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
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.
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 Dec. 31, 2020.
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:
-
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.
-
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