Updates
CMS issued new policy guidance on 3/30/2020 that further relax existing telemedicine and supervision requirements. Below is a list of key changes significant to radiation oncology with section and page references to the attached CMS document.
- Weekly management visits (CPT code 77427) can now be conducted via telehealth (audio & video), if deemed appropriate (section II.17, pg 40).
- CPT codes 99441-99443 that cover audio-only communication with patients will receive payment with RVUs established by the RUC in 2008 (section S, pg 122).
- History and physical examination documentation requirements will be removed for new or established patient encounters if performed by telehealth (audio & video) with selection of level of encounter based on either time or medical decision making (section W, pg 145).
- The definition of direct supervision is revised to allow for real-time interactive audio and video technology during the COVID-19 pandemic, which applies to radiation therapy services at free-standing centers (section E, pg 55).
- Diagnostic services such as image guidance radiation therapy will now fall under general supervision requirements (section E.1, pg 58).
May one perform weekly management 77427 with phone only (no video)?
Many patients do not have access to video options.
ASTRO leadership to please represent hospital based and free standing practices in a similar way in discussions with CM telemedicine and supervision rules during COVID-19 epidemic (reg. of your update from 3/31/20 on direct supervision rules that apply to free-standing centers, if I understand you correctly). Thank you.
@Thomas D. Wynne both audio and video are required to meet the definition of telehealth for weekly management. Here is the direct language copied from the regulation below:
"For the duration of the public health emergency as defined in § 400.200 of this chapter, Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.”
"While OCR is not imposing penalties for noncompliance with the regulatory requirements under HIPAA against covered providers in connection with the good faith provision of telehealth during the PHE for the COVID-19 pandemic, HHS, OIG, and DOJ continue to actively monitor for any healthcare fraud and abuse, including potential Medicare coronavirus scams," (section C, pg 42).
Thank you, @Amar Rewari for your tireless work on these matters.
We are moving to telemedicine for consult, FU and OTV whenever feasible.
What are the telemedicine logistics for OTV? Thanks.
If the patient desires, then do through FaceTime.
I would refer you to Section V of the ASTRO guidelines I linked above. At present, Medicare's telehealth expansion does not apply to weekly management 77427 charges. A letter was sent to CMS requesting non-enforcement of the face-to-face requirement for OTVs during the COVID pandemic. We are still awaiting the agency's response. Until then, it's up to practices to best determine their individual risk / benefit of seeing OTVs virtually vs. face-to-face, recognizing that until further clarity is provided by CMS, it's unclear how these encounters will be reviewed.
https://www.astro.org/ASTRO/media/ASTRO/News%20and%20Publications/PDFs/ASTROCOVID-1977427Request.pdf
Yes aware of that (OTV), but above plan is passed on patient and health care worker safety.
Our department is rapidly evolving to move almost all patient encounters to be virtual. We have an existing telemedicine platform but there is limited infrastructure. To supplement we have Zoom meetings with patients in exam rooms or at home. As an ad hoc solution, we purchased iPads with the Zoom app for use in the clinic. Attending and resident can both participate from separate locations. These encounters also include undertreatment visits where the physician is physically present in the facility but not in the same room. This required some compliance discussion in the context of the pandemic. Note that CMS has relaxed rules for the platforms that are used. I admit that the tumor types that I treat may be more amendable to an initial virtual consultation than some other tumor types.
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
We are using Zoom or VSee, but I am reluctant to use it for consults.
We are using www.doxy.me and are reasonably pleased with it. We are using it for new patient consults as well as established follow ups.
Telemedicine is an important and useful tool that allows us to practice valuable social distancing to protect our patients and staff. ASTRO has released guidance on the use of Telehealth during the COVID-19 pandemic based on the waiver CMS issued on March 17th. Telehealth visits for new or established patients will be reimbursed by Medicare at the same rate as face-to-face visits. Medicare has requested private payors to follow suit. It's important to note that currently these telehealth visits still require BOTH audio and visual components. CMS granted a HIPAA waiver as part of this emergency to allow for video chats through products such as FaceTime and Skype.
On a COVID stakeholders call that CMS convened on 3/24, many providers raised concerns regarding the challenges they are facing with the video requirement for telehealth, particularly for elderly, inner city, and economically disadvantaged patients. CMS administrator Seema Verma acknowledged that the agency is aware of these concerns and stated that the temporary expansion issued on 3/17 was just the first step and to expect further guidance.
https://www.astro.org/Daily-Practice/Coding/Coding-Guidance/Coding-Updates
As of today at Washington University in Saint Louis, we have been approved to do telephone consults and follow-ups. OTVs we still have to see physically, but hopefully that will be solved. We don't have a telemedicine solution yet available, although there is some piloting going on.
Related Questions
Starting 3/16, we began offering lower-complexity / lower-risk patients the option of having a Tele-medicine consult vs re-scheduling to a later date. This offer has been extended broadly to all new consults at our facility when the provider indicates that s/he can extend comparable service virtually. We have used Tele-medicine consults in cases ranging from HR+ DCIS to 2nd opinions regarding treatment options (when both the patient and referring oncologist feel comfortable with this, and we have relevant outside studies available for review). Patients who strongly desire an in-person visit continue to be accommodated at this time.
Our expectation remains that patients starting chemotherapy or therapeutic clinical trials, or those of higher complexity, continue to receive at least 1 in-person visit. However, we have "stood-up" virtual processes for Tumor Boards, consenting, chemotherapy education, and follow-up visits that are largely discussion-based (such as reviewing an Oncotype RS). General response from patients appears to be positive, with many new consults electing for Tele-medicine visits rather than postponement.
Along with preserving social distance, this approach reduces patient anxiety, facilitates triage (we can convert to an in-person visit) and preserves consult capacity for future weeks (after all, there will still be new diagnoses taking place!). Not incidentally, we have also been able to utilize the services of our quarantined or immune-compromised physicians.
These services have been supported by rapid IS build by our organization, and more specifically by our Cancer Centers physician builders and Beacon team with Oncology-specific new and follow-up visit Tele-medicine templates, MyChart messaging, and virtual consent content.
Did you already have telemedicine platform softwares integrated with IT in your healthcare or using platforms such as Skype, FaceTime in the wake of COVID-19? Appreciate your input.
We've got Vidyo, but this is confined to inpatient at the moment. We are in the process of standing it up for outpatient oncology, hopefully by next week. We're largely relying on phone at this time, and given a large rural population, we will continue doing some this way. Although HHS has relaxed the guidelines re: platforms, the word from legal is that we should avoid using Skype, etc, because privacy breaches could still result in civil suits.
Do you have policies at the hospital for the usage of the telehealth platform? We have been using Vidyo at the hospital but would like to have some formal guidelines implemented.
Dr. @Nafisa D. Burhani, yes, we do have policies re the allowed platform for conducting a video visit.
We do many, many visits via telemedicine. Majority are of my pre-surgery breast patients, early-stage lung cancer, prostate cancers initial consultations. For exam considerations, if for some reason I know I need to do an exam, we have them come in or set up an exam at the time of simulation. It works fairly well if there are no AV / IT issues. Patients seem to like it.
We use eVisit and it works pretty well. There are some flaws and they are working on them.