Drafted by the SAGES COVID-19 Rapid Response Team. This was approved by the SAGES Executive Committee.

This document was updated on March 23, 2020

Introduction:

The use of telemedicine is essential to ensure uninterrupted medical and surgical care to our patients during the COVID-19 pandemic. In response to the COVID-19 pandemic, SAGES has prepared this special primer on telehealth. Telehealth is the use of telecommunications technology to deliver a wide breadth of health services including diagnosis, consultation, treatment, education, monitoring, and healthcare administration. Prudent use of technology may facilitate ongoing interaction with patients, other physicians, students, residents, administrators, and caregivers.

There are a number of platforms that allow for both synchronous interactions using real-time audio, video, or messaging, and asynchronous “store and forward” transfers of medical records or images. As national and state policy is adjusting in response to the pandemic, it is important to closely follow updates to policy regarding privacy, coding, and reimbursement to provide optimal care to your patients via telehealth, while being aware that certain policy adjustments may be temporary. When uncertain, we recommend consulting with your institution’s compliance officer, healthcare compliance attorney, the Centers for Medicare and Medicaid Services (cms.gov), and the U.S. Department of Health and Human Services (hhs.gov).

Clinical Triage:

As outlined in the recently published SAGES COVID-19 guidelines, all elective non-urgent procedures should be postponed until after the pandemic shows adequate evidence of a decline of new cases. All office visits that cannot be delayed and that do not require a physical exam should be eligible for a telehealth encounter. The use of relaying images for evaluation of pathology or wound progress should be done within the guidelines covered in the visit guidelines section below.

Telehealth Privacy, Licensure, Coding, and Reimbursement during the COVID-19 Pandemic

UNITED STATES

1. When possible, technology compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) should be used for telehealth involving Protected Health Information (PHI) (www.hhs.gov/answers/hipaa).
   1. HIPAA Compliant Technology: Common telecommunications platforms such as GoToMeeting, Skype for Business, or Microsoft Teams can be used safely when discussing PHI by entering into a business associate agreement (BAA) with the entity. There are also a number of health technology companies dedicated to facilitating HIPAA-compliant communication – e.g., InTouch Health, Doximity Dialer, Starleaf, Amwell, and Teladoc.
   2. Non-HIPAA Compliant Technology: Social communication technologies such as Facetime, Zoom, WhatsApp, text messaging, and email may be appropriate for use during the pandemic when there are no other alternatives. Effective March 17, 2020, the Centers of Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services announced they will waive potential HIPAA penalties and will not perform audits during the COVID-19 nationwide public health emergency for telehealth services that are used in good faith.

Licensure

Prior to the current COVID-9 pandemic physicians had to have a license for each state they practice medicine including telemedicine.   As telemedicine has become more utilized in the past several years, legislature to support its use across state lines has produced the Interstate Medical Licensure Compact (or IMLC).  Physicians are able to qualify for licensing outside of their state of principle license through the IMLC. There are currently 29 states, in addition to the District of Columbia and Territory of Guam, participating in the agreement.  During the pandemic, CMS has waived the interstate licensing possibly allowing physicians to practice across state lines.   Final approval for CMS and Medicaid is determined by the individual states.  Several states have already followed CMS and eased the restrictions with regards to practicing across state lines. Private payers are starting to expand  their policies to match the CMS and individual state changes. This licensure issue is changing rapidly.   For more information, follow the Federation of State Medical Boards COVID-19 updates and the latest on State Emergency declarations and licensing waivers

Providers

Services must be provided by a physician or authorized practitioner. Hospitals, physicians, physicians assistants, nurse practitioners, psychologists, dietitians, and social workers may provide telehealth.

Coverage

As of March 6, 2020, CMS will temporarily provide coverage for telehealth services throughout the country for the duration of the COVID-19 pandemic. The expanded benefits will allow greater flexibility for providers and patients utilizing this critical tool to care for patients remotely. Prior to this expansion, telehealth services were only covered for patients receiving services in rural or remote locations and they were not allowed to receive the telehealth service from their home. Patients are now able to receive telehealth services in any healthcare facility, including a physician office, skilled nursing facilities, and in the home. For more information, visit the Medicare Telemedicine Health Care Provider Fact Sheet.

Medicaid is state-dependent but already provides a varying degree of flexibility to states regarding telehealth. The Center for Connected Health Policy, a non-profit organization focused on national telehealth policy, has created an up-to-date resource for State Telehealth Laws. At the current time, California is the only state to enact a law to remove barriers to telehealth during the current pandemic.

Private payers are starting to follow suit with CMS. Large commercial insurers, such as Aetna, BlueCross Blue Shield, Cigna, Humana, UnitedHealthcare and more are moving to expand telehealth policy. For some, it is expressed that these policy changes may become permanent, even after the current public health crisis has resolved.

Regardless of coverage, receiving and providing telehealth medicine is not prohibited. Rather, the controversy lies in its reimbursement and coverage.

Documentation

Despite relaxed policy on the use of telemedicine, proper documentation is still imperative. Many of the technologies utilized for telemedicine can be linked or embedded in the electronic medical record (EMR) for easier documentation.

Written informed consent for the use of telehealth should be obtained whenever possible. Verbal consent is allowed during this pandemic. It is considered best practice by SAGES to discuss both the use of telehealth and the technology being utilized.

Complete documentation should include:

1. The informed consent discussion.
2. Statement that service was provided via telehealth, including the type of telehealth being utilized. The potential use of a non-HIPPA compliant technology should be mentioned, as well.
3. The location of the patient and provider.
4. The roles of people participating if not otherwise clearly stated.
5. Documentation to support appropriate coding.

For telehealth visits occurring in place of office visit during the pandemic, proper documentation is still vital. An example of this documentation is as follows:

“This visit has been changed from an in-person office visit to a phone visit to lower the risk of exposure and/or spread of the current pandemic with the COVID-19 virus. This is based on guidelines from the CDC and other health agencies.”

Coding and Billing

Telehealth Outpatient Visits

Telehealth is defined as synchronous audio and visual visits between patient and clinician. There must be capability to have real time two-way audio-visual interaction.

Modifiers

POS Code 02	Services rendered via synchronous interactive audio and video telecommunication. Use after E/M code to bill for telehealth.
GT	Services rendered via synchronous interactive audio and video telecommunication. No longer required after 2018. Replaced by POS code 02
GQ	Telehealth via asynchronous telecommunications. Required if part of federal demonstration program for Alaska and Hawaii
95	Synchronous telecommunications service, typically overlaps with GT and now POS code 02.

Q3014 Telehealth Originating Site Facility Fee

This is the facility fee for the originating site (physician’s office, hospital, etc) for telehealth visit. Not applicable in the current pandemic environment.

Additional HCPCS category/class 2 codes for interest can be found here: Coding and Documentation Guidelines for APPs and Teaching Services_03-18

Inpatient/Emergency Room Telehealth Consultations

Video interaction is required per CMS.

Consultations ordered for Patients Under Investigation (PUI) and COVID-19 Positive Patients in the Emergency Room and/or Inpatient status require a request for an inpatient or emergency department telehealth consultation from an appropriate source and a report of the consulting provider’s findings and recommendations.

Initial Visit		Subsequent Visit
G0425	30 minutes	G0406	15 minutes
G0426	50 minutes	G0407	25 minutes
G0427	70 minutes	G0408	35 minutes

Telephone Evaluation and Management

Telephone evaluation and management services provided by a physician or healthcare professional to established patient, parent or guardian. No E/M billing can be used within the previous 7 days or in the following 24 hours.

The following codes are currently not covered by CMS but may be covered by commercial payers.

Physician billing CPT Code	QNP* code	RVU	Minutes
99441	98966	0.25	5-10
99442	98967	0.50	11-20
99443	98968	0.75	21-30

*Qualified NonPhysician (QNP): dietician, speech pathologist, physical/occupational therapist, social worker.

Digital Visits

Digital Visits using technology for evaluating the possible need for an office visit. Communication must be patient driven. This does not lead to E/M service. This is for established patients only for a time limited to 7 days.

For CMS use HCPCS codes G2010-G2012. For more details, visit CMS.gov. For commercial payers, use codes 99421-99423. Additional information, including information regarding remote patient monitoring, can be found through the AMA Quick Guide to Telemedicine.

E-Consultations

Interprofessional consultations are provider to provider consultations via telephone, internet or EHR. Must include a verbal and written consultative report to the patient’s treating physician. Codes 99446-99449 are typically used. Where appropriate, 99451-99452 codes may be alternatively used.

COVID-19 ICD-10 Coding Guidelines

Effective February 20, 2020, new diagnosis coding guidelines were released for encounters related to the COVID-19 Coronavirus Outbreak. These guidelines can be found here: https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf

CANADA:

For surgeons practicing in Canada, several resources are available for conducting a practice by telehealth and for circumstances specific to the SARS-nCoV-2 pandemic.

1. The Canadian Medical Protective Association (CMPA) offers advice on liability for duty of care and for treating patients with COVID-19 via telehealth. These can be found at: https://www.cmpa-acpm.ca/en/covid19.
   1. With respect to duty of care, the professional obligations and legal principles that usually apply to all surgeons continue in the context of COVID-19. Where in-person consultation is not required, consultation by telephone or other means of telehealth (virtual care) may be expected.
   2. The CMPA resource for practising telehealth can be found here: https://www.cmpa-acpm.ca/en/membership/protection-for-members/principles-of-assistance/practising-telehealth.
   3. While surgeons are reminded to follow their Colleges’ guidelines for delivery of telehealth, two important considerations should be addressed:
      1. The technology used for telehealth should be specified, in the medical record, for each encounter.
      2. Informed consent for the use of virtual care should be obtained. A template is available at: https://www.cmpa-acpm.ca/static-assets/pdf/advice-and-publications/risk-management-toolbox/com_16_consent_to_use_electronic_communication_form-e.pdf
2. In Ontario, since 2006, telemedicine has been offered securely through the Ontario Telemedicine Network (OTN). Until recently, these services have required patients to go to a healthcare facility host site. Since 2014, the OTN has piloted direct-to-patient video visits using OTNinvite, a secure videoconferencing service that allows physicians and patients to connect from any location in Ontario using their own electronic device. This service is only available to family doctors. In accordance with the Ontario Medical Association (OMA), surgeons wishing to provide virtual care to patients are able to do so using non-OTN technology with the following conditions:
   1. A temporary fee code for non-OTN, specialist, virtual care (K083) has been developed.
   2. Informed consent is obtained, as above
   3. Documentation of technology employed is recorded, as above.
   4. An OMA recommended patient information text, for surgeon websites or office posting, explaining the limitations of virtual care technology and potential privacy concerns is available here: https://www.oma.org/member/section/practice-&-professional-support/virtual-care?type=topics, as is a recommended virtual care disclosure text for inclusion in eth electronic medical record.
   5. OMA Recommended virtual care platforms are available here: https://content.oma.org/wp-content/uploads/private/VC-Covid19-visual-V4.pdf

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