Telehealth in the FMC and in the Residency Curriculum

Telehealth (or Telemedicine) is a critical skill for all family physicians. Residents routinely use Telehealth in the FMC to provide patient care.

QUIICK LINKS:

Telehealth Guidelines for the FMC are found HERE.

According to residency policy, residents must be assessed for competency in Telehealth prior to providing Telehealth visit care. Information regarding assessment is detailed below. The Evaluation Form required for all R1s is linked HERE.

Residency Telehealth Curriculum

PROGRAM GOAL & OVERVIEW:

The TCH/UC FM Residency Program includes the goal that all graduating residents are competent in providing healthcare via Telehealth communication platforms including Video Telehealth Visits, Phone-only Visits, After-Hours Phone Management, and asynchronous secure email.   

The full curriculum, with all figures and additional references is linked HERE. Please email Dr. Spata or Dr. Rich if you have any questions, concerns, or ideas regarding FMC Telehealth curriculum or management.

TELEHEALTH POLICIES:

1. Residents may only provide care for patients via virtual visit if qualified per residency policy (ADDENDUM 1: RESIDENT TELEHEALTH TRAINING)

2. Residents should be familiar with the definitions and types of virtual visits (ADDENDUM 2: TELEHEALTH DEFINITION & VISIT TYPES)

3. Patient care should only be provided via virtual visit if appropriate (ADDENDUM 3: PATIENT CRITERIA FOR TELEHEALTH)

4. Residents must precept all virtual visits according to the Telehealth Precepting policy (ADDENDUM 4: TELEHEALTH PRECEPTING)

5. Residents providing billable telehealth care must adhere to FMC Policy[i] including use of smartphrases that ensure correct documentation

6. All use of virtual visits/Telehealth must be CMS, ODH, HIPAA, DEA, and ACGME compliant

7. Documentation of all billable virtual visits must include all required elements, including: [ii]

   1. Patient informed consent

   2. Patient identifier, location

   3. Provider location

   4. Length of visit

8. Residents must provide care for each type of virtual visit in line with TCH and FMC Policy (See FMC Policies & Procedures):

   1. Telehealth Visits

      • Must be video or live precepted with Preceptor

      • Use Epic EZ Care/Zoom video[iii] for HIPAA compliance unless PHE relaxation allows for other video, in which case video method must be documented

   2. Telephone-only Visits

      • Should be billed based on time (99441-3), even for residents

      • 99996 (Tel Admin) may be billed if provider is unsure of billing

   3. Virtual Check-In – Should not be billed by residents

   4. E-Visit – N/A

9. Billing and coding must be in compliance with CMS guidelines, including the GE/GC modifier.  Though billed Telehealth visits require additional modifiers, FMC providers should not add these modifiers, since these are added by TCHHN billing and coding department.

10. Residents providing care during a Public Health Emergency (eg, COVID), must adhere to TCH and FMC Policy related to the emergency

REFERENCES:

[i] FMC Telehealth Policy: https://www.evernote.com/l/AM_TuxZhVGpCLY9kb9LX676KmzkLUocN288

[ii] From TCH/OSMA:  https://osma.org/aws/OSMA/asset_manager/get_file/435710/webinarslides_ohiotelemedpresentation-3.23.20.pdf

[iii] EZ CareVideo summary and patient link: See https://www.thechristhospital.com/services/additional-services/video-visits 

ADDENDA:

1. RESIDENT TELEHEALTH TRAINING:

1. Telehealth training is required for all TCH/UC FM residents to ensure patient safety, patient satisfaction, and appropriate billing procedures, and to align with national standards of care[i].  Telehealth training and includes the following components:

   1. Proper use of the telehealth equipment and technology

   2. Adequate documentation of services provided

   3. Effective communication techniques

   4. Understanding appropriate application to clinical care

   5. Delivery of services within the scope of practice

2. Residents must be directly observed by a preceptor for their first telehealth visit, or a simulated visit, for the entirety of the visit (except in the case of an emergency, in which case their Level of LOS for outpatient care applies).  Once this direct observation is complete and their competency checklist is signed-off by an attending and filed, their LOS (Level of Supervision) for outpatient care applies to telehealth visits.

2. TELEHEALTH DEFINITION & VISIT TYPES:

1. Definitions[i]:  Virtual visits, also referred to as “Telemedicine” or “Telehealth”[ii] refer to a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies. These include live video, secure email, and remote patient monitoring.

2. Types:  Virtual visits can occur in the following 4 ways (3 are CMS/Medicare compliant, with the fourth, telephone-only, compliant by exception in emergency)(SEE FIGURES 1, 2 & 3 IN FULL CURRICULUM LINK):

   1.  Telehealth Visits - real-time audio and video visits substituting for a in-person/on-same-site encounter

      1. Billed with normal visit (such as E/M) codes: 99211-5 (established) or 99201-5 (new)

      2. Billed based on documentation (ie, History + MDM complexity, +/-PE) or time-based if >50% involves counseling or coordination of care (Residents cannot bill based on time)

      3. If not in real-time, may be billed as G2010 (Virtual Check-in)

      4. Can be patient or provider initiated

      5. Reimbursement: CMS reimbursement is same as in-person

   2. E-visits - online email-based E/M visits, using EHR, initiated by patient

      1. Use 99421-99423 time based billing (eg, 99421: 5-10 minutes; 99422: 11-20 minutes; 99423: 21 or more minutes)

      2. Must be patient initiated (but office can invite the use of this)

   3. Virtual Check-ins – assessments by telephone or other telecommunication device to determine whether an in-office encounter is needed for the patient’s concern

      1. Use G2012 for a 5-10 minute discussion that is not recorded

      2. Use G2010 for a recorded video or images submitted by a patient that is then interpreted and followed-up virtually with the patient in 24 hours

      3. Virtual Check-In billing can only be used when an E/M service has not been provided in the past 7 days or within the next 24 hours or soonest available appointment

   4. Telephone/Audio-only E/M visits – Typically not covered by Medicare but may be covered by some private payers (Covered in national emergency as a Telehealth visit related to 1135 Waiver):  

      1. Use time-based codes; Residents cannot bill based on their time except by PHE exception (99441: 5-10 minutes; 99442: 11-20 minutes; 99443: 21-30 minutes (or more))

      2. Cannot relate to E/M visit within the last 7 days or next 24 hours/first available

      3. If Medicare patient, or insurance that will not reimburse, can substitute G2012 Virtual Check-In visit

   5. Other – There are other categories less important to primary care and not utilized by physicians or APPs in the FMC, for example: Remote Physiologic Monitoring (99457, 99453-54) or 

3. Other background and terminology

   1. CMS (Center for Medicare) sets the standard for Telehealth; most insurances follow their lead.

      1. 1135 Waiver[iv] – Effective March 6, 2020 for national emergency; expands CMS/ Medicare benefits for services anywhere in the US without previous geographic/access restrictions for telehealth billing

   2. In virtual visits, there are two “sites”:  1) Originating site – where the patient is (Prior to 2019, Medicare was picky about this and only approved Telehealth Visits for patients with limited access, such as rural); 2) Distant site – where the provider is (in billing denoted as the Place of Service (POS)

   3. POS 02 – POS is “Place of Service”.  This allows Medicare to reimburse for a “Facility Fee”.  There are many POS designations in Medicare, eg, POS 23 is an Emergency Room, POS 50 is an FQHC[iii].  For Telehealth, POS 02 is added to a visit code and denotes the billing address:  For providers that provide care part of the time at an office, the billing address is always the Provider’s office, even if the provider did not provide care for the patient at their office at the time of the service (ie, was remote); for providers working 100% from home, POS is their home address.  There are many other POS designations in Medicare, eg, POS 23 is an Emergency Room, POS 50 is an FQHC.  The POS code is NOT entered by Providers, but by TCH Billing Department.

   4. Modifiers – typically two digits that provide additional information to payers to ensure that providers get paid correctly for services rendered.  More than one modifier can be used for a single visit.  Key modifiers in virtual visits include:

      1. GE/GC – These codes are still used for all precepted encounters, ensuring reimbursement by Medicare for precepted resident physician services

      2. GT – In Medicare, only for Critical Access Hospitals (CAH’s) using “Optional Method II”; Ohio Medicaid also uses this code for Telehealth Visits

      3. 95 – Used for all private payers (commercial insurance) to denote a virtual visit

      4. U1 – Patient location (home); there are others

3. PATIENT CRITERIA FOR TELEHEALTH IN THE FMC:

1. Patients that meet the following criteria are typically appropriate for Telehealth during the pandemic, unless a physical exam/vital signs or other in-person intervention are needed to ensure adequate care:

   1. Routine patients who prefer a TeleHealth visit

   2. Those who are already quarantined but need routine or new visit care 

   3. Patient unable to come to clinic but requesting evaluation

   4. Patients with a cough, fever, or influenza-like illness (NOTE: If PE needed, and in TCH system, refer to respiratory clinic or ER)

   5. Elderly or other high-risk patients with chronic illnesses (for whom vital signs, exam, or testing are not likely to change management or for whom the absence of such testing is not likely to cause adverse outcomes)

   6. Immunocompromised patients such as those seen by transplant, oncology, or autoimmune disease providers

2. Visits that require the following are not appropriate for Telehealth: 

   1. Required physical, in-person examination (abdominal, extensive eye exam, vascular exam in which pulses need to be checked, etc.)

   2. Recording of vital signs

   3. Use of diagnostic equipment

   4. Labs (Ex: nasal swabbing)

   5. Imaging

   6. Procedures as part of their care 

4. TELEHEALTH PRECEPTING:

1. All billable Telehealth Visits (Video or Phone-Only) provided by a resident must be precepted.

2. Precepting of Telehealth visits requires the same Precepting documentation as is required by in-person visits.  For example, a 99213 E/M code does not require the Preceptor to meet with/see and examine the patient, but a 99214 E/M* or Preventive code does.  Teaching modifiers should also be added (GE, GC).  (*NOTE: For COVID19 Pandemic PHE, Preceptors are not required to meet with/see a patient to bill 99214-5 or 99204-5)

3. All video Telehealth Visits must be precepted face-to-face, with the preceptor seeing the resident live or via video.  

4. The ACGME requires the following regarding precepting of Telehealth Visits: “…supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.”  This means the preceptor must have access to the EMR and the patient at the time of the encounter, but the preceptor does not need to be present with the patient and/or the resident.  (NOTE: During the COVID19 Pandemic PHE, patients, residents, and/or preceptors can be remote from each other.)

5. For additional Precepting guidelines for Telehealth, see FMC Policies & Procedures: 1) Telehealth; 2) Precepting

REFERENCES:

[i] AHIMA Telemedicine Toolkit:  https://healthsectorcouncil.org/wp-content/uploads/2018/08/AHIMA-Telemedicine-Toolkit.pdf

[ii] “Virtual Visits” is a less confusing term for the overall category of these types of visits; however, “Telehealth” is often used (and used by CMS) as the overarching categorical term.  Within the category of Telehealth, there are 4 types of visits, one of which is a “Telehealth visit.”

[iii] Additional examples of Medicare POS:  Telehealth (02), school (03), office (11), home (12), assisted living facility (13), group home (14), temporary lodging such as hotel (16), workplace (18), SNF (31), nursing facility (32), hospice (34), independent clinic (49), public health department (71)

[iv] CMS Telemedicine Fact Sheet (3/17/2020):  https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

[i] AHIMA Telemedicine Toolkit, ibid:  “A training program should include a review of the organization’s telemedicine policies and procedures, and any state regulations associated with telemedicine that must be followed. During the initial training, if possible, a hands-on element is crucial along with an assessment of key objectives and a refresh process. Technol- ogies and monitoring processes should be in place to assess the telemedicine provid- ers on the established competencies and goals of the telemedicine program as well as adherence to the telemedicine policies and procedures. The monitoring process should be automated (to the greatest extent possible) to ensure awareness and adherence is met.  The Telehealth Resource Centers have developed an in-depth strategy for tele- medicine training.” (https://www.telehealthresourcecenter.org/knowledgebase_category/training-strategy/)

FIGURE 1[i]: 3 CMS-COMPLIANT VIRTUAL VISIT TYPES

FIGURE 2[ii]:  4 VIRTUAL VISIT TYPES WITH CODING & RVUs 

FIGURE 3[iii]: VIRTUAL VISIT CODING ALGORITHM

Resident Telehealth Competency Feedback Form & Checklist

Form:  https://ucfm.wufoo.com/forms/p1nghd0i1ti7yt7/

 Per residency supervision policy, the “Telehealth Direct Observation Evaluation Form” is to be completed by an FMC attending confirming resident competency.  The form is to be completed by FMC faculty based on one-on-one observation of TCH/UC FM/FMP R1s, preferably during their first block of residency.

A resident is progressed to the LOS that matches their FMC Outpatient LOS once they have been observed by faculty for each of the following Telehealth visit types and completed the checklist below: 1) Telehealth Visit (video-based); 2) Telephone Visit (audio-only; does not have to be billable); 3) E-Visit (or MyChart clinical management; does not have to be billable).  The direct observation form must be completed by a faculty member to confirm the R1 has been observed in all the noted areas.  An LOI of 3 or more on the form is anticipated and is adequate for the resident to advance from LOS0 to an LOS matching their FMC LOS.

Checklist:

• Accesses and utilizes the FMC Policy & Procedure Manual and FMC Telehealth webpage to ensure adherence to Telehealth guidelines

• Ensures provider-side environment is secure and private

• Ensures patient-side environment is appropriate for privacy and safety

• Correctly documents required Telehealth components for a billed visit, including patient ID and location, provider ID and location, type of visit, and time of visit

• Correctly precepts based on type of visit (Must "see" preceptor for all billed visits; preceptor must "see" patient for video E/M level 4 or preventive billing)

• Uses video appropriately for communication, including looking at camera periodically to simulate eye contact and using hand gestures to assist communication

• Balances attention appropriately between patient and documentation

• Speaks naturally with appropriate volume

• Manages video call correctly to start, end, accept, reject, or handoff, through Epic Zoom or other compliant format

• Arranges clear plan for management and follow-up through team-based approach (utilizing MA/Front Office as appropriate)

• Recognizes indications for changing Telehealth visit to in-person visit (such as need for vital signs or physical exam)

• Correctly bills or does not bill for Telehealth visits, using E/M, preventive, phone-only codes and modifiers appropriately

• MyChart/Secure Email: Demonstrates effective communication in use of secure email with a patient, including adequate detail, avoidance of excessive writing, and use of patient-friendly understandable language

• MyChart/Secure Email: Recognizes when patient email communication should be re-directed to a visit

REFERENCES:

[i] AAFP Start-Up Toolkit for National Emergency COVID-19:  https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/crisis/CMSGeneralTelemedicineToolkit.pdf

[ii] https://www.aafp.org/fpm/2020/0500/p5.html

[iii] FPM 3/23/2020: https://www.aafp.org/journals/fpm/blogs/inpractice/entry/telehealth_algorithm.html?cmpid=em_FPM_20200325

Special thanks to Drs. Anna Schweikert, Christopher Champlin, and Alex Vance in helping to prepare this page