PHN Grand Rounds:

Telemedicine Best Practices and Opportunities for Improvement

April 10 @ 12:00-1:00PM Presented by: Sandy Chung, MD Eduardo Fox, MD Rachel Bakersmith, Practice Manager Susan Cheng, Practice Analyst

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A few notes about today’s Grand Rounds

• All lines are muted throughout the webinar.

• Please use the Chat function to ask questions or make comments.

• To avoid feedback noise, please do not have computer audio and phone audio active at the same time.

• Today’s Webinar recording and slides will be posted to the PHN website following the presentation. www.pediatrichealthnetwork.org

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COVID-19 Response (as of April 7,2020)

• Children’s National Hospital is open for business.

• Telehealth is deployed system-wide. Patients can request telehealth during scheduling appointments with the call center.

• Full time specialists available for real time consults – to contact dial Physician Access Line 202-476-4880 (M-F 8a to 5p; hospital operators 202-476-5000 after hours).

• Explore and participate in shared learning opportunities Childrensnational.org/webinars.

• Drive up/walk up specimen collection site (limited to patients age 22 or under as referred by a primary care physician). Childrensnational.org/COVID19testforms.

• Most elective surgeries are postponed.

• Hospital is preparing for a surge in patients and is taking measures to preserve the health of clinical staff in the event of influx.

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Children’s National Resources

Stay informed with the latest resources for providers, staff and patients on the Children’s National Coronavirus (COVID-19) Resources for Primary Care Practices

https://childrensnational.org/healthcare-providers/refer-a-patient/covid

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Upcoming April Grand Rounds

April 14 @ 12:00-1:00PM Caring for Quaranteenagers: Telehealth &

Confidential Care

Presented by: Children's National Division of Adolescent Medicine

Adolescent Medicine specialists will address:

• Strategies for STI and contraceptive management that can be used when in-person care is strictly limited

• New considerations for conducting video telehealth visits with teens

• Changes in clinical management for urgent, typically confidential concerns when social distancing is a necessary barrier to in-person care

April 23 @ 12:00-1:00PM Primary Care Management of the Infant Born to a

Mother with COVID-19 & Resources to Support Families of Newborns During the Pandemic

Presented by: Karen Fratantoni, MD, Lamia Soghier, MD, and the Child Health Advocacy Institute Team

Our speakers will provide guidance on:

• Primary care management of an infant born to a COVID-19 positive mother

• Management in the perinatal period including how to screen for concerns

• How to provide support and resources when needed by our families

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Neuroscience and Behavioral Medicine Lecture Series

April 8 Headache: Cause and Management in the Pandemic Marc DiSabella, DO Director, Headache Clinic

April 15 Pandemic Exacerbation of Stress and Depression: Diagnosis Management and Prevention Adelaide Robb, M.D. Chief, Division of Psychiatry and Behavioral Medicine

April 22 Home Management of the Autistic or Disruptive Child during the Pandemic Kelly Register-Brown, M.D. Medical Director, Center for Autism Spectrum Disorders

April 29 Home Schooling: Challenges for Children with Learning and Attention Difficulties Laura Kenealy, Ph.D. Director, Executive Function Clinic

May 6 Anxiety in Children in a Pandemic: Diagnosis, Management and Prevention Lilia Mucka, Ph.D. Director, Research in Anxiety Disorders Program

All meetings occurring on Wednesdays, 12pm-1pm

View all future Virtual Lunch and Learns at ChildrensNational.org/Webinars

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Welcome Panelists

Rachel Bakersmith Practice Administrator

Children First Pediatrics

Sandy Chung, MD Trusted Doctors (Fairfax Pediatrics)

PHN Medical Director

Eduardo Fox, MD Children’s National

Susan Cheng Practice Analyst

CNP&A

Agenda

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• Children’s National COVID-19 Response

• Telemedicine best practices - early lessons learned

• Implementing well child visits using telemedicine

• Challenges encountered (barriers; technology, language, etc.)

• Targeting key patient groups for telemedicine visits

• Q & A

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COVID-19 Response (as of April 7,2020)

• Children’s National Hospital is open for business.

• Telehealth is deployed system-wide. Patients can request telehealth during scheduling appointments with the call center.

• Full time specialists available for real time consults – to contact dial Physician Access Line 202-476-4880 (M-F 8a to 5p; hospital operators 202-476-5000 after hours).

• Explore and participate in shared learning opportunities Childrensnational.org/webinars.

• Drive up/walk up specimen collection site (limited to patients age 22 or under as referred by a primary care physician). Childrensnational.org/COVID19testforms.

• Most elective surgeries are postponed.

• Hospital is preparing for a surge in patients and is taking measures to preserve the health of clinical staff in the event of influx.

Telemedicine Best Practices & Lessons Learned

Sandy Chung, MD

Trusted Doctors (Fairfax Pediatrics)

PHN Medical Director

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Telephone care vs telemedicine (video visit) care

Telephone E/M service by MD/QHP provided to established patient (parent/guardian)

• Not originating from related E/M service in previous 7 days or leading to related E/M service in next 24 hours or soonest available appointment (include work in billed FTF E/M service)

CareFirst has announced it will pay flat fee $20 for CPT 99441 for all telephonic visits, regardless of time, through April 17, 2020- then re-assess

Telephone Services

99441 5 – 10 mins

99442 11-20 mins

99443 21-30 mins

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Platform Restrictions/HIPAA Compliance

A covered health care provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients.

• Under this Notice, covered health care providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype, to provide telehealth

• Under this Notice, however, Facebook Live, Twitch, TikTok, and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers.

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Platform Restrictions/HIPAA Compliance

The list below includes some vendors that represent that they provide HIPAA-compliant video communication products and that they will enter into a HIPAA BAA.

• Skype for Business / Microsoft Teams

• Updox

• VSee

• Zoom for Healthcare

• Doxy.me

• Google G Suite Hangouts Meet

• Cisco Webex Meetings / Webex Teams

• Amazon Chime

• GoToMeeting

• Spruce Health Care Messenger

* - for COVID-19 Related Visits, even if patient is screened negative ** - Plan Specific Coverage

DC & MD Provider Coding Grid Payer Telehealth Copay Waived Telehealth

Modifier

Telephone Visit Covered/CPT Electronic Visit (digital EM):

Communicaton btwn an established

patient and their provider through an

online patient portal

United Healthcare Commercial Yes* 95 99441-99443 99421-99423 (POS 11, No Modifier)

CareFirst Yes* GT or 95 99441 99421-99423 (POS 2, GT or 95 Modifier)

Aetna Yes GT or 95 99441-99443 99421-99423 (POS 11, No Modifier)

Cigna Yes* GQ G2012 (5-10 Min. Virtual Check-in);

Telephonic EM Visits:

99211-99215

TBD

Multiplan/PHCS Yes GT 99441-99443** 99421-99243** (POS 11, No Modifier)

Tricare/Humana Military Yes GT Not Covered Not Covered

Kaiser Select HMO Yes GT 99441-99443 TBD

DC Medicaid Not Applicable GT 99441-99443 Not Covered

AmeriHealth Not Applicable GT 99441-99443 Not Covered

Amerigroup DC Not Applicable GT 99441-99443 Not Covered

Trusted Health Plan Not Applicable GT 99441-99443 Not Covered

HSCSN Not Applicable GT 99441-99443 Not Covered

MD Medicaid Not Applicable GT 99211-99213 (Add UB Modifier) Not Covered

Maryland Physician Care Not Applicable GT 99211-99213 (Add UB Modifier) Not Covered

Medstar Family Choice Not Applicable GT 99211-99213 (Add UB Modifier) Not Covered

JHHC/Priority Partners Not Applicable GT 99211-99213 (Add UB Modifier) Not Covered

United Healthcare Community Plan Not Applicable GT 99211-99213 (Add UB Modifier) Not Covered

Amergrioup Maryland Not Applicable GT 99211-99213 (Add UB Modifier) Not Covered

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Virginia

Provider

Coding Grid

PayerEffective Dates

(DOS) *May extend

Telemed Copay

Waived (*for COVID

Allows Telemedicine Well

Checks (no modifier, POS 2)

Telemedicine

POS

Telemedicine

Modifier (Sick E/M

Telephonic Consult

Code (no modifier)

Aetna 3/4/20-6/4/20 Yes 11 GT or 95 99441-99443

Anthem 3/17/20-? Yes* Yes 2 GT or 95 99441-99443**Anthem

Healthkeepers

Plus

Yes Yes (Add modifier) 2 GT or GQ Can bill telemed for

Telephonic Visits Only

CareFirst 3/17/20-4/17/20 Yes* Yes 2 GT or 95 99441

Cigna 3/2/20-5/31/20 Yes* Yes 11 GQ G2012

Johns Hopkins No 2 GT or GQ or 95 99441-99443

Multiplan/PHCS Yes 2 GT or 95 99441-99443**

Tricare 3/6/20-? Yes 2 GT or GQ N/A

UHC 3/18/20-6/18/20 Yes* No 11 95 G2012

UHC Community 3/18/20-6/18/20 Yes* Yes (POS 11) 2 GT or GQ 99421-99423

VA Medicaid 3/6/20-? Yes Yes (POS 11) 2 GT or GQ Can bill telemed for

Telephonic Visits Only

VA Premier ?-5/31/20 Yes 2 GT or GQ

Telemedicine Jurisdiction Waivers - Updated

• Currently, only Maryland and DC have waived the Telemedicine licensure jurisdiction requirements.

• Therefore, a patient must physically be located in Maryland or DC during the time of the visit to be able to be seen by a DC or MD licensed provider.

• https://www.fsmb.org/siteassets/advocacy/pdf/state-emergency-declaration-licensure-requirements-covid-19.pdf

• Check with your malpractice carrier and check state laws to see if you are protected from liability laws if you patient is in a different state

What? Well Visit Telemedicine?

Rachel Bakersmith, Practice Administrator

Children First Pediatrics

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Strategies to Implement

• Given a moments notice….do not reschedule patients too far in advance and be willing to adapt quickly!

• Type out protocol for each staff member involved and be clear. Things are changing very rapidly so having something in writing for the staff to refer to is important. You can change add/delete as needed if the foundation is there.

After getting the notification that Carefirst of Maryland (and now Amerigroup-as of 4/7/2020, Cigna and Anthem 4/8/2020) allowing well visits we implemented:

• Still seeing well visits in office for all insurances for 2 yrs and younger

• 2 ½ yr visits and older are turned into televisits automatically (Carefirst of Maryland to start: but stay tuned….)

• Went back for last 2 weeks and anyone that canceled with Carefirst we offered to do a televisit instead of waiting until May/June or who knows!

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Front Desk Protocols

Goes through schedule a week at a time and changes visit type to televisit and then texts the family (preset message) that the visit will now be done by video. Or, if patient calls in to reschedule we inform them we will be doing by televisit now and go over instructions:

A nurse will be calling them to do screenings and go over process a few days before their televisit with the provider

Text them link-log in just a couple minutes before time

Patient must be present

IF Teen visit, parent will be asked to step out for part of the visit

Get a height and weight for when the nurse calls if possible

THEN…….

Front desk texts link to family (can email, etc).

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PDSA Cycle

Look through schedule for any televisit scheduled as a well visit -do a few days in advance

If leaving a message be clear for them to call and speak to a nurse prior to their televisit to get some information and note on appt screen that you “LM on 3/30/2020 to do nurse previsit…RB”

Call the cell phone numbers on file FIRST!!

Ask for height and weight (or make sure they do it before visit and tell provider). Note in vitals in ECW with note that the vitals were done at home

Do all necessary screenings that can be done verbally (PHQ-9, PSC 17, CRAFFT, MCHAT)…if questions are in ECW then note right in EMR. If usually done on paper then fill out the paper putting patient name and “DONE VIA PHONE/VERBALLY WITH PATIENT” at the top. Note results in ECW as you normally would. Leave for front desk to scan

Make sure they have the link from front desk—text again if needed

Ask normal triage-any new hospitalizations, allergies, meds, etc.

Schedule nursing visit for shots for this week or for middle of May or after

The screening calls pre-well visit take about 20-30 min per visit (great use of nurse time)

Nursing Staff Protocols

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Billing

• Well Visit itself: All of these insurances say to use 99391-99395 with no modifier for a televisit.

• If you bring in the office same day for shots you add to the televisit well visit, if you bring in a different day to do shots you bill the nurse visit 99211 with immunizations

• Screenings: same as before 96127, etc.

• Still no word from other insurances. Look for the 1135 Waiver to dictate what the state of Maryland is saying which will dictate what the private payors should follow.

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/1135-Waivers

• Modifiers for televisits: 95 or GT

• For all televisits-should be reimbursed the same as if you saw them in the office including the well visits

• Place of service should remain 11 and not 02….but some insurances may vary-but payments SHOULD NOT!

• Billing needs to keep eye out for payments and denials

• Continue using a verbal consent of the televisit and note that this was done during the COVID 19 state of emergency

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Notables

Consider:

1. Having someone look at schedule for cancelations (our pts can do by text) and call if they have one of insurances allowing this and change to televisit

2. Send out mass texts/emails, etc. to Cigna/Anthem/Carefirst/Amerigroup patients over 2yrs old letting them know

3. Send out mass message to other insurances asking them to check with their insurances

4. Social media reminders

5. Have a method where you will be able to recall for shots, possible physical exam, etc.

6. Nurse screening calls can be done from home if needed

7. Be ready to challenge and appeal claims not paid correctly or denied!!

8. We have reduced staff hours so we had to have a very specific protocol in place to make sure someone can pick up where another person left off –place to put screenings not completed yet for all to check….tracking in our EMR so we know that screenings have been completed for a patient, etc.

Telemedicine Visits Targeting Key Patient Groups

Susan Cheng, Project Lead Analyst

CNP&A

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Targeted Outreach - Patients

• Asthma

• ADHD

• Depression/Anxiety

• Developmental Delay

• Obesity

Identify High Risk

Patients

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Targeted Outreach – How?

Reports

Data Warehouse (Customized Reports)

Dashboard

Canned/Stock Reports

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Existing Appointments via Schedule

Convert Scheduled Future Appointments

• Ex: If asthma rechecks are every 3 months, go back to your schedule from 3 months ago

Lookback Based on Follow-up Frequency

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EMR Support

Additional existing outreach reports?

Telehealth related resources as a result of COVID-19?

Send blast emails/texts to all patients.

Utilize your patient portal!

Request a custom outreach report. Reach out to other community practices on the same EMR to create a demand.

Customer Support

EMR Account Manager

Power in Numbers

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Phreesia – Patient Intake System

Q&A: Challenges encountered (barriers; technology, language, etc.)

Eduardo Fox, MD & Panel

Please use the Chat function to ask questions or make comments

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Virtual “Physical” Exam

Don’t underestimate the power of observation. Think of all the exams you’ve performed in the past over the phone.

If using established patient codes, there is decreased “pressure” on your exam as you only need 2 of 3 components of your visit (history, exam, medical decision making).

Can keep exam focused.

• Skin exam • phone camera sometimes works best

• Flashlight can be a bit bright

• Have patient/family pretend they’re taking a picture

• Behavior observations- consider not interrupting patient’s activity

• ENT- can use flashlight for throat exam in cooperative patient

• Abdomen- distended? Guarding when parent palpates or when patient jumps up and down?

• Joints: swelling, color changes, range of motion, weight bearing

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Sample Exam

• General: The patient is in no acute distress and is well-nourished

• Eyes: Extra-ocular muscle movements are intact

• Head/Neck: The head is normal in shape and size, without external evidence of recent trauma. Neck is supple.

• Lungs: No increased work of breathing.

• Cardiovascular: Pink, no cyanosis

• Abdomen: deferred.

• Neurological: normal gait, alert and oriented

• Musculoskeletal: The patient was observed moving all extremities equally. Well perfused. No edema.

• Skin: There were no obvious rashes or lesions noted. No acanthosis was evident at the nape of the neck.

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Consent

Informed Consent for New Patients

Telehealth Consent

• Acknowledge remote video/audio communication

• Location of patient at time of visit

• Financial waiver

Adolescent Consent (upcoming PHN Grand Rounds)

Ideally done at time of registration or scheduling

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Other frequent questions…

• Billing, billing, and billing

• Increasing telemedicine traffic

• Workflow for video visits that need to be seen in-person (higher acuity, need labs or procedures, vaccines)

• Engaging families with limited technology or health literacy

• Language barrier

For more information, visit our website:

http://pediatrichealthnetwork.org

Email us at:

phn@childrensnational.org