Using Telehealth to Care for Patients During the COVID-19 Pandemic

Fighting for Family Medicine: AAFP Advocates for CMS to Relax Key Regulations

After the AAFP advocated for telehealth latitude(2 page PDF), CMS announced on March 30 plans to temporarily relax a number of key regulations.

This will help family physicians better respond to the COVID-19 pandemic and includes other measures to relieve administrative burden and reinforce staffing.

COVID-19 banner

Telemedicine and virtual care have quickly become important tools in caring for your patients while keeping yourself and your staff safe as the COVID-19 pandemic quickly evolves. Here is what you need to know when providing telehealth services.

How do I quickly implement telemedicine in my practice?

Expansion of Telehealth and Licensing Waivers During the COVID-19 Pandemic

Fighting for Family Medicine: AAFP Advocates for CMS to Relax Key Regulations

After the AAFP advocated for telehealth latitude(2 page PDF), CMS announced on March 30 plans to temporarily relax a number of key regulations.

This will help family physicians better respond to the COVID-19 pandemic and includes other measures to relieve administrative burden and reinforce staffing.


How do I get reimbursed?

The Centers of Medicare & Medicaid Services (CMS) has loosened the regulations for telemedicine in response to the COVID-19 pandemic. Telehealth services may now be delivered to Medicare beneficiaries by phone as long as video capability is available. 

Review the links below for more information and read more on the FPM Journal Getting Paid blog.


Selecting Technology for Use

Providing care virtually doesn’t have to be complicated!

Beginning on March 6, 2020, Medicare — administered by the Centers for Medicare & Medicaid Services (CMS) — will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country. For more information please see the FAQ(edit.cms.gov) and Guidance(www.medicaid.gov). It removes the telehealth stipulation that telehealth can only be provided in rural areas with specific audio-visual equipment.

It's as simple as using your phone, smartphone or laptop with a shared link to enable video, or other electronic devices. Free to low-cost telehealth platform options are available. As of the March 17 HHS OCR announcement(www.hhs.gov), effective immediately (and during the COVID-19 National Public Health Emergency) you may use popular apps that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype, to provide telehealth without risk that OCR might impose penalties for noncompliance with HIPAA.

Note: Facebook Live, Twitch, TikTok, and similar video communication apps that are public facing should not be used to provide care virtually.

Coding for COVID-19

The CDC announced a new diagnosis code for coronavirus or the illness it causes, COVID-19, in the U.S.

Examples of Telehealth Platform Vendors

AAFP does not endorse specific products or companies and of course recommend carrying out your own due diligence in investigating, but telehealth platforms we are aware of members using in private practice include:

Doxy.me(doxy.me) – Self-touted to be “a simple, free, and secure telemedicine solution.” The AAFP understanding is Doxy.me has a “freemium” business model, with a free base option and other options available at cost a la carte.

eVisit(evisit.com) – The AAFP has heard member reports eVisit ranges from $50/month to $150/month.

SimpleVisit(simplevisit.com)  – The AAFP has heard SimpleVisit runs approximately $150/month. 

VSee(vsee.com) – The VSee site notes one can “get it free," though the AAFP has heard members report it costing up to $250/month.

Mend (MendFamily)(www.mendfamily.com) – The AAFP has heard of pricing at approximately $250/mo to $500/month, with mention that $500/month includes billable condition-specific questionnaires that can be pushed to patients and info gathered in advance of the visit.
Note: Mend is available only in certain areas; though those are not definitively known to the AAFP and continue to expand.

Spruce Health(www.sprucehealth.com) – Spruce Health is often used by direct primary care (DPC) family medicine practices. Its telehealth capabilities are integrated with Elation Health EHR, though Spruce can be used alongside other EHRs without integration with EHR. The AAFP is not yet aware of pricing info.

Key Questions to Answer When Exploring Telehealth Platforms

The AAFP is gathering answers to these questions across vendors:

  • Can I exit my contract at any time (i.e., not locked into a 2-year contract)?
  • Is there a waiting room feature so I can queue my patients up?
  • Is the platform device agnostic (i.e., can physicians/providers and patients use device of their choosing for virtual care)?
  • Is there an out-of-office message noting we’re not available to take your call right now? (i.e., during off hours or overnight)?
  • Does the software has the ability to schedule a visit? Note: This is a more advanced feature; it's not absolutely required to have now, but it's very nice to have
  • Is the platform deployable in days?

CMS Relaxes Regulatory Requirements

On March 30, 2020, CMS published an interim final rule (Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency) to provide additional flexibility to physicians during the COVID-19 pandemic. The following changes are effective as of March 1, 2020, and for the duration of this current public health emergency.

  • Added Medicare coverage of, and payment for, telephone evaluation and management (E/M) services (CPT 99441-99443). These services may be provided to new or established patients.
  • Allows physicians to select the level of office/outpatient E/M furnished via Medicare telehealth based on medical decision making (MDM) or time.
    • Time is defined as all the time associated with the E/M on the day of the encounter. The current typical times associated with office E/M are what should be met for the purposes of level selection.
    • CMS is maintaining the current definition of MDM.
    • CMS has removed any requirements regarding documentation of history and/or physical exam in the medical record for such visits.
  • Clarifies the Office of Inspector General’s (OIG) Policy Statement to state that physicians will not be subject to sanctions for reducing or waiving cost-sharing for a broad category of non-face-to-face services, including:
    • telehealth visits
    • virtual check-in services
    • e-visits
    • monthly remote care management
    • monthly remote patient monitoring
  • Expands the list of services that can be provided via telehealth. The updated list can be found here(www.cms.gov).
  • Provides payment for telehealth services at the non-facility rate under the Medicare physician fee schedule when appropriate
    • Physicians must bill the telehealth service with the Place of Service (POS) code they would have used if the service had been provided in person. Physicians must also append modifier -95 to the claim lines that describe services delivered via telehealth.
    • Any service reported with POS 02 (Telehealth) will be paid at the facility rate under the Medicare physician fee schedule.
  • Allows telehealth, virtual check-ins, e-visits, and telephone E/M services to be provided to any patient — new or established.
  • Clarifies that consent must be obtained annually and may be obtained either before or at the time of service.
  • For Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) — expands the services included in Virtual Communication Services (HCPCS G0071) to include the services reflected in CPT 99421-99423.
    • CMS will revise the payment amount of G0071 to the average national non-facility amount for HCPCS G2012 and G2010 and CPT 99421-99423.
    • All virtual communication services billable using HCPCS code G0071 will also be available to new patients that have not been seen in the RHC or FQHC within the previous 12 months.

Medicare Telehealth Services

  • Are provided using telecommunication technology and include office, hospital visit, or other services that generally occur in person. CMS recently updated the list of Medicare telehealth services(www.cms.gov).
  • Are considered the same as in-person visits and paid at the same rate as in-person visits.
    • To receive payment at the same rate as an in-person visit, CMS is instructing physicians to bill services delivered via telehealth with the same Place of Service (POS) code they would have used if the service had been provided in-person.
    • Physicians should append modifier -95 to the claim lines that describe services delivered via telehealth.
    • Claims billed with the POS 02 will be paid at the facility rate under the Medicare physician fee schedule.
  • Physicians can select the level of office/outpatient E/M furnished via telehealth using medical decision making or time.
    • Time is defined as all the time associated with the E/M on the day of the encounter. The current typical times associated with office E/M are what should be met for the purposes of level selection. They can be found here(www.cms.gov).
    • CMS is maintaining the current definition of medical decision making.
    • CMS has also removed any requirements regarding documentation of history and/or physical exam in the medical record for office/outpatient E/M encounters provided via telehealth.
  • Can be provided to established Medicare patients via phone if the phone allows for audio-video interaction between the physician and patient.
  • The Department of Health and Human Services (HHS) has announced that it will not conduct audits(www.cms.gov) to ensure a prior relationship existed for claims submitted during the COVID-19 public health emergency. Therefore, telehealth services can be provided to new and established patients.
  • Can be provided in all settings, including a patient’s home. Originating site restrictions have been waived(www.cms.gov).

  • The HHS Office of Inspector General (OIG) is allowing practices to waive cost-sharing for telehealth visits(www.cms.gov).

Medicare Non-Telehealth Services

Telephone Evaluation and Management Services (CPT 99441-99443)

On March 30, 2020, CMS finalized payment for telephone evaluation and management (E/M) services (CPT 99441-99443). Effective March 1, 2020, the codes will be considered active and payable for the duration of the COVID-19 pandemic. CMS will allow physicians to provide telephone E/M services to new and established patients.

  • Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment.
  •  The following codes may be used by physicians or other qualified health professionals who may report E/M services:
    • 99441: telephone E/M service; 5-10 minutes of medical discussion
    • 99442: telephone E/M service; 11-20 minutes of medical discussion
    • 99443: telephone E/M service, 21-30 minutes of medical discussion.
  • Physicians can reduce or waive cost-sharing for these services.

Medicare Virtual Check-ins (G2012)  

  • Enable a quick visit with a patient to determine if an in-person visit is necessary. Effective March 1, 2020, these services can be provided to new and established patients.
  • Are brief (5-10 minutes) conversations with a physician or other clinician, where the communication is not be related to a medical visit within the previous seven days and does not lead to medical visit within the next 24 hours (or soonest appointment available).
  • Can be conducted through multiple communication technology modalities, including
    • synchronous telephone conversation or
    • exchange of information through video or image.
  • Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal.
  • Are initiated by the patient, and patient must provide verbal consent. Consent may be obtained before or at the time of service.
  • Physicians can reduce or waive cost-sharing for these services.
  • G2010 can be used when a captured video or image is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment).

Medicare E-Visits (online digital evaluation and management services)

  • Are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently.
  • Effective March 1, 2020, these services can be provided to new and established patients.
  • Patients must verbally consent to services. Consent may occur before or at the time of service.
  • Physicians can reduce or waive cost-sharing for these services.

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes.

  • 99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • 99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
  • 99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

Clinicians who may not independently bill Medicare for E/M services (i.e., physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can use the following codes.

  • G2061: Qualified non-physician health care professional online assessment and management, for a patient, for up to 7 days, cumulative time during the 7 days, 5-10 minutes
  • G2062: Qualified non-physician health care professional online assessment and management, for a patient, for up to 7 days, cumulative time during the 7 days, 11-20 minutes
  • G2063: Qualified non-physician health care professional online assessment and management, for a patient, for up to 7 days, cumulative time during the 7 days, 21 or more minutes

Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication.

Documentation Requirements

Documentation requirements for any form of virtual care (telehealth service or non-telehealth digital online service) are the same as those for documenting in-person care.

  • If a code is time-based, evidence of time must be documented. 
    • CMS is allowing physicians to select the level of office/outpatient visit E/M for services delivered via telehealth using either time or medical decision making. Time is defined as all time associated with the E/M on the day of the encounter.
    • The current typical times associated with office E/M are what should be met for the purposes of level selection. They can be found here(www.cms.gov).
      CMS is maintaining the current definition of medical decision making. Current guidelines can be found here(www.cms.gov).
      CMS has also removed any requirements regarding documentation of history and/or physical exam in the medical record for office/outpatient E/M encounters provided via telehealth.
  • If exchanged asynchronously, videos, images and communications must be stored and retained according to state regulation.
  • Real-time (synchronous) videos, such as during a video visit or video phone call, are not required to be stored.

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

The CARES Act recently provided additional flexibility for billing telehealth services. FQHCs and RHCs can now serve as the distant site for telehealth services. They were previously limited to serving as the originating site. CMS has also expanded the services included in HCPCS G0071 and adjusted payment accordingly.

Virtual Communication Services

  • FQHCs and RHCs can bill for Virtual Communication Services (HCPCS G0071). G0071 includes:
    • 5 minutes or more of virtual (non-face-to-face) communication between an RHC or FQHC practitioner and RHC or FQHC patient; or
    • 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner, occurring in lieu of an office visit; or
    • the services as described by CPT codes 99421-99423.
      •  Online digital evaluation and management for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes, 11-20 minutes, or 21 or more minutes
  • The services are no longer restricted to established patients and can be provided to new and established patients.
  • Consent may be obtained prior or at the time of service.
  • Effective for services furnished on or after March 1, 2020, CMS will revise the payment amount for HCPCS G0071 to reflect an average of the national non-facility payment rates for G2012, G2010, and 99421-99423.
  • The RHC and FQHC face-to-face requirements are waived for these services.

*The HHS Office for Civil Rights (OCR) will exercise enforcement discretion(www.hhs.gov) and waive penalties for Health Insurance Portability and Accountability Act (HIPAA) violations against health care providers that serve patients in good faith through everyday communication technologies, such as FaceTime or Skype, during the COVID-19 public health emergency.