, but goodness gracious, y'all, by the way, we're only going to get 80% of the allowable. It's up to you as to whether you want to charge the rest of it to your patients.

Again, I want to make sure I emphasize we have the flexibility to waive cost share, but it doesn't mean that Medicare is going to pay you 100% of the allowable. There is an exception, however, and that exception started on March 18th, because of the Families First Coronavirus Response act, Medicare part B is allowing you to put a CS, and C stands for catastrophe, CS modifier on claim lines in which, as you can see, there is a COVID-19 test that is rendered or ordered. For these circumstances, if you put the CS modifier on those CPT codes on those claim lines, we, at Medicare, will pay you 100% of the allowable. The other interesting thing is the government came out and said, by the way, this isn't just Medicare. This act, this law that was passed really relates to all payers.

All of you, Blue Cross Blue Shield, Aetna, etc, any time there is a COVID related test, or you have a test ordered, we're expecting you to waive the patient's cost share. Now, they're not requiring this modifier CS. That's really just for Medicare part B, and other payers are varying slightly in their policy. I know some payers are only doing it for tests while others are doing it when a test is ordered. Again, this is one of those areas where, as you're really building up, your intelligence about this creating your grid, you may need to look at this, but I did want to emphasize, for Medicare, if you render a test or you order a test, please add the CS modifier to your claim lines, because it will trigger that 100% of the allowable.

You want to make sure you add it before the 95, because the 95 is like basically an information-only modifier while the CS is indeed a payment modifier. We do know that our friends and FQHC and RHCS did have a pretty exciting announcement that came out on April 17th, and I will make sure to refer you to memorandum SE, that's a Southeast, SE 20016. This was published on April 17th. It was too much to put here. It's a multi page. It walks through what is actually a fairly complex approach, because it goes pre-July 1st to after July 1st, 2020 in terms of what you are to do at a community health center.

So, I'd encourage you to take a look at that. Now, let's go ahead and just walk through, I've given you a little bit of workflow, and then I'll turn it back over to Lea and we'll have some time as well for questions. What are these best practices, talking to a physician practices across the country? Definitely a best practice is to role-play, literally have four swim lanes. You can role play this out loud, you can role play this through a diagram where you have a swim lane for the patient. What does the patient say? What does the scheduler say? What does the medical assistant or nurse say? And what does the physician say and do?

Of course, as you're role-playing this, you want to introduce things like the patient who says, yeah, I don't want to do a telehealth visit. Why do I have to do a telehealth visit? I want to come in and see you, or vice versa. I don't want to come into your office. Why aren't you offering me a telehealth visit? So, all of the role-playing, I think, is important and very, very, very critical, is to arm your frontline team members, those who pick up the phone, those who are scheduling patients with scripts so that they can really, really have the ability to respond back to patients in a consistent manner.

Any digital capture. This is our chance. I don't want you to be bringing into patients this whole notion of the front office, y'all, I think we will never, ever, ever go back to that clipboard, receptionist front office approach. We got to rethink the workflow and really understand how we can start capturing signatures, insurance, cars, etc. I just did it myself as a patient. It was beautiful. I took a picture with my computer because I have a video of the back and front of my insurance card, uploaded, and boom, loved it. I think this is important to recognize that our patients are getting used to this. Again, going back to that line at the front office, I'm not sure that's in the card. Let's start thinking out of the box now.

A virtual rooming process. I love this. Have your medical assistant or nurse, many practices are doing this in conjunction with the physician so that we can make sure all of those kind of, well, I can't really see you Ms. Jones, or I don't want the doctors. I don't want our precious asset, our advanced practice providers to be spending the first five or six minutes teaching the patient how to use the video camera, the web cam on their computer. We really want you, again, as we think about that role playing, who's going to have that responsibility.

I love the virtual rooming process because we, in essence, eliminate no shows for the doctor. If I can make sure I room the patient before the doctor gets on to the video camera, to the telemedicine, I've eliminated any problems with my non-arrival rate. Then, as we've talked about that visit type on the schedule, can't emphasize that enough. That's a really key area to be able to do, instead of doing it on the backend from a coding and billing perspective. It's really going to allow you, I think, to have a much better reimbursement opportunity. Hopefully these have given you some ideas about where we are from a telemedicine and remote non-face-to-face services, from a regulatory perspective, as well as workflow. Super excited to be able to answer any questions that you may have. Lea, I'll go ahead and turn it over to you.

LEA CHATHAM: Thank you, Elizabeth. Yeah, so we're going to have just about five minutes or so, and then I think what we'll do, if Elizabeth will work with me on it over the next couple of days is try to get all the questions answered and put them in a blog post or something and send that out to you because there's a lot of questions and not a ton of time, but her transition here was perfect for me. I just quickly wanted to mention, SR Health, as the sponsor of the webinar today, and one of the things I think is just important to highlight here is that, SR Health and the Solutionreach platform, both are designed to provide an end-to-end workflow to support telehealth.

Whether you're using a third-party telehealth solutions or you want to use our new telehealth solution, SR telehealth, what we can help you set up is a way to get those messages out to patients letting them know how to schedule those appointments and how they work, sending out those appointment reminders with pre-visit instructions related to the type of telehealth visit. Then if you need a telehealth solution, we can offer you the ability to launch HIPAA compliant high resolution video from text message conversations with patients. If you're interested in learning more about any of that in terms of that end to end workflow, or in terms of how that SR telehealth solution works, we're happy to have somebody walk you through that.

Just let us know in the survey at the end, it'll ask you if you want somebody to reach out. Also, really quickly, there are some people who are on here who, I'm just going to go to this really quick, who came to us through PAHCOM, and there is a PAHCOM CEU available today, and we will get you those certificates. If you can just put in the question or the chat that you would like to PAHCOM CEU certificates, I don't think it's ... We should have added that to the survey and I didn't, so I apologize for that. So, throw it in the questions before you leave if you want that PAHCOM CEU certificate.

Then, if you, again, are interested in talking to someone about SR Health and telehealth, you can also email us. There are some promotions going on, obviously right now, to help support people making this transition in terms of making it more affordable and easier to get up and get running very quickly, so we'll work with you on that. Okay. Let's answer a couple of quick questions, and then Elizabeth, you and I can work on maybe sending something out to everybody later, since there's a lot of detailed questions here, and I don't know that we have time to really get into the weeds.

A big one that people have been throwing in here is just wanting to clarify. So, telephone visits are not paid at the same rate as video or as an in-person visit would have been paid, right?

ELIZABETH WOODCOCK: That is correct for Medicare part B. Because of course, we have no single payer system in the US, that reimbursement policy does vary by payer. A number of our payers are paying for really "full rate." What I think of is like the office based E&M codes by telephone, but not Medicare part B. Lea.

LEA CHATHAM: Okay, great. Thank you. That was another thing that's come up a lot, is people asking, well, are my commercial payers paying the same rates for all of these various services that Medicare, and I think you've said, you really need to check with your commercial payers because it just varies so much from payer to payer, right?

ELIZABETH WOODCOCK: That is correct. Lea, just as make sure to mention to our attendees, in addition to the URL provided on the slides, I've put together, for our attendees, a fact sheet that includes links to all of these regulatory issues, but also all of the major payers and their COVID related reimbursement policies. Even though that's going to take a few minutes to put together the grid, hopefully that will save you a bunch of time by having the hot links to each one of those, that major payers policies. Lea.

LEA CHATHAM: That's great. Thanks. And just as a reminder, everyone, you're going to get an email that's going to have these handouts and the recording and all that stuff later on. The other thing that lots of people are asking about Elizabeth is, when we're talking about remote monitoring, is there somewhere to kind of find out what types of devices might be included in that? People are asking, well, does that include blood glucose monitors? Does that include CPAP machines? Does that include any kind of device they may be using for patients? How do they know what might be included there?

ELIZABETH WOODCOCK: That is a really great question. Of course, there are really two components to it. One is the CPT code itself. As a reminder, the CPT code itself uses the term, etc. Meaning they don't define. They give some examples, it is "physiologic parameters." That's the CPT code, and they give weight, blood pressure, pulse-ox, and respiratory flow rate as just as examples. I will say, from a coding perspective, there is no specific definition of what device we're talking about. Actually, I think that's a good thing because they don't create a framework for you, or they create a framework, but you fill in the dots.

Then, of course, Lea, we have the reimbursement issue. You do want to make sure that you look to your payers to see, oh, do they actually have any specific exclusions, etc? The reason I brought up that YouTube video from CMS is they're really plugging that with pulse-ox for COVID, and so I thought that was really good news. They though do not have any specific exclusions either, but they're going to the framework of the CPT codes. I don't want to say it's limitless, but I would use that physiologic parameters as really the guideposts for what you can do with regard to RPM. Lea.

LEA CHATHAM: Great. Thank you. I don't want to keep people over too much, so maybe we'll just do one more quick question, and like I said, we'll try to get a bunch of answers out to you through some kind of method like a blog post in the next week or so. I think the last one here, Elizabeth, we both could maybe just give a quick sentence or two on. There are a couple people in specialties who said, well, Hey, I'm an OB/GYN. People need to come in for physical exam. How do I do that over telemedicine? I think you'd probably agree, you can't. I mean, there are some things you can't do over telemedicine. You can't do a Pap smear over telemedicine, and there are people you're going to have to see in person. Elizabeth, has there been any guidance in specialties like that where a lot of stuff really is physical?

Has there been some guidance from CMS about what you can realistically, maybe do over telemedicine versus where you need to put some processes in place to protect people and have them come into the office?

ELIZABETH WOODCOCK: It's a great question. Of course, we're starting to see, now that we are seeing some relaxation in terms of non-emergent services being able to start back up. For example, I just saw that the GI community is holding a big call early next week about reopening endoscopy centers. I, in fact, was just on a call yesterday where the department chair of obstetrics and gynecology at one of the nation's largest academic medical centers were talking about their approach. For them, they had collectively decided as a department to stretch out the pre-OB services, prenatal services by an extra two to four weeks, and had put in place a clinic, in-person clinic services that allowed for social distancing, so the appointment durations. This is something you can think about in your template. So, you may have one in-person at the top of the hour followed by.

The typical duration I'm seeing for telemedicine is 20 minutes or 30 minutes. So, you could have, okay, I'm going to see that patient at 9:00 AM, but I'm going to see the next two patients via telemedicine. That then extra 40 minutes allows the first patient to depart and the second one to come in. I think really looking at that schedule is a great way to start blending where it's appropriate your mix of in-person and telemedicine. Then lastly, to really look at our specialty societies, because I think we'll continue to see a lot more guidance come out in the next few weeks as we start seeing and reopening of our practices. Lea.

LEA CHATHAM: Yeah. The last thing I'll add, if you are sort of struggling to find the right balance there, we actually have just recently produced an entire program around sort of what to be doing now, what to be doing when you're ready to fully reopen, and then how to deliver care moving forward. It is on our website at solutionreach.com. It's called our 2020 comeback program. You might find some useful resources in there around how best to provide those limited visits right now, and then how best to manage your office moving forward. Again, thank you so much, everyone. We've stayed on an extra five minutes to cover some questions.

Like I said, we'll do our best to get you answers to the rest of the questions through some other means here in the next week. I want to say thank you to Elizabeth for being here. That was a great webinar, so thank you so much for taking the time to do that.


LEA CHATHAM: And thank you everyone for joining us. Please stay safe and have a great rest of your week. Goodbye, everybody.