These are unprecedented times—and the rapidly changing healthcare landscape is leaving many rehab therapists feeling lost, adrift, and concerned about their future. That’s why earlier this week, our in-house experts, Dr. Heidi Jannenga, PT, DPT, ATC, WebPT Chief Clinical Officer and Co-Founder, John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management, and Veda Collmer, WebPT In-House Counsel and Compliance Officer, got together to host a webinar about business continuity and telehealth. We received hundreds of questions during our Q&A session—too many to answer!—so we answered the most commonly asked questions here. Can’t find the answer you’re looking for? Feel free to leave us a comment at the bottom of the page and we’ll do our best to answer it. 

Business Continuity

Health and Safety

How do we protect our patients in the clinic and during at-home visits?

For in-clinic appointments, follow the CDC’s guidelines for social distancing. That means making sure each patient is always at least six feet away from any other patient. Therapists should wash their hands and thoroughly disinfect all equipment and treatment surfaces before and after the session. For in-home care, we recommend limiting the equipment and personal items brought into the home, washing hands before and after the session, using a pad or protective surface when placing bags and equipment on the ground, and/or using an alcohol-based cleanser. Additionally, we encourage therapists and clinic owners to:

  • implement a policy to encourage sick leave when therapists or their family members feel ill, and
  • leverage telehealth whenever possible—if your state authorizes it and your payers will reimburse for it.

For more information on adjusting clinic operations in light of the pandemic, check out this article. For an in-depth look at leveraging telehealth in rehab therapy practice, go here.

How do we implement social distancing in a private practice rehab setting?

Some practices are already being asked to implement social distancing in their clinics; but even if you haven’t been officially asked yet, it is the best large-scale preventive measure we have at our disposal. That essentially means minimizing the staff and patient density in your facility by:

  • reducing the number of concurrent appointments; 
  • encouraging non-clinical personnel to work from home;
  • keeping your patients (and staff members) at least six feet away from one another at all times;
  • filtering your schedule to exclude the most vulnerable patients, and therefore help shield them from exposure (for example, anyone who is frail and elderly; is immuno- or respiratory-compromised; or has severe comorbidities such as diabetes and obesity);
  • preventing visitors from entering the clinic; and
  • asking patient family members to wait outside or in their cars as opposed to the clinic waiting areas.
When we reopen following the social distancing and quarantine period, will patients have to sign a note stating they understand that there is the possibility of continued risk?

According to our in-house counsel, there is no obligation for therapists to warn patients of risk, unless your state has issued an order stating otherwise.

How do I train my staff to safely handle patient visits right now?

Remind them that therapists are well-versed in handling infection control. In fact, we are masters of it! Review your infection control, hand washing, and universal health precaution policies (more on those here). Remind them to disinfect equipment regularly and to educate patients about the risk of in-person appointments.

What should I do if an employee tests positive for, or shows symptoms associated with, COVID-19?

Best practices here are really quite straightforward: 

  • The very first thing to do is review that employee’s schedule with him or her to determine with whom he or she was in close proximity—meaning within 6 feet—over the last two weeks. 
  • Then, assist the employee with obtaining the medical support that he or she needs as quickly as possible. 
  • Finally, send home every employee that person came into contact with—and get in touch with all patients who may have been exposed to inform them about the situation. 

Just be sure not to share any identifiable information about your ill employee, as that would be a breach of workplace privacy laws. Instead, you could say something to the effect of: “I have reason to believe you have been in contact with someone who has either tested positive for COVID-19 or is exhibiting symptoms. While there is no cause for immediate alarm, you may need to self-quarantine while monitoring for symptoms per current CDC guidelines.”

Do you recommend we wear personal protective equipment (PPE) in the clinic? 

The Occupational Safety and Health Administration (OSHA) requires employers to furnish a workplace free from hazards that are likely to cause death or serious physical harm.  Employers should reference state and federal OSHA standards regarding employer obligations to reduce harm in the workplace. According to the OSHA guidelines related to COVID-19 on the Department of Labor website, the World Health Organization has determined COVID-19 is a low risk to healthcare workers. OSHA standards require employers to provide personal protective equipment (including masks and respirators) to employees with exposure to COVID-19. So, employers are only required to issue masks if the provider is treating a patient with a known case of COVID-19. In other cases, the provider should practice social distancing and other measures (e.g., hand washing and cleaning equipment) to reduce the risk of infection.  

This may not be much comfort for the provider who is treating potentially asymptomatic patients and potentially exposing their families and other patients. However, PPE is pretty scarce right now, so, in accordance with OSHA guidelines, providers may consider wearing PPE only if the patient is visibly coughing or sneezing and the session cannot be adapted to avoid close contact. Continue to implement other precautions, such as hand washing and infection control.  If no PPE is available, then adapt the session to create more distance between the PT and patient and provide less hands-on care. 

The APTA has joined up with other healthcare organizations (like the American Association of Nurse Practitioners and the American Occupational Therapy Association) to pressure the government to:

  • provide PPE to all healthcare providers, and
  • definitively communicate which providers get PPE priority. 

Employee Benefits

Does the Families First Coronavirus Response Act (FFCRA) apply to my practice?

According to the US Department of Labor, “The paid sick leave and expanded family and medical leave provisions of the FFCRA apply to certain public employers, and private employers with fewer than 500 employees.” To learn more about the act, how it helps small businesses with the financial burden of paid leave, and what exceptions apply, check out this article.

If we cut hours for our PT staff, are they eligible to receive unemployment benefits? 

We don’t yet have details about how employees will receive federal unemployment dollars under the recent stimulus bill. Aside from the federal relief, unemployment guidelines are handled at the state level, so please check with your state.

Do companies have to compensate employees who are furloughed or laid off for accrued time off?

When considering layoffs and furloughs, the employer should consider issues associated with employee health benefits, unemployment benefits, applicable wage and hour laws, and paid time off rules. Employees that are laid off may qualify for unemployment benefits. Whether the employer has to pay accrued PTO during a furlough depends on the type of furlough (e.g., a week-long furlough versus only a few days) and whether the employee is salaried or hourly. Employers should also consider how the furlough or layoff will affect employee benefits and whether the employee qualifies for COBRA during the furlough. If the employer elects to pay employees PTO during a furlough, then those employees may not qualify for unemployment benefits.  

In summary, there is no simple answer to this question. This resource from the DLA Piper COVID-19 Resource Center provides an excellent summary of the different considerations associated with layoffs and furloughs. However, please do not rely solely on Internet publications when deciding the best course of action. You should consult an employment attorney for more information on applicable federal and state laws specific to your business.

Miscellaneous Continuity Questions

How can I access the cash I need to keep my practice afloat through an extended closure?

While updates are being provided daily, we’re still waiting for details from the federal government about the broader COVID-19 economic stimulus package for individuals and businesses. But we do know that disaster relief loans are available through the US Small Business Administration. If your practice is struggling to make ends meet during this pandemic, then you can apply for a low-interest, long-term loan on the Disaster Loans page of the Small Business Administration website. Small businesses may borrow up to $2 million for economic injury. The SBA is also committed to assisting small businesses in “accessing federal resources and navigating their preparedness plans.” To learn more, visit the SBA website.

Are outpatient home visits covered for SLPs? Can any outpatient PT or OT provide home-based services for any patient?

Medicare covers outpatient home visits for SLPs, OTs, and PTs—but not all commercial payers do. You’ll have to check in with your individual commercial payers to learn more about your coverage.

Keep in mind Medicare has implemented some reimbursement limitations to outpatient home health: it will only pay if the patient is “not homebound or otherwise are not receiving services under a home health plan of care (POC).” In other words, Medicare will only pay for outpatient home health if the patient is not actively receiving Medicare Part A services. 

Telehealth 

Foundations and Best Practices 

What are some telehealth best practices?

The first thing you’ll need to do is educate your patients, because rehab therapy telehealth probably isn’t something they’ve experienced before. Discuss their concerns and explore whether it makes sense to serve them via telehealth. You’ll also want to make sure telehealth falls under your professional scope of practice in your state and that the majority of your payers cover it (if you plan to receive reimbursement through insurance). If you determine that a large portion of your patients would like to receive care in this way, then you’ll need to find a compliant platform—ideally, one that will enter into a business associate agreement (BAA)—and train staff and patients on how to use it.

How should we train our staff to provide telehealth?

This CMS telehealth toolkit has excellent resources for setting up your telehealth environment. We recommend hosting a few training sessions for your staff to help them plan their telehealth visits and get used to your platform. PTs, OTs and SLPs are highly adaptable; they should get the hang of things quickly with your support. Need some inspiration? Check out this blog post on a clinic in New Jersey that quickly implemented telehealth in response to the pandemic. 

Is it possible to provide telehealth if you do not use an EMR?

Yes; you would simply need to do all of your documentation by hand. So if, for example, you provided an e-visit, you would need to record: 

  • how the patient initiated the service, 
  • that the patient consented to receive these services, 
  • all of your patient interactions, and
  • all of the supplementary activities you conducted to help contribute to the guidance you provided the patient. 

That said, we always recommend using an EMR, if your practice setting allows for it. 

Can I provide services that are typically hands-on via telehealth?

No; you cannot provide hands-on services via video conference, as there would be no way to actually carry this out. Instead, consider what other services you could provide to support this patient in his or her care.

Can we conduct initial or new evaluations over telehealth—or do they need to be conducted face-to-face at the clinic?

Currently, there are not any specific codes that would allow you to bill evaluative services delivered via telehealth. That being said, some states are mandating that any service normally provided in-clinic be covered when delivered via telehealth—provided that you are able to provide the service via telehealth. So, be sure to check with your state board as well as your individual payers.

If you are sending pre-recorded videos, is that synchronous or asynchronous?

Sending pre-recorded videos could technically be synchronous or asynchronous depending on how you choose to do so. If you and a patient are holding a live conversation and you send him or her a link to a pre-recorded video, then this would be synchronous (or in-sync) telehealth. However, if you and a patient are communicating over a long period of time (i.e., you’re not online at the same time) and you send him or her a pre-recorded video, then this would be asynchronous (or out-of-sync) telehealth. 

Scope of Practice

How do I find out if telehealth falls under my scope of practice? 

If you have any questions about your state practice act or scope of practice, contact your state licensing board, as it will be your best source. If you have trouble getting through, try contacting your state APTA, AOTA, or ASHA chapter.

My state practice act doesn’t mention “telehealth” or “e-visits.” Can I provide any kind of telehealth services?

In general, if your state practice act does not include any language with regard to a specific procedure or protocol—in this case, telehealth—then you should contact your state licensing board to inquire about its stance. With respect to billing Medicare for e-visits, keep in mind that because these services are not technically telehealth, you are able to provide them even if your state practice act is silent on telehealth.

Will California PT practices be able to administer telehealth services to their patients?

While PT telehealth is authorized by California statutes (Cal. BCP 2290.5), MediCal (California’s Medicaid service) does not reimburse for this method of service delivery—and commercial payers also may not reimburse. Check you policies for reimbursement guidelines and balance billing requirements to determine whether the patient can pay cash for the services.

Advocacy 

How do I contact my state representatives to advocate for greater expansion of telehealth opportunities for PTs, OTs, and SLPs?

Click here for the House directory.

Click here for the Senate directory.

Do you have any verbiage we can use to advocate for telehealth expansion?

The APTA has created a template that you can access here

Where can I find APTA telehealth updates?

Consult the APTA’s telehealth page and its coronavirus updates page.

What other advocacy opportunities are available to me?

Jannenga covered telehealth advocacy in great detail in this recent blog post. Be sure to check it out!

E-Visits

How should I document for e-visits and other virtual care services?

Your documentation for these services should emphasize your:

  • patient’s concerns and questions;
  • assessment and clinical decision-making;
  • counsel, instruction, or advice to the patient, and
  • plan for the patient moving forward.

For a more detailed explanation on how to document for e-visits, please refer to this FAQ.

Is there a way for a PT to establish a relationship with a new patient who does not want to come into the clinic for an in-person evaluation?

According to the APTA, the answer is no: “The patient must already be under the care of the therapist. Check your state practice act for additional guidance on what is considered an ‘established patient.’”

Do e-visits apply to Medicare’s therapy threshold?

At this time, CMS has not specifically addressed this topic. However, therapists are not currently required to add the GP, GO, or GN modifiers to e-visit services, so it’s possible that they do not count toward the threshold.

Do e-visits count toward a patient’s visit limit and/or visit count?

According to the APTA, e-visits do not factor into a patient’s visit count for progress note purposes. The association also does not believe e-visits count “against the number of visits permitted under Medicare coverage rules.”

Can we bill multiple units of the e-visit G-codes over the course of seven days?

No. You should bill only one unit for one code based on the cumulative amount of time you spent providing applicable services to the patient.

What’s an example of an e-visit (e.g., chart review, home exercise updates, and other activities outside of the patient interaction)?

An e-visit is comprised of assessment and management time that’s generally used to:  

  • address a patient’s concern about function, pain, or a change in status, or 
  • answer questions about the patient’s HEP or other self-care and home management. 

When counting up e-visit time, you can also include time you spent consulting with a physician or other provider, as well as the time you spent gathering information about the patient’s request or concern.

Do e-visits have to take place over a video call, or can they occur over a telephone call?

E-visits can take place via interactive video or over the phone. Regarding telehealth services, some states only authorize and/or reimburse for live interactive video. Some states, such as Massachusetts and Connecticut, have issued executive orders expanding telehealth to cover audio in addition to video.

E-visits are not synonymous with video visits. However, if you are using video, make sure your platform is not publicly accessible or public-facing. (That being said, the regulations around approved platforms have been relaxed to allow greater access to care.) Generally speaking, e-visits encompass the following:

  1. The patient has a concern, question, change of function, or other challenge with care.
  2. You assess what the patient is telling you and use your clinical reasoning and decision-making ability to create a plan for the patient to move forward. (For example, if the patient tells you he or she is able to easily complete his or her current HEP, you may adjust the HEP to be more challenging and then send the new HEP to the patient.)
  3. You document all of these activities and bill for the cumulative time you spent on those activities over the course of seven days.
Can we conduct e-visits via email?

As far as we can tell, the APTA and CMS have implied that secure email communications would be an acceptable method for conducting e-visits. However, we caution providers who are considering conducting e-visits via email: not only will these visits be asynchronous, but also—unless your email is encrypted and meets HIPAA standards—you are at risk of exposing any protected health information (PHI) that you include in your messages. Instead, we recommend using a secure platform with real-time communication such as WebPT HEP.

What is the definition of an “established patient?”

As we explained here, with respect to e-visits. “The APTA recommends consulting your state practice act to see how it defines ‘established patient.’ Generally speaking, these codes are available only for patients who are currently under the care of the billing provider.” That being said, some definitions may include any patient who has been seen in your practice.

If a person comes into my clinic for a physical visit, can he or she do an e-visit the same week?

No. According to the APTA, “An e-visit cannot be billed if a face-to-face visit occurs within seven days before or within seven days after the e-visit.”

Can we conduct a re-evaluation via an e-visit?

No. Re-evaluations do not fall under the umbrella of assessment and management services that therapists can provide via an e-visit.

How is the seven-day e-visit billing period defined?

The seven-day period begins when the provider responds to the patient’s initial inquiry.

I work with the elderly, and their most advanced technology is a phone. If I call them for an e-visit, do I need to have them call me back to make the encounter “patient-initiated?” Or, is it enough for them to say they want to participate in e-vist?

We would recommend using—and clearly documenting your use of—very specific verbiage indicating that the patient wishes to initiate an e-visit. For example, if you call the patient to inform him or her of this option, and the patient requests to participate in an e-visit immediately, say something like, “Would you like to initiate an e-visit?” Additionally, Medicare has indicated that it is permissible to conduct e-visits by phone during the COVID-19 response period.

Once a patient has been seen for one e-visit, do you have to see the patient in person before you can provide another e-visit?

We don’t believe so. However, the APTA is seeking clarity from CMS regarding the use of multiple e-visit codes for multiple consecutive (or non-consecutive) seven-day periods.

What’s the difference between e-visit care management and the education that would normally fall under therapeutic exercise? I am always refining HEPs and counting that time toward therex; how is this different than discussing the same topic via a patient-initiated phone call?

There isn’t much—if any—difference between these two actions. Whether you factor this into your in-person therex minutes, or you’re providing these services remotely through e-visits, you’re still billing for your assessment and management of a patient’s care as well as your clinical reasoning.

Billing

What’s the difference between telehealth, telehealth visits, telephone visits, and e-visits? 

When we talk about telehealth, we’re referencing any and all remote services that clinicians across the healthcare spectrum provide to their patients. Telemedicine is telehealth, and telerehab is telehealth. It’s important that you don’t mix up telehealth as a general concept with specific types of virtual care visits:

  • Telehealth visit: When you remotely treat a patient (e.g., providing ther-ex virtually). 
  • Telephone visit: When you remotely communicate with your patients and complete case assessment and management.
  • E-visits: When you complete assessment and case management services and specifically bill Medicare—or the other payers that now allow rehab therapists to bill these codes.
What are the differences between place of service (POS) codes 02, 11, and 12?

POS 02 indicates that the “site” of a service is a telehealth interaction. In general, you should use POS 02 if you are delivering actual telehealth services via a true synchronous telehealth platform—and not all commercial payers cover those services for rehab therapists. So, be sure you’re up to snuff on payer policies before delivering and billing for any telehealth services. Now, if you’re billing one of Medicare’s e-visit codes, then you’ll want to use 11 for your POS to indicate that you’re providing the service from an office, or 12 to indicate that you’re providing the service from your home. POS 11 and 12 also apply to telephone visits.

What CPT codes should I use to bill for virtual care services?

During this crisis response time, use G2061, G2062, or G2063 to bill Medicare for e-visit services. These are the only virtual care services Medicare is currently reimbursing for rehab therapists. If you’re billing a commercial payer, you’ll typically use CPT codes 98970, 98971, and 98972 to bill for these services, as they are the CPT equivalents of the e-visit HCPCS G-codes. However, we highly recommend reaching out to each payer to verify its guidelines for remote care billing. Keep in mind that while there are other codes for telephone services (e.g., 98966–98968), due to relaxed requirements around codes 98970–98972, you can also use those codes for telephone services at this time.

Finally, in a handful of states, you may be able to bill standard rehab therapy CPT codes (e.g., 9700-series codes) with the appropriate modifier and POS code. But, you absolutely must verify this with your state board before proceeding.

What’s the difference between Medicare’s G-codes for e-visits (e.g., G2061–G2063) and the online digital E/M codes (e.g., 98970–98972)? 

G2061, G2062, and G2063 are the HCPCS equivalents of the digital E/M CPT codes (98970–98972). So:

  • use G2061–G2063 when billing Medicare (or any payers following CMS guidelines on e-visits); and
  • use 98970–98972 to bill commercial payers and workers’ compensation payers that are not using the CMS codes.
Which modifier(s) should I use to bill telehealth and virtual care services? 

There are four telehealth modifiers that therapists should acquaint themselves with before billing for telehealth services. It’s critical that therapists understand how these modifiers differ, because each one only applies in certain situations. In other words, you cannot affix a telehealth modifier to any CPT code and bill it as a telehealth service. You must ensure you’re always following telehealth compliance protocol. That means using specific telehealth CPT—or e-visit HCPCS—codes and affixing the correct modifiers as required. 

The first telehealth modifier is 95. Use this modifier when you administer real-time, synchronous services for the telephone CPT codes. Just to be clear, the CMS e-visit codes do not require the 95 modifier.

The second telehealth modifier is GT—and it is also used to indicate that you provided real-time synchronous services. However, modifier 95 replaced GT back in 2017, and while you can still technically bill GT in certain instances, modifier 95 will likely be the more appropriate choice. Some commercial payers do continue to use GT for covered telehealth services, though, so you must check in with your individual payers to determine which modifier they prefer to use. 

The third telehealth modifier is GQ. It indicates that services were delivered asynchronously. Asynchronous telehealth is slowly getting phased out and replaced by synchronous telehealth, which makes GQ an “old”—albeit functional—modifier.  

The final modifier, CR, indicates that services are catastrophe or disaster-related per the 1135 formal waiver issued by CMS for the COVID-19 pandemic. Rehab therapists must use this modifier when billing the e-visit codes Medicare recently made available to rehab therapists—regardless of whether the services are delivered synchronously or asynchronously.

Can I bill normal face-to-face codes with telehealth POS numbers and modifiers?

As Wallace mentioned during the webinar, he only knew of a handful of payers who were allowing that. To be clear, you cannot use this billing method with Medicare, and most other payers are not allowing direct personal contact codes to be billed as telehealth. Furthermore, it’s important to check what your state practice act says on the matter, because you can’t always rely on your payers to have up-to-date state practice act information.

Can you explain the difference between the sites (e.g., originating and distance) and the place of service?

The originating site is the patient’s location; the distance site is the provider’s location. The place of service is the same as the distance site (i.e., the providers location), but it is shared via a code. If you’re billing CPT codes for telehealth visits, make sure to designate the place of service (or POS) as 02. If you’re billing one of Medicare’s e-visit codes, then you’ll want to use 11 for your POS to indicate that you’re providing the service from an office, or 12 to indicate that you’re providing the service from your home. POS 11 and 12 also apply to telephone visits.

Can inpatient facilities bill Medicare Part A (i.e., on a UB04) for e-visits? 

Yes. Use the condition code DR and the CR modifier in the Institutional 837 billing format, along with the appropriate revenue codes for PT, OT, and SLP.

If I host an online instruction session for a group, can I use any of these codes to bill for it?

It depends on payer policy, but generally speaking—and as far as Medicare is concerned—these codes are not for group use.

Do we charge patients the same copay, deductible, and coinsurance rates for telehealth services as we do in-person services?

This also depends on the payer. When billing Medicare for e-visit codes, according to this CMS fact sheet, “The Medicare coinsurance and deductible would generally apply to these services.”

Can we waive copays for telehealth right now?

Yes; On March 17, 2020, the Office of Inspector General announced that, due to COVID-19, providers could temporarily elect to waive cost-sharing (e.g., copays or coinsurance) for telehealth services without sanction or penalty.

Can PTs bill a telehealth visit as an adjunct to a physician?

If you practice “incident-to” a physician, you cannot bill the same day as the physician bills certain designated codes. If you work for a physician in a Part B setting and you still use your own NPI, then you may bill the e-visit codes the same day regardless of what the physician bills.

Can we provide—and bill Medicare for—e-visits and then charge the same patient directly for other telehealth services provided at the same time?

That depends. As with in-clinic services, if the other services are ones typically covered by Medicare, then you will not be able to accept out-of-pocket payments for them. We recommend reaching out to your MAC to confirm which services you can bill patients for directly.

Coverage and Reimbursement

What are Medicare’s telehealth reimbursement rates?

At this time, Medicare will not reimburse PTs, OTs, or SLPs for telehealth visits or telephone visits—at all. Medicare is only paying rehab therapists for e-visits, which—according to this CMS fee schedule search tool—have current reimbursement averages of:

  • G2061: $12.27
  • G2062: $21.65
  • G2063: $33.92
How real is the possibility that we’ll be able to bill (and be paid for) telehealth services for any payer in the near future? 

Everything is changing rapidly—which means everything is in the realm of possibility. Watch for updates from CMS, the APTA, your local payers, and of course, WebPT.

Do I have to individually contact each payer to check telehealth coverage? 

Yes, because commercial carrier coverage may vary.

If a patient’s plan of care (POC) has expired, can you continue to bill for e-visits? 

We would recommend updating the plan of care to incorporate the need for continued care.

What insurances cover e-visits?

Medicare was the first payer to cover e-visits, but some other commercial payers are following suit (e.g., Aetna, some local BCBS plans). You need to check in with your payers to determine whether or not they will cover these new e-visit codes.

Is workers’ comp covering telehealth? 

That depends. For all treatments associated with workers compensation, it’s best to get preauthorization. That way, you’ll know whether or not your services are covered before providing them.

Is Medicaid providing reimbursement for telehealth visits, telephone visits, or e-visits—and where can I look up the information for my state?

Some Medicaid programs do pay for telehealth. We recommend checking out this telehealth guide from the Center for Connected Health Policy and reaching out to your Medicaid contact to learn more. 

Self-Pay

Are patients able to do self-pay for telehealth visits and circumvent their insurance at this time?

That depends on the contractual relationship you have with the payer and its rules for collecting payment directly from patients.

How do I create a cash-based telehealth fee schedule? 

Just as with in-clinic cash-pay services, you’ll have to determine the market value of your services and price accordingly. To establish a baseline, consider reaching out to other providers in your region to determine what they’re charging and/or what insurance companies are paying. 

If you provide a superbill to cash-pay patients and they submit it to their insurance company, will they get reimbursed at an out-of-network rate?

That depends on the relationship that you have with that payer and its coverage of telehealth services.

Is there any scenario in which you can’t collect cash payments from patients? 

Yes; if a payer’s medical policy classifies telehealth therapy services as “not medically necessary” or says that “its effectiveness is not established,” then you cannot balance bill the patient. If you do end up charging the patient and sending the bill to the payer, then it will assign the balance to the clinic or to the therapist who provided the services.

Can I provide telehealth services beyond e-visits to Medicare patients on a cash-pay basis?

Yes, but you should follow the appropriate advance beneficiary notice of noncoverage (ABN) protocol. Learn more about ABNs here.

Does an established patient need to sign a telehealth consent form prior to every session? 

According to Collmer, some states explicitly require providers to obtain patient consent prior to delivering any telehealth. However, obtaining consent is always a good idea. So, consider providing your staff with a template to read when initiating a telehealth intervention program. This script should explain the risks to privacy and health information security that are unique to this delivery method, emphasize that the patient should feel comfortable with this mode of service delivery before consenting to it, and make clear that the patient can withdraw consent at any time. Additionally, explain that your platform is HIPAA-compliant (if it is, indeed, HIPAA-compliant) and that the therapist will take every possible measure to protect the patient’s privacy. Then, once you’ve received consent, document informed consent at the beginning of your treatment note.

What are our options for patients who are not tech savvy or don’t have access to the technology necessary for telehealth? Could they take a photo of their signed telehealth consent forms and email it to us? 

A photo of the signed consent form that you upload into your EMR patient record should suffice; however, patients will still need to be able to use technology to access the videoconference. This shouldn’t be too difficult, but it may take some extra time and instruction to help non-tech savvy patients get used to the new format.

HIPAA Compliance, Liability, and Privacy

How do I set up a HIPAA-safe video interaction?

First, when it comes to choosing a platform, you’d normally have to conduct a comprehensive risk assessment before picking a telehealth software. But, under the current circumstances, the HHS Office for Civil Rights (OCR) is giving providers a little bit of wiggle room. As of March 17, for the duration of the nationwide public COVID-19 health emergency, the OCR is exercising enforcement discretion for healthcare professionals who provide “good faith” telehealth services to patients through everyday communication technologies. In other words, you won’t have to go conduct an entire, thorough comprehensive risk assessment when equipping yourself for telehealth during this crisis, which makes it a little bit easier to get your teleservices off the ground. 

If you’re considering this option, OCR specifically recommends platforms like Skype for Business, Facetime, Updox, Vsee, Zoom for Healthcare, Doxy.me, or Google Hangouts. Rapid Response from Bluestream is another option we mentioned during the webinar. That being said, we highly recommend selecting a HIPAA-compliant platform that will enter into a business associate agreement (BAA) with you—even if you do so at a later date.

A consumer-facing platform may fit the bill at this time, but patient privacy should still be a priority—even if it’s not your first or second priority right now. And when you have an opportunity to vet your platforms through a comprehensive risk assessment, we recommend doing so. And please understand that these suggestions are not affiliated or officially endorsed by WebPT. 

As for physically administering the visit, we recommend that the provider deliver services from a private location where his or her conversation and the video cannot be observed. Similarly, we recommend that the patient receive services in a private location. Finally, avoid recording the session.

What’s a comprehensive risk assessment?

The HIPAA Security Rule requires Covered Entities to perform a comprehensive risk assessment to protect the confidentiality, integrity, and availability of PHI. In layman’s terms, that means assessing systems that will store, access, or transmit PHI to make sure they have adequate safeguards to protect PHI. According to the US Department of Health and Human Services, there isn’t a single best practice method for conducting a risk analysis, but HHS does say that your risk analysis—however it is conducted—must contain the following steps: 

  • “Identify and document potential threats and vulnerabilities; 
  • Assess current security measures;
  • Determine the likelihood of threat occurrence;
  • Determine the potential impact of threat occurrence;
  • Determine the level of risk; and
  • Finalize documentation.”

The above-cited resource provides a handy link to a security risk assessment tool you can use.  WebPT has also written about strategies for tackling a HIPAA risk assessment and why the HIPAA risk assessment is important.

In the case of performing a HIPAA risk assessment for a telehealth platform, you may consider reviewing the vendor’s security whitepapers and asking for evidence of completion of a security audit (e.g., ISO27001 or SOC 2). Find out how the vendor is protecting PHI on their systems:

  • Does it encrypt data?
  • Does it audit and monitor its systems?
  • Does it have a named information security officer?
  • Does it have privacy and security policies in place?

You don’t have to be a security expert, but you are expected to ascertain whether the vendor has reasonable and appropriate safeguards in place.

What about telehealth liability issues? Do I need my own liability insurance for this, or will my employer cover any possible issues?

Telehealth liability concerns may include such issues as medical malpractice, lack of informed consent, and privacy or security breaches. Employers and independent contractors should check with their insurance carrier or insurance broker to ensure they have appropriate coverage for providing telehealth services. Insurance coverage may include malpractice, cyber liability, and general liability coverage. Employees should check first with their employer to make sure they are covered under the company malpractice insurance policy. If necessary, you can purchase additional malpractice insurance through such carriers as HPSO, although you should confirm that the policy covers liability related to telehealth.

If you provide telephone visits from home, how do you keep your phone number private from patients?

You can use a calling service such as Google Voice, which gives you an alternate phone number to use for these interactions. You may also be able to block your phone number through your telephone provider; however, you’ll need to let your patients know that you are calling from a blocked number to ensure they answer the call. Alternatively, your company may be able to route office numbers to staff cell phones. That way, a patient could call your office number and be routed to your personal cell phone for the duration of this crisis. 

Miscellaneous Telehealth Questions

Will physician referrals need to specifically state “telehealth” on the order, or will a standard order for an eval and treatment suffice? 

Physician referrals may need to specifically state telehealth; it will depend on the payer and direct access rules and regulations in your state.

We’ve been told that different payers sometimes maintain different telehealth vendor requirements. Could I use a different vendor for each patient I see? 

This could quickly become quite expensive, but theoretically, yes.

If we are able to provide telephone or e-visit services, who initiates the call? Do the patients have to be the ones to call?
The patient must be the one to request the visit, but he or she doesn’t necessarily have to initiate the call. However, providers are allowed to notify patients of the availability of the services and the requirement that they must be patient-initiated.
How can I offer telehealth to patients who are working on board a ship in international waters?

State licensure requirements still apply in telehealth situations, so before you start treating patients outside of your state, exercise caution, and contact your state licensing board—or consult with a healthcare law expert—first. Beyond that, if you’re providing rehab therapy under a workers’ compensation plan, get it authorized. If the patient has commercial insurance, contact the payer directly to determine if it will allow you to provide the services.

Is there a limit to how many days per week or number of sessions that we’re allowed to provide patients (and bill) over telehealth? 

That depends on the code you are billing. If, as in the case of the e-visit G-codes, the code description indicates that you may bill one code for each seven-day period, then you would count all time spent delivering associated services toward your billing of one code. That one code would cover a period of seven consecutive days (for e-visits, this seven-day period begins when you respond to the patient’s initial request).

Therapy Assistants

Can PTAs and COTAs provide telehealth—and is it reimbursable? 

As of right now, physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) cannot provide e-visit services to Medicare beneficiaries. However, many states that have authorized telehealth have included PTAs as authorized providers. Check your state laws or email your state licensing board for more details. Also, check your payer policies to make sure PTA services can be reimbursed.

Assuming PTAs can supply telehealth, how does supervision work? 

Your state practice act still dictates supervision rules. If the practice act requires general supervision of a therapist assistant, then the licensed therapist has to be available at minimum by phone; if it requires direct supervision, then the therapist must be in the same building or line of site. Check the practice act for specific definitions. For Medicare beneficiaries, refer to the Medicare guidelines as well as your state practice act and implement the stricter of the two.

Pediatric and School-Based Telehealth 

How can I provide telehealth services as a school-based rehab therapy provider?

During the webinar, Wallace recommended checking in with your school or district medical director or program coordinator for guidelines on patient management during this crisis response period. If you get the green light to continue managing patient care, find out whether you should follow CMS guidance or commercial payer guidance. If you are following CMS guidance, bill for these services using the e-visit G-codes. Otherwise, use CPT codes 98970–98972. When treating pediatric patients who are covered by commercial insurance, you should follow the same process you would for adult patients. That is, check in with the payers to determine what their current telehealth policy is—and how rehab therapy providers should bill for remote care services. Finally, keep in mind that many state Medicaid programs already had rehab therapy telehealth coverage prior to the pandemic, so if you’re seeing a Medicaid-covered child, be sure to check in with your state Medicaid program.

What online materials (e.g., worksheets, interactive programs) could I share with my pediatric patient population? Are there any platforms that have customizable content for children? What if I need sensory or tactile resources? 

Remember that the e-visits and telephone visits are assessment and management sessions; when billing these codes, you will not be able to supply the entire gamut of hands-on services you deliver in your office setting. Instead, focus on how you can help parents and guardians manage the child’s program from home. 

Also, you can email any necessary materials to the patient or caregiver as long as you don’t include PHI in the email. As for interactive programs, check with your professional association, professional trade groups, and peers who may have resources available to share.

Some Medicaid programs and commercial payers reimburse for telehealth services, which are virtual therapy sessions (similar to in-person visits). Here are three sites you may find useful for pediatric telehealth visits:  

As for developing sessions that integrate sensory or tactile resources, telehealth will require you to be creative and use resources in the patient’s environment. Those resources can be in the form of people (e.g, teaching the parent how to apply proprioceptive pressure) or equipment (e.g, using a mini trampoline or soft pillows) or materials (e.g., using things like Play-Doh, rice, or finger paints). Telehealth requires some pre-planning, but it also allows you to educate parents about sensory resources available right in their home and thus, facilitate your patient’s use of these resources long after the session is over. Send the parent a list of items—or even a treatment session agenda—in advance so he or she can help set up the environment. 

How do I increase parent buy-in if I want to provide telehealth services for pediatric patients? Many parents just say “no”—even though we’ve issued a company statement—because they assume it’s not a good fit for them or their child. 

As Collmer explained during the webinar, when speaking with parents, you should focus on the child’s needs. Consistency and continuity of care are critical for the child’s well being. In fact, it is especially critical to maintain these services during this time when families are largely confined to the home, and the child’s schedule may be disrupted by school closures. If social distancing and other measures continue for several months, it could result in significant setbacks for the child. If you’re still experiencing objections, consider asking parents to try out telehealth for a few visits or hop on a video call to discuss their concerns about telehealth. Be sure to explain that this is an excellent opportunity to try a new mode of service delivery, and if it is successful, it may be used in the future when the parent is unable to schedule an in-clinic appointment.

How does all of this relate to school-based PTs? Teachers are not being required to teach our children for 7.5 hours a day; so, are we expected to still follow our IEP service times?

That largely depends on the essential provider rules outlined by your state and the expectations established by your school and school district. We recommend reaching out to your employer to determine requirements in this crisis.

WebPT

Which telehealth services are compatible with WebPT—and do you plan to add a HIPAA-compliant telehealth service to your system in the future?

The WebPT EMR already has e-visit billing codes and the ability to specify the necessary place of service code for remote services. Additionally, our HEP platform includes the functionality necessary to conduct an e-visit. Any CPT code not already available can easily be added in the custom CPT code fields on the billing section of a SOAP note. If your patient visit requires a virtual, face-to-face interaction, you can use a free, HIPAA-compliant telehealth service like Doxy or Rapid Response from BlueSteam. (Although HIPAA guidelines are relaxed during the national emergency and allow for non-HIPAA compliant services like Facetime or Skype, we recommend finding a long-term solution that will work for your clinic.) We’re also currently investigating additional telehealth updates to our platform. 

How do I document telehealth in WebPT? 

In the WebPT EMR, e-visit codes are already available in the billing section of a SOAP note, and you can add any CPT codes for telehealth that aren’t already available as custom CPT codes. You can then bill these codes out to your billing software—whether that’s RevFlow, Therabill, or a third-party integrated billing product.

How does WebPT facilitate e-visits?

Our HEP includes functionality that allows patients to download an app and use it to securely communicate with their therapy providers. The app allows patients to initiate the request for an e-visit—which is a requirement for billing—to which the provider can respond appropriately. You can then continue communicating with the patient as necessary—and update the HEP based on those interactions. Finally, you can send updated HEPs directly to patients through the app.

Where in WebPT can I change the POS and site location?

You can update the POS for each individual case within the case itself in the patient chart, or for an individual date of service on the Objective/Billing tab within the SOAP note. This article from the WebPT Community provides step-by-step instructions on how to do this as well as how to ensure every user has the ability to edit the POS.

Have the telehealth billing codes and modifiers that you mentioned during this webinar been uploaded to WebPT?

Yes; however, you may need to manually enter the modifiers into the WebPT EMR. If you’re a WebPT Member, this article from the WebPT Community will walk you through the process of doing so.

Miscellaneous

We don’t use WebPT at Reach. Is there another platform you would recommend to provide general email updates to our community?

We highly recommend Reach, as it is completely secure. There are other basic email platforms that you can use to reach your community (e.g., Mail Chimp and Constant Contact). Just be sure that you are always blind copying your list and not discussing any protected health information, as these platforms are not HIPAA-compliant. You can learn more about selecting the right email platform for your marketing needs in this free e-book.

Who is considered an essential provider? If we’re considered an essential provider, are we required to continue working despite concerns about our own safety?

Decisions regarding essential providers are determined at the state level. 

We have reached out to the payers, but after hours on the phone no one is able to tell us which codes to bill or how to bill (even for payers that say they will cover telehealth). What is the best way to get through to a person who actually knows helpful information?

When reaching out to payers, the first person you speak with will most likely be a Tier 1 support representative who can answer basic questions about claim status and provide general information regarding plan benefits. So, to get to someone who can answer more specific questions, you may need to ask to speak with the person above that support rep. If the next person can’t assist you, you’ll probably have to go above him or her, too. You may need to keep trying until you can speak to someone who can either provide you with that information or direct you to someone who can. Also, remember to make a note of who you speak with whenever you call—as well as what information they gave you. That way, you can place the onus on the payer should you receive conflicting information.

What if the patient has two separate diagnoses and is being treated by two PTs? Can we provide two telehealth visits in the same week?

Medicare’s rules regarding patients with multiple diagnoses remain the same as they are in the clinic: a patient can see more than one PT on different days for separate issues provided that the PTs are part of the same clinic.

How can we set a plan of care duration when we don’t know how long this crisis will last?

Do your best to make an educated guess given the information you have available to you right now. You can reassess as time goes on and we learn more about the expected duration of this crisis.


Didn’t see an answer to your question? Feel free to drop it below, and our team will do its best to give you an answer. Stay safe, be healthy, and best wishes to everyone. 

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