SDSMA Advocates for Key Changes to Telemedicine Regulations During COVID-19 Emergency


The laws and rules concerning telemedicine in South Dakota and the nation have changed considerably to expand access and loosen regulations during the COVID-19 pandemic. The state has taken actions to enhance the use of telemedicine, and SDSMA has suggested specific regulations to suspend pertaining to telemedicine in order keep our health care workers and patients safe amid the COVID-19 pandemic.

The SDSMA has advocated in support of physicians and practices in enhancing and expediting the implementation of telemedicine, so care can continue to be provided to those who need it most.

Telemedicine Updates


(Updated June 24, 2020) The following is an update regarding the use of telehealth in response to meeting the medical needs of patients during the COVID-19 pandemic.

Medicare: 

Medicare telehealth services include many services that are normally furnished in-person. CMS maintains a list of services that may be furnished via Medicare telehealth; the list is available here: https://www.cms.gov/Medicare/Medicare-GeneralInformation/Telehealth/Telehealth-Codes.

These services are described by HCPCS codes and paid under the Physician Fee Schedule. Under the emergency declaration and waivers, these services may be provided to patients by physicians and certain non-physician practitioners regardless of the patient’s location. Medicare also pays for certain other services that are commonly furnished remotely using telecommunications technology but are not considered Medicare telehealth services. These services can always be provided to patients wherever they are located, and include physician interpretation of diagnostic tests, care management services, and virtual check-ins.

Of note, per the broadened 1135 waiver authority granted by the CARES Act, all health care practitioners who are authorized to bill Medicare for their professional services may also furnish and bill for telehealth services. This allows health care professionals who were not previously authorized under the statute to furnish and bill for Medicare telehealth services, including physical therapists, occupational therapists, speech language pathologists, and others, to receive payment for Medicare telehealth services. Additionally, telehealth services performed by auxiliary personnel who cannot independently bill Medicare for their services, such as respiratory therapists, can be furnished and billed incident to the services of an eligible billing practitioner. Hospitals do not bill for Medicare telehealth services. However, if a hospital employs certain practitioners who are not authorized to independently bill Medicare for their services, such as respiratory therapists, the hospital may bill for the outpatient hospital services provided by that staff using telecommunications technology. Hospitals should review requirements for providing hospital services in relocated provider-based departments including the patient’s home and temporary expansion locations as appropriate. We note that Medicare cannot pay for services that are furnished by a physician or practitioner located outside of the United States (see 42 CFR 411.9).

Currently, CMS requires most telehealth services to be furnished using telecommunications technology that has audio and video capabilities that are used for two-way, real-time interactive communication. For example, to the extent that many mobile computing devices have audio and video capabilities that may be used for two-way, real-time interactive communication, they may be used to furnish Medicare telehealth services. CMS has used its waiver authority to allow, beginning on March 1, 2020, telephone evaluation and management codes and certain counseling behavioral health care and educational services, to be furnished as telehealth services using audio-only communications technology (telephones or other audio-only devices). A list of those services is available here: https://www.cms.gov/Medicare/Medicare-GeneralInformation/Telehealth/Telehealth-Codes.

For all other services, a Medicare telehealth service requires, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

State Regulation:

April 9, 2020 Gov. Noem issues Executive Order 2020-15 which states, “I hereby extend three Executive Orders related to the suspension of administrative rules and statutes due to the COVID-19 emergency for the duration of the emergency: Executive Orders 2020-07, 2020-10, and 2020-14.” 

Executive Order 2020-07 includes the following provisions:

  • Section 1 Telehealth and Telemedicine Services – Pursuant to SDCL 34-48A-5(4), I temporarily suspend the regulatory provisions of ARSD 67:16, 67:61, and 67:62, which limit or restrict the provision of telehealth or telemedicine services and which require face-to-face treatment, visits, interviews, and sessions with providers.

  • Section 2 Medications – Pursuant to SDCL 34-48A-5(4), I temporarily suspend the regulatory provisions of ARSD 67:16:14:06.03, which limit the ability to dispense certain necessary medication in a timely manner.

Third-Party Payers

Avera and DAKOTACARE:

In March, Avera Health Plans and DAKOTACARE announced modifications to our reimbursement policy for telehealth services to preserve access to care while preventing the further spread of the novel coronavirus. The original announcement on telehealth during the pandemic was effective with dates of service March 17 through June 14. Avera Health Plans and DAKOTACARE will continue to support this expanded access to telehealth services through Dec. 31, 2020, or as long as the federal government permits, which allows enhanced care access and improved health care quality with no cost to our members.
As a recap, their provisions include:

Expansion of the list of CPT codes normally permitted to be performed via telehealth. Our standard Telehealth Policy is a compilation of all of the standard CPT codes permitted by CMS (notwithstanding a Public Health Emergency declaration) and all of the CPT codes listed in CPT Appendix P. The current, complete list of telehealth eligible services is available on the Avera Health Plans and DAKOTACARE websites.

  • Reimbursement rates at the equivalent in-person (non-facility) fee schedule values.

  • Waiver of member cost share regardless of whether the telehealth service was related to COVID-19 or not.

Relaxation of the HIPAA requirements and technology platforms permitted for telehealth consistent with the prior announcement posted by the Health and Human Services Agency including use of telephone (audio-only) technologies where appropriate. The audio-only provision ends Aug. 31, 2020. Beginning Sept. 1, 2020, only those telehealth services which use real-time interactive audio-video technologies are considered eligible for reimbursement.

Avera will continue to monitor the situation and adapt any additional CPT® codes that may be announced by CMS. With each of the prior releases of CPT® code expansions announced by CMS, the changes were made retroactive to March 17 and any prior claims that may have been denied were reprocessed accordingly. Telehealth claims for services billed outside of the scope of CPT® codes we approved in our listing will continue to be denied. We encourage you to check the online listing frequently for any updates.

As a reminder, for accurate reimbursement of telehealth claims, Avera encourages providers to follow the billing standards outlined in our Telehealth Reimbursement Policy including:

  • Use of the telehealth place of service code 02.

  • Do not use modifier GT.

  • Modifier 95 is acceptable but not required.

  • When use of audio-only telephonic technology is used, it should be documented as such in the medical record.

  • Telehealth services require the same level of medical record documentation as any equivalent face-to-face encounter or service. The totality of the communication and information exchanged between the health care professional and patient during the course of the telehealth service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

Of note, self-funded employer groups are being presented with this position on telehealth extension as a recommended option, but each self-funded employer group will make their own benefit determination.

Sanford:

Specific to COVID-19, for telemedical visits – via e-Visit, Sanford Health Plan will follow the federal guidelines until the end of the emergency.  Specific to COVID-19, for telemedical visits – via e-Visit, Sanford Health Plan is waiving co-pays.

Additional changes specific to COVID-19 include:

  • The waiving of the co-pays for Video visits;

  • Testing and initial diagnosis – covered at 100 percent;

  • Office visits and ER visits for COVID 19 testing- cost share waived and covered at 100 percent;

  • Rule out testing for other respiratory illness (RSV, influenza, etc.) covered at member cost share – specific to member plan;

  • IP stays are covered at member cost share – specific to member plan; and

  • All prior authorizations for COVID waived.

SDBOP:

To help slow the spread of the COVID-19 pandemic, the South Dakota State Employee Health Plan will

  • Cover 100% of the cost for Telehealth services between March 16 through August 31.

    • Telehealth services are a convenient and affordable alternative that can help minimize exposure for others during the COVID-19 pandemic. 

  • The South Dakota State Employee Health Plan is pleased to offer video visits with medical providers. A video visit is a service that allows medical professionals to remotely diagnose and treat patients through any video-capable device.

  • All members may utilize video visits, which are available from Avera, Monument Health (formerly Rapid City Regional Health) and Sanford Health.

  • Members can schedule a video visit with a medical professional within minutes for a large number of conditions, including:

    • Aches and Pains

    • Minor Infections

    • Mental Health 

    • Seasonal Allergies

    • Sinus Infections

    • Cold and Flu

    • Rashes

    • Pink Eye

    • Vomiting

    • Acid Reflux

    • Fever

    • Headache

Wellmark:

To support the healthcare system and providers to contain and minimize the impact of COVID-19, Wellmark has made several significant changes very quickly in response to the rapidly evolving pandemic.

Virtual visits. To avoid the spread of coronavirus (COVID-19), Wellmark fully-insured members have access to virtual health care visits for all appropriate medical and behavioral health visits with no member cost-share using an in-network provider or Doctor On Demand®. Some self-funded plans that Wellmark administers may elect to require cost share of their members. Wellmark's Iowa and South Dakota network providers will receive the same fee for virtual visits as an in-person visit. These changes apply to all appropriate medical and behavioral health virtual visits (see codes under Virtual Visits)  with any Wellmark in-network provider. Wellmark will allow telephonic visits when audio/visual capabilities are not accessible. 

Covering diagnostic tests for COVID-19. Members will have no cost-share for appropriate testing to establish the diagnosis of COVID-19 (see COVID-19 codes to use). 

Treatment of COVID-19. For fully insured plans, Wellmark will waive members' cost-share related to the treatment of COVID-19 (copay, coinsurance and deductible) when seeking care from an in-network provider, effective Feb. 4, 2020, through June 16, 2020. Effective for admissions beginning June 17, 2020, cost share will be waived for inpatient COVID-19 treatment only. Some self-funded plans that Wellmark administers may elect to require cost share of their members.

Prior approval. Wellmark will extend prior approvals through Aug. 31, 2020, for certain services that have been processed, approved and have not expired. 

Precertification and concurrent review requirements. To facilitate inpatient capacity across the health care system during the COVID-19 pandemic, Wellmark will suspend precertification and concurrent reviews for all in-network, eligible Iowa and South Dakota providers through Aug. 31, 2020.

Increasing access to prescription medications. Wellmark prescription drug benefit plans allow for early refill. We also will ensure formulary flexibility if there are medication shortages or other access issues. Members will not be liable for any additional charges if they receive a non-formulary medication as a result of a shortage of their current medication. Learn more

Supporting members 24/7. Members also have access to Wellmark's BeWell 24/7SM (844-842-3935) service that connects them to real people who can help with a variety of health-related concerns.

Working with individuals and businesses suffering economic disruption. Wellmark will allow our individual and small business policyholders to request a 60-day grace period when making premium payments for due dates between March 17, 2020, and June 16, 2020, in order to maintain their coverage. We will work with any mid-size or large groups on a case-by-case basis to determine appropriate payment timeframes. 

30

99356

PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR

99357

PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN

 Therapeutic Services

CPT Code

Description

92521

EVALUATION OF SPEECH FLUENCY

92522

EVALUATION OF SPEECH SOUND PRODUCTION

92523

EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION

92524

BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND REASONANCE

92526

TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION

92507

TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL

92609

THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION

97110

THERAPEUTIC PROCEDURE

97112

NEUROMUSCULAR REEDUCATION OF MOVEMENT

97161

PT EVAL LOW COMPLEX 20 MIN

97162

PT EVAL MOD COMPLEX 30 MIN

97164

PT RE-EVAL EST PLAN CARE

97165

OT EVAL LOW COMPLEX 30 MIN

97166

OT EVAL MOD COMPLEX 45 MIN

97168

OT RE-EVAL EST PLAN CARE

97530

THERAPEUTIC ACTIVITIES

97535

SELF CARE/HOME MANAGEMENT TRAINING

97152

BEHAVIOR IDENTIFICATION-SUPPORTING ASSESSMENT, ADMINISTERED BY ONE TECHNICIAN UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PORFESSIONAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES.

97153

ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN UNDER THE DIRECTION OF A PHSYICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES.

97155

ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, WHICH MAY INCLUDE SIMULTANEOUS DIRECTION OF TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES.

97156

FAMILY ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (WITH OR WITHOUT THE PATIENT PRESENT), FACE-TO-FACE WITH GUARDIAN(S) / CAREGIVER(S), EACH 15 MINUTES.

More information regarding Wellmark and COVID-19 can be found at: https://www.wellmark.com/Provider/CommunicationAndResources/covid-19-updates.aspx