Disclaimer: We keep monitoring the situation in relation to Telemedicine options available to Neuro-Ophthalmologists and will be sharing new resources on our listservs and our website as they become available. The guide below has been created to provide some guidance and resources for NANOS members in this unprecedented time. However, as information from CMS is changing rapidly, we encourage you to go directly to their sources for more up-to-date information.

FAQ

Does NANOS have any resources available to members about Telemedicine in Neuro-Ophthalmology? Yes, NANOS volunteers have sent out several updates on the NANOSnet and YONO listservs about Telehealth in Neuro-Ophthalmology. The situation is rapidly changing but the shared resources can be found below.

• Virtual Eye Examination video visits:
  • Adult Patient Video Visits (created by Byers Eye Institute at Stanford)
  • Pediatric Patient Video Visits (created by Byers Eye Institute at Stanford)
• Survey of Telehealth Adoption by Neuro-ophthalmologists During the COVID-19 Pandemic - Published in JNO June 30, 2020
• Tele-Neuro-Ophthalmology: Vision for 20/20 and Beyond - Published in JNO June 26, 2020
• Tele-Neuro-Ophthalmology During the Age of COVID-19 - Published in JNO June 25, 2020
• Teleneuro-ophthalmology
• Neuro-ophthalmology in the Era of COVID-19: Future Implications of a Public Health Crisis
• May 2 update
• April 15 update:
  Ophthalmic Mutual Insurance Company (OMIC) just released some guidance for ophthalmologists using telemedicine from a medical malpractice insurance perspective. Click here for more information and download a sample consent form.
• April 10
  Resources shared on April 10:
  CMS Update: https://cms.gov/files/document/covid-final-ifc.pdf 
  AMA Resouces: AMA Quick Guide to Telemedicine in Practice
  Other helpful articles from AMA:
  1. How to keep your physician practice going during COVID-19 pandemic
  2. Helping private practices navigate non-essential care during COVID-19
  3. Overcoming practice sustainability challenges during COVID-19
  4. First payments issued for COVID-19 financial relief
  5. Physician Practice Financial Relief Guide
• March 31
• March 17
• March 15

I'm not on NANOSnet, YONO or WIN listservs. How can I sign up to receive any future updates? Email info@nanosweb.org and we'll be happy to add you to our listservs.

NEW!! Is the symposium on Telemedicine presented at the NANOS 2020 Annual Meeting available for streaming? Yes, the symposium entitled Telemedicine 20/20 in 2020: How Far Have We Come, Where Are We Headed and How Is It Relevant to Neuro-Ophthalmology is now available on demand on NOVEL.

What's recent from CMS?

Are there any webinars about telemedicine? Here's the link to the Webinar: Outpatient Telemedicine Billing and Coding in the Age of COVID-19 that was presented by Dr. Melissa Ko on March 18.

Are there any apps that can be used for telemedicine services? HHS has a list of examples of apps that can be used for telemedicine services during this time.

Are there any forms that can help me with providing telemedicine services? The American Telemedicine Association (ATA) has sample forms that institutions have donated to figure out consents, documentation, etc.

Are there any telemedicine data sheets? The AAN and AAO have released telemedicine data sheets to help with figuring out the coding stuff - if you see a discrepancy between what I've said previously and what these say, probably should err on the side of what those resources say (they've had their billing experts review it, and I've been mostly trying to keep up with the updates in between clinic and trying to triage my schedule).

• AAN Data Sheet
• AAO Data Sheet

What is Live Synchronous ("Real-Time Video")?

• You are talking with the patient in real-time with video through a privacy-compliant application.
• While some electronic medical record (EMR) programs already have this feature available, others do not but this type of encounter can still be achieved through 3rd-party vendors.
• The medical history is collected in the same manner; depending on the technology, equipment, and technician services available where the patient is located, some elements of the physical exam may also be available for interpretation.
• You document your encounter in the typical "SOAP" (Subjective-Objective-Assessment-Plan) fashion.
• Time spent on call may be helpful if billing based on time.
• You counsel the patient live as you would in person.
• If billing Medicare/Medicaid, the patient must be located in a healthcare provider shortage area (http://hpsafind.hrsa.gov/) Other plans may be more flexible, including Medicare Advantage plans (see below).
  ♦Healthcare provider shortage area requirements have been waived for Medicare/Medicaid patients during the COVID-19 emergency.

What is "Virtual Check-In"?

• This is either a phone call or video chat with an ESTABLISHED patient.
• The communication is initiated by the patient.
• The goal of this type of encounter is to determine whether or not the patient needs to be seen in clinic for a NEW problem or CHANGE to existing problem.
• Documentation includes nature of the visit, medical decision making (including whether or not the patient needs to be seen), and time spent on call.
• Non-qualified calls:  calls related to follow-up of recent visit diagnoses (within the last 7 days) including test result updates, calls that result in scheduling urgent evaluation (within 24 hours or next available appointment)

What qualifies for Review/Interpretation of Remote Patient Data?

• An ESTABLISHED patient securely messages you photos/videos of their condition, which you review, interpret, and then call the patient back to discuss management.
• Documentation includes interpretation, phone discussion summary, and time spent on evaluation.
• Non-qualified calls:  evaluation related to recent visit diagnoses (within the last 7 days), test evaluation prompts urgent evaluation (within 24 hours or next available appointment).

What qualifies for Online Patient Portal Communication?

• An ESTABLISHED patient securely messages you through patient portal. The back-and forth conversation may involve medical decision making, but may be an exchange of information (patient questions).
• The communications can take place over a 7-day period.
• Documentation is through the message exchange, and total time spent during entire exchange (provided it is within a 7-day period) is used as billing reference.

What is Interprofessional Consult ("E-Consult")?

• NEW patient or ESTABLISHED patient with NEW or CHANGE in existing condition
• Initiated by a doctor or APP to consultant
• Verbal or written request
• Written report (+/- verbal summary to consultant) summarizing data review and recommendations, as well as time spent (data review and summary are considered separately for time)
• Non-qualified calls:  calls related to recent visit to consultant (within 14 days), calls prompt evaluation by consultant within 14 days, patient is still at referring doctor's office, patient had similar E-consult within last 7 days

How do I bill for Telemedicine Services (U.S.)? We recognize that many of our non-U.S. members will have different rules regarding the billing of telemedicine services. Within the U.S., Medicare and Medicaid have some rules regarding billing that may or may not be recognized by other insurers. While cash payment (concierge-type services) is the most direct method for payment, not all patients will choose to use this route. While the focus of this section is geared towards some of the specific billing/coding regulations in the U.S., we hope that this discussion will also be useful in other contexts.

With the declaration of a national emergency in the U.S., many of the restrictions previously placed on telemedicine services have been temporarily lifted, including restrictions on requiring separate state licenses if a physician is remotely treating a patient located in a different state (4). Some private insurers have announced measures to also aid in telemedicine services, though the scope of these waivers remains variable and may be limited to COVID-19-related visits (5).

What are the reliable sources when it comes to billing for Telemedicine? The Centers for Medicare and Medicaid Services (CMS) has several articles on their website addressing implementing and utilizing telemedicine services that may be helpful:

• Telehealth benefits in Medicare are a lifeline for patients during coronavirus outbreak (9 March 2020)
• CMS takes action nationwide to aggressively respond to coronavirus national emergency (13 March 2020)
• COVID-19 emergency declaration health care providers fact sheet (PDF) (13 March 2020)
• CMS Current Emergencies webpage
• Coverage and Payment Related to COVID-19 Medicare (PDF) (5 March 2020)

The CDC also has many resources listed on their website.

There have been several press releases discussing the recent emergency funding laws and the broad language that is designed to waive restrictions on telemedicine care for Medicare and Medicaid patients (6, 7). Unfortunately, the details of what specific restrictions were waived and how to apply for those waivers (if necessary) were not readily apparent on the CMS website.

Based on previous articles from CMS regarding the use of telemedicine services prior to the COVID-19 outbreak, Medicare and Medicaid patients can receive telemedicine services of the types listed above, and Medicare/Medicaid can be billed for those services. The patient must provide verbal or written consent for the service and billing their insurance (documented in the chart) prior to the service, as they may be responsible for a co-pay. Some private insurers will also reimburse for the same codes (dependent on state parity laws or other emergency policies).

How do I bill for Live Synchronous ("Real-Time Video")?

• Coding is dependent on where the patient is located (office, hospital, ER, etc.).
• Standard E&M codes are used for billing (99201-99205/99211-99215 for outpatient office visits, etc.). Criteria for E&M coding is the same as that of an in-person visit.
• On the claim, the place of service should be the typical location for the service provided (11 signifies office visit, 21 for hospital, etc.). The modifier -95 should be used to signify telemedicine service.
• Reimbursement per Medicare/Medicaid is the same as that for an in-person visit.
• Traditional Medicare and Medicaid require that the patient be located in an Healthcare Provider Shortage Area.
• Medicare Advantage allows telehealth services in any geographic location, "INCLUDING IN BENEFICIARIES HOMES".
• Use the 95 modifier.

How do I bill for "Virtual Check-In"?

• G2012 is the CPT code used.
• The 2020 National CMS Reimbursement is listed at $14.80.

How do I bill for Review/Interpretation of Remote Patient Data?

• G2010 is the CPT code used.
• The 2020 National CMS Reimbursement is listed at $12.27.

How do I bill for Online Patient Portal Communication?

• 99421-99423 are the CPT codes used for these types of communication; they are time-based codes.
  • 99421 (5-10 minutes) reimburses $15.52
  • 99422 (11-20 minutes) reimburses $31.04
  • 99423 (≥21 minutes) reimburses $50.16

How do I bill for Interprofessional Consult ("E-Consult")?

• 99451 is the CPT code typically used for written-only consults >5 minutes. It reimburses $37.53 in 2020.
• 99446-99449 are time-based codes and require both a verbal and written report to the referring provider.
  • 99446 (5-10 minutes) reimburses $18.41
  • 99447 (11-20 minutes) reimburses $37.17
  • 99448 (21-30 minutes) reimburses $55.58
  • 99449 (≥31 minutes) reimburses $73.98
• The time counted is for summary and verbal consultation only, not for data review. If >30 minutes was spent in data review, 99358-99359 (non-face-to-face) codes can be used (99358 = $113.68, 99359 is billed for >74 minutes with 99358 = $113.68 + $55.58 = $169.26).

Summary: We want to support and encourage all providers during this challenging situation. One of the ways we may be able to help serve our patients better is to start considering new methods of delivering care without compromising quality. We welcome additional ideas and considerations as we work together as a community to innovate and adapt. We hope everyone stays safe and healthy!

References

1. Shah A. "Coronavirus prompts hospitals to fast-track telemedicine projects." The Wall Street Journal. 13 March 2020.
2. Ducharme J. "The Coronavirus outbreak could finally make telemedicine mainstream in the U.S." Time. 3 March 2020.
3. Hollander JE, Carr GB. Virtually Perfect? Telemedicine for Covid-19. NEJM.org. 11 March 2020. DOI: 10.1056/NEJMp2003539.
4. Cohrs R. "Trump declares COVID-19 emergency, asks hospitals to activate emergency plans." Modern Healthcare. 13 March 2020.
5. Chauvin Y. "Horizon Blue Cross Blue Shield waives costs for telemedicine." New Jersey 101.5. 13 March 2020.
6. O'Brien J. "President Trump signs $8.3B coronavirus funding bill, telehealth restrictions waived." HealthLeaders. 6 March 2020.
7. Wicklund E. "Coronavirus scare gives telehealth an opening to redefine healthcare." mHealthIntelligence. 5 March 2020.