FAQ: Telehealth and Continuity: Strategies for PTs, OTs, and SLPs During Crisis

Please note that regulations and guidelines on telehealth and remote care administration are changing rapidly. A lot has changed since the original publication date of this resource, and while we are doing our best to keep it updated as new information emerges, we always recommend confirming all guidance with the original source—whether that be your state or national association, your payers, or CMS. This post was last updated May 15, 2020.

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 we’ve hosted a series of COVID-19 and telehealth-focused webinars to address the questions and concerns of rehab therapists across the country. We’ve called upon 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; Veda Collmer, WebPT In-House Counsel and Compliance Officer; and Rick Gawenda, PT, CEO and Founder of Gawenda Seminars & Consulting, to share their expertise and help the rehab therapy community better navigate this crisis. Throughout the course of this webinar series, we’ve received a couple thousand questions—too many to answer individually!—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 deliver the information you need.

Haven’t viewed the webinars yet? Check out the recordings:

• Telehealth and Continuity: Strategies for PTs, OTs, and SLPs During Crisis (March 25, 2020)
• Telehealth and E-Visits: The Latest on Coverage, Documentation, Coding, and Payment (April 8, 2020)
• Navigating COVID-19: Telehealth, Loans, and Regulatory Updates (April 16, 2020)
• Tackling Telehealth: How PTs, OTs, and SLPs Can Treat Virtually—and Get Paid (May 14, 2020)

Business Continuity

Health and Safety

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

On April 19, 2020, CMS published recommendations for “Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare” with the caveat that the “recommendations are not meant to be implemented by every state, county, or city at this time.” If you end up providing critical in-person services, then follow those CMS guidelines in addition to the CDC’s infection control guidelines. That means:

• keeping patients at least six feet apart,
• asking staff to frequently wash their hands,
• wearing face masks,
• “installing physical barriers or partitions in waiting room areas,”
• “placing curtains or partitions between shared patient areas,” and
• thoroughly disinfecting all treatment surfaces and equipment before and after each session.

For in-home care, we recommend that all parties wear masks in addition to:

• 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 guidance about how to safely reopen your clinic, check out this advice from WebPT Chief Compliance Officer Veda Collmer. For an in-depth look at leveraging telehealth in rehab therapy practice, watch this webinar or read this article.

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

Social distancing 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;
• asking patient family members to wait outside or in their cars as opposed to the clinic waiting areas; and
• requiring all patients and personnel to wear masks.

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 in this blog post). Remind them to wear masks, disinfect equipment regularly, and 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 six 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.”

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

Yes—if you can find it or have access to it. Some states are even shipping out PPE—so look on your state’s department of health website to see what actions it is taking to protect its healthcare workers. Additionally, the CDC recommends that everyone—symptomatic or not—wear some sort of mask, so it would be wise to require all staff and patients to don a face covering before entering your clinic. According to the CDC, any sort of cloth mask (even a bandana) will help reduce the incidence of transmission.

Aside from that, you should also put policies in place that protect employees. Jannenga suggested requiring your employees to:

• Wear masks and gloves;
• Wash their hands in front of patients before and after treatment;
• Wear a set of scrubs or “clinic clothing” that they can take off before they go home;
• Stay home if they’re symptomatic.

You should also make an effort to screen your patients. Consider implementing temperature checks, and don’t allow symptomatic patients to enter your clinic.

Finally, OSHA released guidance for employers regarding workplace policies and procedures to protect employees. View OSHA guidance for employers here.

In the unfortunate circumstance that your staff is exposed to COVID-19, the CDC and OSHA are both requesting that employers report exposure to state and local health officials for tracking purposes.

What is the best personal protective equipment to use in my practice? When will we be able to reopen without fear of having to quarantine because a patient tested positive?

The CDC has guidelines and recommendations for personal protective equipment as well as best practices for healthcare workers to protect themselves, their staff, and their patients. In terms of when you can—and should—re-open, unfortunately there is no cut-and-dried answer. This will largely depend on your ability to continue protecting your patients and your staff from transmitting the virus by enforcing disease mitigation best practices—as well the conditions in your specific region. It’s likely that practices in some parts of the country that were hit less hard by the pandemic will be able to resume business as (mostly) usual before others.

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?

Unemployment guidelines are handled at the state level, so you will need to reach out to your state government for specific details. That said, under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, “the federal government will fund an additional 13 weeks of unemployment benefits—through December 31, 2020—after employees have exhausted their state unemployment benefits.” Keep in mind that unemployment benefits typically are only available to individuals who can prove their unemployed status.

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 who 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.

Financial Assistance

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

While the federal government did allow businesses to apply for several loan and financial relief programs, many of those programs are now limited or completely shut down. One program that still has funds to distribute as of May 12, 2020, is the Paycheck Protection Program (PPP). According to our in-house counsel, this program “helps small businesses (i.e., those with fewer than 500 employees) cover payroll expenses and other operating costs from February 15 until June 30, 2020 (in the legislation, this time frame is denoted the ‘Covered Period’). Small businesses may take out Small Business Administration (SBA) loans for up to $10 million to cover payroll for employees earning up to $100,000 per year. (The formula for individual loan amounts is based on payroll costs.)”

Unfortunately, the SBA disaster loan (also known as the Economic Injury Disaster Advance Loan [EIDL]) is now only accepting applications that provide relief to US agricultural businesses. Additionally, Medicare’s Accelerated and Advance Payment Program is no longer accepting new applications.  

We temporarily laid off employees, but we just received funds via a PPP loan. Can we rehire?

Yes. Just keep in mind that if your employees have collected unemployment, that might affect your unemployment insurance at a later date. We don’t have too many details about the impact on unemployment insurance yet, but we would recommend rehiring your staff, using the loan to cover payroll expenses, and requesting forgiveness on those amounts.

If we receive funds via the PPP, can we still require employees to use their paid time off?

Paid time off is included as part of payroll expenses, so you can use these funds to cover your staff’s paid time off and receive forgiveness on that amount.

Can we hire additional therapists to reach the numbers we need to fulfill the 75% PPP loan requirements?

Yes, we believe that you can.

If loans start back up again with more funding, how can I choose the right bank to get a loan?

On the SBA website, you can locate available lenders in your area by zip code.

I submitted a loan application and received approval, but the program paused before I received my funds. Am I not going to get my loan?

We don’t expect that to be the case. It seems more likely that the government preemptively stopped accepting new applications because based on forecasts that funds were running out (not based on running out of cash to fund already-approved loans). That said, it’s a good idea to stay in contact with your lender about the status of your application.

Can you explain how the PPP interacts with Economic Injury Disaster Loans (EIDL)?

EIDLs are low-interest emergency loans. If you are requesting advance money, you can use that first $10,000 for anything—and you don’t have to repay it. If you used any EIDL funds to cover payroll, rent, and utilities, you can later refinance that EIDL amount into a PPP loan. The benefit of refinancing the loan is that some PPP expenses are forgivable, whereas EIDL loans cannot be forgiven. Please note that while the PPP began accepting new loan applications on April 27, 2020, EIDL eligibility is, as of May 14, 2020, restricted to US agricultural businesses.

Explain more about tax-free employer student loan contributions. What is the benefit to the employer?

This is an existing program that employers can use to pay down employees’ student loans. Employers who are paying student loans as an employee benefit can provide up to $5,250 in non-taxable loan payments. In other words, the employer will not be assessed for any taxes on this amount, and the employee does not have to count the repayment money as income.

Can you use PPP funding to provide back pay for employees who have not been able to work?

Most likely—but we advise you to review the loan requirements posted on the SBA website. And make sure that you have documentation proving that you paid those employees, because you will need that evidence when applying for forgiveness. At this time, we’re still waiting for additional details and clarification from the SBA. What we do know is that the PPP is intended to provide employers with the funds they need to retain their employees. So, employee compensation—and even back-pay compensation—seems to fall under this umbrella. So, as long as it remains within the $100,000 a year limit, it seems likely that the amount spent on back-pay would be forgiven. Remember, though, that this is ultimately a loan, so you could essentially spend it on anything; but during this covered period (which ends June 30), only costs associated with payroll, rent, utilities, and mortgage interest payments are forgivable.

Is the Medicare Advance Payment Program different from the CARES Act Provider Relief Fund?  

Yes; the CARES Act authorized two funds specifically to cover business expenses and lost income for healthcare providers. The Medicare Advance Payment Program advances payments to providers to help mitigate crisis-related disruptions to claims submission and processing. The funds are provided in advance of the billed therapy services, and CMS will later recoup those payments. In other words, it’s a loan.    

The CARES Act Provider Relief Fund is money paid to providers to compensate for revenue and income lost due to the COVID-19 pandemic. These funds are not a loan, and providers do not have to pay them back. Eligible providers:

• received Medicare fee-for-service reimbursements in 2019;
• agree not to collect out-of-pocket payments from patients above payment amounts authorized for in-network providers; and
• provided care for individuals with possible or actual COVID-19 diagnosis (care does not have to be specific to COVID-19).

The CARES Act Provider Relief Fund dedicated $30 billion to rapidly offset business and income losses related to COVID-19 and to ensure uninsured individuals receive care. If you qualify, you will receive an electronic payment with HHSPAYMENT as the payment description. Payments are being dispersed as of April 10. You do not have to apply for these funds; HHS will determine your eligibility and send you the money. For more information about the program, see the HHS website.

Please note that providers may no longer apply for the Medicare Advance Payment Program.

Miscellaneous Continuity Questions

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 and Other Virtual Care Services

Foundations

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

First things first: Telehealth is considered remote care because it’s not delivered in person—but not all remote care is telehealth. Telehealth is the one type of remote care that’s like a normal, in-person appointment. You might provide an initial evaluation, or perhaps gait training. Other types of remote care, however, are more like consultative and assessment work. That said, there are four types of remote visits that therapists can provide:

• Telehealth visit: When you remotely treat a patient through a live, synchronous video stream (e.g., providing ther-ex virtually).
• Telephone visit: When you remotely communicate with your patients via telephone and complete case assessment and management.
• Virtual check-ins: When you remotely connect with a patient to discuss his or her care and complete assessment and management services—either through “asynchronous” information exchange (i.e., sending images and videos via secure messaging or email) or through a live telephone call.
• E-visits: When you remotely connect with a patient and complete assessment and case management services through an online patient portal.

To learn more about virtual check-ins, telephone visits, and other remote services—and to see some examples—check out this blog post.

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.

How can we use telehealth in practices today?

Assuming your payer and state allow it, you can use telehealth to treat patients, check in with patients and monitor their progress, or review exercises with patients and adjust their HEP as necessary. Getting new patients to try a telehealth program might be tough, but it’s doable, and we hope that therapists will continue to offer telehealth in some shape or form even post-COVID-19. But, Gawenda thinks that, moving forward, we must remember that telehealth will not replace in-person services, but serve as a supplement to face-to-face treatment.

What standardized tests can we perform virtually?

Consider the standardized tests that you perform in your clinic when the patient is present—and pick out the ones that you can safely conduct via telehealth. At the end of the day, you, the therapist, will need to use your clinical judgment when you decide which tests to administer.

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 could benefit from this type of care, then you’ll need to find a platform—ideally, one that’s HIPAA-compliant and 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—and we’ve also written a handful of telehealth advice posts. 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.

How can we get patients to buy into telehealth?

This really comes down to patient education. First, you have to inform patients that this option is available to them. You can do that by sending out an email to your entire patient database or by advertising your services on Facebook or other digital channels. We’d also recommend adding a page to your clinic website that describes which telehealth or remote care services you offer, how those services are conducted, and what the benefits are to the patient. If you know that certain in-network insurances are paying for telehealth, be sure to include that information. It may take more than one email or advertising push to see a response, but we believe persistence will pay off. Check out more telehealth marketing tips here.

Can we use common platforms like Skype or Facetime to deliver telehealth and e-visits?

Technically yes—but generally speaking, we don’t recommend using Facetime or Skype to provide any type of virtual services, even with the OCR’s current HIPAA relaxation. We think it’s better for rehab therapists to look at telehealth in the long term, which means—if you continue to provide virtual services post-COVID—you’ll need a fully functional HIPAA-compliant software.

Additionally, the OCR waiver temporarily approved Facetime and Skype for telehealth visits—not e-visits, so as of the publication date of this article, therapists still must use a secure and HIPAA-compliant solution to provide e-visits.

If you’re providing telehealth treatment to minors, do parents or guardians have to be present?

First things first: Check your state practice act and see if it specifically addresses treating minors in general—and treating minors through telehealth, specifically. It may require the parent or guardian to stay in the room—but it might not. If your state practice act does not require the parent or guardian to remain nearby while you provide treatment, establish an emergency action plan. What do you do if an emergency occurs—or if the child does not behave? How do you get in touch with the patient’s parent or guardian? When crafting your plan, you’ll want to adhere to your state rules and make sure you’re always acting in the child’s best interest.

During a video consultation, what is the best way for a PT to demonstrate a movement pattern or a therapeutic exercise and evaluate the patient who’s attempting to replicate it?

It helps to have access to a video-based exercise demo that you can share with the patient—either through live screen-sharing or by sending the video through other means. If you don’t have a pre-recorded video, though, simply demonstrate the exercise live! In other words, stand up, adjust your camera so the patient can see you, and perform the activity yourself—making sure to verbally describe what you are doing as you’re doing it. Also, encourage your patient to talk about how he or she is feeling about the exercise. You might not be able to read a patient’s facial expressions or pick up on subtle muscle tension over video, so it’s paramount that patients vocalize where they feel the exercise—and if anything hurts.

It may be a little frustrating to constantly think on your feet and adapt your treatment—and telehealth might feel a little awkward at first—but with practice and repetition, you will improve over time. Try looking at it as an opportunity to improve your adaptability and communication as a therapist.

Limitations

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 in the clinic?

In many cases, yes. As of April 30, 2020, Medicare and many major commercial payers have lifted telehealth restrictions, and some will pay for remote initial evaluations. However, please note that every state has its own telehealth laws, and telehealth may not fall under your scope of practice in your state. So, be sure to check with your state board as well as your individual payers.

Are there restrictions on how often we can provide telehealth?

It’s very possible that your payer or state practice act could restrict different aspects of providing telehealth. That’s why it’s absolutely critical that you contact each of your individual payers to learn about and understand their guidelines.

When it comes to Medicare, there is no limit to the number of e-visits you can provide in a week—instead, there is a limit on the total time per week, as you can only bill one code over the course of the seven-day period. As it stands, there are no similar limitations on Medicare telehealth services during the COVID-19 emergency period.

Do initial evaluations have to be synchronous?

Yes. You can only provide a remote initial evaluation via telehealth which, by nature, must occur in real-time.

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 e-visits, virtual check-ins, and telephone 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.

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.

Can you provide telehealth across state lines?

You technically can provide telehealth across state lines, but you must be licensed in the state that the patient is in—or that state (and yours) must participate in the PT compact. However, keep in mind that you have to be not only licensed in the patient’s state, but also credentialed with the patient’s payer.

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

PT telehealth is authorized by California statutes (Cal. BCP 2290.5), and—according to this bulletin from the California Physical Therapy Association—“all health plans and Medi-Cal managed care health plans operating under the Department of Managed Health Care and the Department of Health Care Services shall, effective immediately, reimburse providers at the same rate, whether a service is provided in-person or through telehealth, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim.”

That said, policies and guidelines are still in a state of flux, so be sure to reach out to Medi-Cal representatives to confirm this information.

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.

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.” And while CMS has announced that it is “exercising enforcement discretion” and not conducting reviews to determine if e-visits were delivered to established patients, the APTA advises providers to proceed with caution and adhere to all applicable state and local laws.

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

As of April 8, 2020, Gawenda says “yes,” because CMS has clarified that the e-visit and telephone services CPT codes are considered “sometimes therapy” codes (meaning they require the GP, GO, or GN modifier when provided by a PT, OT, or SLP, respectively).

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 for one patient 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.

Consider this example from one of our blog posts about remote services:

“A Medicare patient calls his physical therapist to cancel an upcoming appointment due to the need to shelter in place. The therapist informs the patient that he can stay in contact with the therapist—and continue receiving instruction and guidance on his home exercises and other home care elements—by initiating an e-visit. The patient agrees to do this. The therapist documents the patient’s initiation of the service as well as his consent to receive it. The therapist sets the patient up with access to a secure patient portal that allows him to send and receive messages and other materials—like exercise videos and images. The patient uses the portal to tell the therapist that he is having trouble replicating some of the exercises at home due to lack of equipment. The therapist makes suggestions on how he can adapt the exercises using household items and sends recorded videos to demonstrate those suggestions. The therapist spends 30 minutes thinking about how to adapt the exercises, preparing the materials, and sending them to the patient. The therapist does not provide any other services over the course of the seven-day period, so she bills one unit of G2063.”

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

E-visits must take place via a secure patient portal. These services are not delivered via a synchronous platform (e.g., video or phone call), but rather involve communication via the portal. 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?

No. E-visits must take place through a secure online patient portal, like WebPT HEP.

What is the definition of an “established patient?”

As we explained in this blog post, 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.

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.

If we are able to provide 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. Additionally, providers are allowed to notify patients of the availability of the services and the requirement that they must be patient-initiated.

How do you document that a patient requested an e-visit?

Simply include in your documentation a statement like, “Patient contacted PT via phone on (date/time)”—and indicate the reason why the patient contacted you.

Can we bill for consecutive e-visits during more than one seven-day period?

We’re still waiting for clarification from CMS regarding consecutive e-visits, but Gawenda believes you should be able to bill consecutive visits.

Can you provide e-visits to a patient with an expired POC?

While we are still awaiting clarification from CMS on this question, Gawenda believes CMS will be lenient, especially considering that e-visits are essentially delivered outside of the plan of care (i.e., e-visits visits don’t count toward the 10-visit threshold that would trigger a progress note). Furthermore, CMS does allow for delayed certifications and recertifications under extenuating circumstances. Jannenga recommends reaching out to those certifying physicians and documenting that you have done so.

Are text messages approved for use when providing e-visits?

No. E-visits must take place via a secure online patient portal—though the communication in that portal may be text-based.

Should we use the KX modifier on applicable e-visits? What about telephone visits?

As of April 8, 2020, Gawenda says “yes,” because CMS has clarified that the e-visit and telephone services CPT codes are “sometimes therapy” codes. This means that they would count toward the therapy threshold—which could trigger the use of the KX modifier.

Are e-visits synchronous or asynchronous?

They can be either, depending on how you provide treatment. However, keep in mind that when you treat Medicare beneficiaries, CMS has stated that you must use a secure online patient portal, which would make the service asynchronous in nature.

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

As the APTA explains on this page, “An e-visit is a patient-initiated online assessment and management service for an established patient that is furnished using an online patient portal, not in real time. The PT and patient exchanges communications and information via messaging through the portal.” A telephone visit, on the other hand, “involves a real-time discussion with the PT over the telephone.” You can learn more about e-visits here and telephone visits here.

Can you use a telephone for e-visits? Or can you only use a telephone for telephone visits?

Now that Medicare has made the telephone visit codes available to PTs, OTs, and SLPs, you should use those codes to bill Medicare for real-time services specifically provided via telephone. Conversely, if you’re using a secure portal (e.g., WebPT HEP) to deliver services, you should use the e-visit codes.

Telephone Visits

Can you bill for both a telephone visit and a video virtual visit during the same seven-day period?

CMS hasn’t released specific guidance about this, but on April 8, 2020, Gawenda believed you might be able to because they’re two separate and distinct codes. Ultimately, you need to check out CMS’s NCCI edits to confirm that you can bill these codes together, and—if you are allowed to bill them during the same seven-day period—ensure that your documentation defends your clinical reasoning. However, Gawenda cautioned therapists against billing a telephone and video virtual visit code on the same day. He said it was unclear whether that’s allowed.

How much will Medicare pay for telephone visit codes?

We’re not sure. Though CMS has instated pay parity for telephone E/M services (99441–99443), it has not announced pay parity for telephone visits (98966–98968). As of May 15, 2020, PTs, OTs, and SLPs can only bill Medicare for telephone visits, which means the pay parity plan does not apply—so we’re unsure how these codes will be reimbursed.

What POS code do I use for telephone services?

Gawenda recommends using POS 11—even if you’re billing these services from home—as they would typically occur in your office. Keep in mind that you can only apply POS codes if you’re billing on a CMS-1500 claim form, as UB-04 forms do not require a POS code.  

What are the correct billing modifiers for telephone calls?

If you’re billing a telephone visit (CPT codes 98966–98968) to Medicare, you’ll need to affix the appropriate therapy modifier (GP, GO, or GN) as well as the KX modifier, if applicable. For commercial payers, the required modifiers may vary. You’ll need to reach out directly to individual payers to determine their rules.

Do standard Medicare copays, coinsurances, and deductibles apply to telephone visits?

Yes. CMS considers telephone service codes “sometimes therapy” codes—which means they require a therapy modifier (GN, GO, or GP) when provided by a rehab therapist. Thus, the patient’s Medicare deductible and coinsurance still apply—and these codes count toward the therapy threshold.

Do telephone visits count toward the therapy cap?

CMS has categorized the telephone visit CPT codes as “sometimes therapy” codes, which means the dollar amount will count toward the therapy threshold. However, the multiple procedure payment reduction (MPPR) does not apply.

Do telephone visits have to be patient-initiated?

According to the APTA, yes.

Billing

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

You absolutely must check in with individual payers to see which codes they want you to use when billing various virtual care services and ensure that your state practice act permits you to supply remote services in your state. That said, you can generally bill the following virtual care codes:

• E-Visits: G2061, G2062, G2063 (Medicare and some commercial payers), and 98970, 98971, 98972 (Commercial payers and worker’s comp)
• Virtual Check-Ins: G2010, G2012 (Medicare and some commercial payers)
• Telephone Services: 98966, 98967, 98968 (Medicare and some commercial payers)

Finally, in many cases, you can now bill standard rehab therapy CPT codes (e.g., 9700-series codes) with the appropriate modifier and POS code to indicate that you provided remote telehealth services. But again, even though Medicare now covers these services, you absolutely must verify with your state board and individual commercial payers before proceeding.

To learn more about each type of remote care visit that is available to rehab therapists, consult this blog post.

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; POS 11 represents an office location; and POS 12 represents the patient’s home. When billing Medicare for telehealth, e-visits, virtual check-ins, or telephone visits, you’ll want to use POS 11 or 12—depending on the location in which you’d normally furnish those services. (In other words, if you operate out of a clinic, use POS 11, and if you’re a home-based therapist, use POS 12.) That said, not all commercial payers use the same POS codes as Medicare. Check in with individual carriers to determine if they want you to use POS 02, 11, or 12.

Which POS code should I use to indicate my distant site? What about my originating site?

When billing under Medicare Part B, you should use one of the following place of service (POS) codes for the distant site:

• POS 11: Office
• POS 12: Home

The code you select will depend on where you normally render services. So, if you usually treat patients in an office/clinic environment, use POS 11. If you usually treat patients in a home environment, use POS 12. Keep in mind, though, that if the patient is commercially insured, then the appropriate distant site POS code is dependent upon the payer’s rules. That said, many private payers use POS 02 for telehealth services.

As for the originating site, according to this telehealth billing resource, “practitioners must use the address where they typically practice in Box 32. If they work part of the time out of a clinic and part of the time out of their home, they may use the clinic address. If they work out of their home 100% of the time, as some providers do, they must use their home address.”

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. Typically, you’ll use this modifier when you administer real-time, synchronous services for the telephone CPT codes. To be clear, Medicare requires modifier 95 when therapists bill telehealth visits—but not e-visits, virtual check-ins, or telephone visits.

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 specifically billing e-visit and virtual check-in codes.

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

Yes, in many—though not all—cases. Medicare, along with several commercial payers, is now allowing rehab therapists to use this billing method (although most payers are not allowing direct personal contact codes to be billed as telehealth). Ultimately, you’ll have to check in with your individual payers in addition to finding out 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 distant) and the place of service?

The originating site is the patient’s location; the distant site is the provider’s location. The place of service is the same as the distant site (i.e., the providers location), and is shared via a code.

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

According to Gawenda, Medicare has approved some group therapy codes for rehab therapists to furnish via telehealth. If any of those are appropriate, you may use them. Generally speaking, the e-visit, virtual check-in, and telephone visit codes are not for group use.

Can a PT bill a telehealth visit incident-to a physician?

No. According to Gawenda, CMS has clarified that PTs and OTs cannot bill telehealth visits incident-to a physician.

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?

No. Because Medicare now covers telehealth provided by PTs, OTs, and SLPs, you can no longer accept cash payment for these services from Medicare beneficiaries.

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.

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.

Should rehab therapists bill telephone visits as timed services? If so, would they count as direct or indirect visit time?

Wallace believes telephone codes would be timed and that you should bill direct minutes, because you’re actively on the phone with the patient at all times. E-visits, on the other hand, would be untimed, as you can only bill one unit per e-visit code.

If I have a phone discussion with a patient and follow up by sending an adjusted HEP via email, how should I bill for that?

According to Wallace, this scenario stretches the limits of the definitions for both e-visits and telephone visits. You can’t bill for an e-visit for the first half of the patient interaction, and you can’t bill for a virtual check-in for the second half. So, you would have to pick and stick with one method of service delivery. Instead of following up with the patient via email, you could send the patient the updated HEP, call him or her again to discuss the updates, and add those minutes to the original telephone code.  

If I already legally provide therapy across state lines (e.g., I participate in the PT compact), do I need to use a special POS?

No. You should bill the payer according to its specifications. So, say you’re an Arizona provider who’s administering care to a Medicare patient located in Utah. If the patient would normally come into your office for care (e.g., you normally operate in a clinic), you’d use POS 11. If you would normally treat the patient in his or her home (i.e., you’re a home health provider), then you’d use POS 12. When submitting the claim, you’d submit it to the Utah MAC, Noridian. Of course, if you were providing care to a patient who was covered under BCBS of Utah, then you’d bill according to that specific payer’s recommendations. Keep in mind that you would have to be credentialed with that commercial payer in order to bill it.

Should I ever use POS 02?

At this time, CMS does not want rehab therapists to bill telehealth services with POS 2; however, some commercial payers might require you to use POS 02. Again, reach out to your commercial payers and confirm the billing protocol that they’d prefer you to follow.

If we billed e-visit codes (G2061–G2063) to Medicare on or after March 1, but the services rendered meet the criteria for true telehealth, can we rebill the visit using the appropriate CPT codes?

Maybe. If you knowingly conducted a true telehealth visit and simply billed for an e-visit because you knew you could receive payment, then you actually owe that money back to Medicare, because this would constitute fraudulent billing. As Gawenda mentioned during the webinar, CMS has been clear that an e-visit is not a service that would normally occur in person, it does not use real-time telecommunication, and it has to be initiated by the patient. Telehealth, on the other hand, does require a real-time, audio-visual connection, but it doesn’t necessarily have to be initiated by the patient. If you actually did provide telehealth—but billed for an e-visit—you could technically rebill for the telehealth visit after refunding Medicare the e-visit reimbursement amount. But if the e-visit service you billed for does not meet Medicare’s telehealth criteria, then you must keep the payment as distributed.

Does it matter if we list GP or 95 first on the claim?

According to this Noridian resource, modifier GP (or GO or GN, if appropriate) should always appear in the first or second position when additional modifiers are required for a particular service line.

Copays, Deductibles, and Coinsurances

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

This also depends on the payer. When billing Medicare for telehealth, e-visits, or virtual check-ins, 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.

Coverage, Reimbursement, and Denials

How real is the possibility that we’ll be able to bill (and be paid for) telehealth services for all payers in the near future?

Everything is changing rapidly—which means everything is in the realm of possibility. In fact, many commercial payers have already given rehab therapists the go-ahead to provide telehealth services. Watch for updates from CMS, the APTA, your local payers, and of course, WebPT.

Has anyone received payment from Medicare for these services or codes?

Anecdotally speaking, we’ve heard that some providers are getting paid and others are receiving nothing but denials or rejections. Without much claims data available to analyze, it’s tough to pinpoint exactly why this is happening—though we suspect that many MACs are unprepared to process these claims and have yet to update their systems. For now, we encourage you to appeal denied claims.

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

Yes, because commercial carrier coverage may vary.

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 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 different telehealth services—but it varies state by state. We recommend checking out this telehealth guide from the Center for Connected Health Policy and reaching out to your Medicaid contact to learn more.

How can I find the payment rates for my locality?

You can use this CMS tool to search for average payment rates by setting and region.

We’ve already received denials for e-visit codes. Why is this?

Some providers are receiving denials for the e-visit codes—even when those codes are billed correctly during one seven-day period. We believe that is because some MACs have not yet had the opportunity to update their software to show these codes as payable for PTs, OTs, and SLPs.

We are receiving denials on Medicare e-visit codes, and the claim denial reason states that the claim is lacking reason for adjudication. How would you recommend we handle this?

Contact your MAC directly. It may be due to issues recognizing the CR modifier—or the therapy modifier. Asking these questions specifically may help you determine the root cause.

Why are MACs denying my telehealth claims?

At this time, many MACs are not prepared to process telehealth claims from rehab therapists—so they’re sending back rejections and denials. Unfortunately, you have to play the waiting game, as some MACs have announced that they won’t update their systems until as late as July 2020.

Does Medicare Part C (a.k.a Medicare Advantage) have to pay the same amount per telehealth service as Medicare Part B? We’ve noticed that Advantage is paying us less for e-visits than Part B is reimbursing.  

No. Medicare Advantage plans are required to cover the same services as Medicare Part B—but the private companies that manage those programs are under no obligation to match Part B payments.

Does Medicaid cover rehab therapy telehealth? If so, how do I bill for it?

It depends. Remember that Medicaid is a state-specific healthcare program, with each state following its own distinct set of rules. You will have to research your state’s Medicaid program to determine whether it allows rehab therapists to provide—and get paid for—telehealth services. If these services are covered, you will have to research further to identify which modifiers and POS codes the program would like you to append to the claim.

Does Medicare pay for telehealth services at the same rate it reimburses for in-person services?

Yes! CMS has confirmed that it’s offering pay parity for telehealth services during the COVID-19 emergency response period.

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. Keep in mind that you cannot directly charge Medicare patients, as Medicare now covers telehealth services.

What cash-pay rates should I charge for telehealth services?

Unfortunately, we can’t tell you what to charge, because your ideal rate will vary drastically depending on your location, costs, patient demographics, and other factors. According to Gawenda, some providers are discounting their telehealth services (i.e., they charge less than an in-person visit) because telehealth costs are cheaper and their appointments are a little shorter. However, he has talked with others who charge patients the full price because appointments are the same length as an in-person visit, and the providers believe they’re still giving patients the full value of their expertise. Neither route is right or wrong—it’s up to you to evaluate what’s right for your practice and your 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. Additionally, you cannot collect cash payments from Medicare patients, as Medicare now covers telehealth services.

Can you provide telehealth on a cash-pay basis to Medicare patients? Do you need an ABN?

As of April 30, 2020, CMS covers telehealth that’s administered by PTs, OTs, or SLPs. Because telehealth is now considered a covered service, you cannot provide telehealth to a Medicare patient on a cash-pay basis.

Do I have to refund out-of-pocket telehealth payments I collected from Medicare patients between March 1 and April 30?

If you’re a private practice provider and you bill Medicare on a CMS-1500, then yes—you will have to refund those patients, because Medicare does not allow rehab therapy providers to collect cash from beneficiaries for covered services. Be sure to refund that patient and submit the claim for the visit to Medicare as soon as possible.

Disclaimers and Consent Forms

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.

How should I obtain signed consent from a patient to conduct telehealth services when that patient isn’t planning to come into the clinic at all?

If your practice has digital intake capabilities, then patients can sign a telehealth consent form remotely using the same method you use to collect their intake information. While you could obtain verbal consent from a patient on a recorded telehealth session and document that this consent took place in your notes, Gawenda explained that every attorney he has spoken with was adamant that providers obtain signed and dated consent forms that are specific to telehealth prior to conducting a telehealth session.

If you don’t have digital intake capabilities, you may want to consider using a digital signature software—like DocuSign—to complete this step. That way, you can create one form and send it to your patients electronically to sign. Gawenda also suggested including space for patients to provide their initials next to each line of your consent forms—and, as always, the best way to ensure that you’re appropriately covered is to consult directly with a legal expert.

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.

Additionally, WebPT has rolled out a Virtual Visits feature that you can access from the WebPT Scheduler. This HIPAA-compliant platform is covered under WebPT’s business associate agreement (BAA), so you can rest assured it is totally secure.

Keep in mind that a consumer-facing platform might 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.

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.

How do I stay HIPAA-compliant when I’m working from home?

Currently, the Office for Civil Rights (OCR) is not acting as strictly as it normally would regarding HIPAA compliance—especially regarding telehealth platforms. But, providers still have an obligation to follow HIPAA rules, so if you’re working at home and your family or roommates are around, work in a private place—like a private room where family members can’t see or overhear PHI. Ensure that the electronics you use to provide telehealth are password-protected, and do not leave them unlocked. And finally, while we can’t control how patients handle their PHI, we can still send them instructions and suggested best practices to help them protect their private information.

Therapy Assistants

Can PTAs and OTAs provide telehealth services?

It depends on your state practice act; some states allow therapy assistants to provide telehealth, but others may not. Your best course of action is to refer to your practice act and check with your state licensing board. If PTAs and OTAs can provide telehealth in your state, CMS has confirmed that they can furnish (and get paid for) services that are provided to Medicare beneficiaries. However, these assistants still must follow the strictest supervision guidelines that apply to them. While CMS has stated that—for the duration of the COVID-19 public health emergency—therapists may provide direct supervision using real-time interactive audio and video technology, remember that you always must adhere to the strictest supervision rule that applies to you. So, if your state requires a stricter degree of supervision—and that requirement has not been relaxed due to COVID-19—then you still must follow that rule.

The Federation of State Boards of Physical Therapy (FSBPT) has created this resource containing the current jurisdiction telehealth laws for all 50 states. If you still have questions about the rules in your particular state, contact your state therapy association or the specific payer in question.

Please note that PTAs and OTAs cannot provide e-visit services to Medicare beneficiaries.

Can SLPAs provide telehealth—and is it reimbursable?

Unfortunately for SLPAs, most major insurance companies do not pay for their services at all, so it’s unlikely that they’ll be allowed to provide (or get paid for) telehealth services.  

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.

Will we need to use PTA and OTA modifiers if a therapy assistant helps provide telehealth?

Medicare has indicated that therapists should bill for therapy services provided via telehealth the same way they would bill for those services had they been delivered in a clinic setting (with the exception of affixing the 95 modifier to indicate the service was rendered via telehealth). We interpret this to mean that the same billing rules would apply for services provided by therapy assistants, meaning services should be billed with the CQ or CO modifier when more than 10% of the service is delivered by a PTA or OTA, respectively. Learn more about the PTA and OTA modifiers in this blog post.

Pediatric and School-Based Telehealth

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

Wallace recommends 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, then you can bill for telehealth services using the same codes you would normally use for in-person services—as long as those codes are part of Medicare’s list of covered codes. 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:  

• OT Telehealth/Teletherapy
• The OT Toolbox
• OT Potential
• Enable My Child

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.

Collmer says 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.

Workers’ Compensation

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 there a limit to telehealth for workers’ comp (e.g., one visit per week)? If so, does that apply to no-fault carriers?  

This depends on the rules established by the workers’ compensation plan or no-fault insurer. You’ll need to verify this information with the payer directly.

Do all workers’ comp and/or no-fault carriers cover telehealth?

No; individual states have moved slowly in changing regulations around telehealth. At this point, workers’ compensation plan changes are expected to roll out subsequent to individual state actions. Check out this page to access an APTA resource that’s updated weekly. Alternatively, search for “Occupational medicine providers telehealth APTA” to follow along when new updates are released.

WebPT

Which telehealth services can I bill through WebPT?

WebPT EMR users can bill telehealth, e-visit, virtual check-in, and telephone visit codes as well as specify the correct POS code. 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.

Will WebPT add a HIPAA-compliant telehealth service to its system in the future?

Yes! We rolled out WebPT Virtual Visits—a HIPAA-compliant telehealth integration for WebPT EMR users—in April. WebPT EMR users can open a secure live video stream directly from the scheduler—and we’re offering this feature at cost. To learn more, check out this page.

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.

Hospitals, Institutions, and UB-04s

How do you provide telehealth in a home care setting—and how does that interact with PDGM?

Unfortunately, home health agencies cannot supply telehealth to Medicare beneficiaries if they bill Medicare on a UB-04 claim form. And (from what we understand) PDGM applies specifically to institutions that bill on a UB-04 claim form. Therefore, these agencies would not be able to bill for telehealth—nor would those payments interact with PDGM. However, we always recommend reaching out to CMS for clarification.

How can hospital-based rehab therapists provide and bill for telehealth (specifically, Medicare Part A)?

As of March 31, 2020, institutions that bill on UB-04 claim forms cannot provide telehealth services to Medicare beneficiaries—it is not covered. However, because the service is not covered, these facilities may collect cash payments from patients.

CMS representatives have talked about a loophole that would allow hospital outpatient departments to bill for telehealth—but it’s a complex work-around. Read about it here.

Can hospitals bill e-visit codes?

We do not believe that Medicare will pay for e-visits furnished by hospital-based providers. In the interim final rule, when CMS designated e-visits as “sometimes therapy” services, it said that the “private practice occupational therapist, physical therapist, and speech-language pathologist to include the corresponding GO, GP, or GN therapy modifier on claims for these services.” This implied that these services would not be paid outside of a private practice setting. For all other payers, you’ll have to reach out to each individual carrier and ask.

The APTA says that hospitals can provide outpatient telehealth if they designate the patient’s home address as a “temporary expansion location.” How does this work?

First of all, Gawenda says that the APTA and CMS do not consider services provided in this manner true telehealth services—but rather, remote services. (For reference, e-visits, virtual check-ins, and telephone visits also fall under the “remote services” umbrella.) Gawenda still maintains that true telehealth can only be provided in a private practice setting.

However, hospitals can provide remote services—and to do that, they’ll need to include the patient’s home as part of their hospital (i.e., designate it a “temporary expansion location”). According to the APTA: “The hospital must notify its CMS regional office by email of the addresses it plans to identify as temporary expansion locations. That notification should be made within 120 days of beginning to furnish and bill for services at the relocation, and should include:

• Hospital’s CMS certification number.
• Address of the current PBD.
• Addresses of the temporary expansion locations (referred to as relocated PBDs in the interim rule).
• Date on which services began at the relocated PBD.
• Brief justification for the relocation and role it plays in the hospital’s response to the public health emergency.
• Attestation that the relocation is consistent with the relevant state’s emergency preparedness or pandemic plan.”

Hospitals can choose to do this throughout the duration of this public health emergency. That said, Gawenda recommends thinking hard before turning to this option, because hospitals will have to consider how this interacts with rules from the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities. He recommends discussing this with key leadership and compliance experts in the hospital before proceeding.

Is an ambulatory care center considered a private practice under Medicare?

Probably not—but it depends how the facility enrolled with Medicare. The best way to figure out if your ambulatory care center is considered outpatient (and can therefore bill Medicare for telehealth) is to reach out to your billing department and ask which claim form the billers use to bill Medicare. If they use a UB-04 form, then your center is an institution, and you cannot bill Medicare for telehealth. But if they bill using a CMS-1500, then you’re technically outpatient and can bill Medicare for telehealth.

Can home health PTs provide telehealth?

Home health therapists billing under Medicare Part A (i.e., as part of a home health agency, or HHA) cannot provide telehealth. However, therapists providing home-based outpatient therapy under Medicare Part B are able to provide and bill for telehealth services.

Miscellaneous Virtual Care Questions

Where can I find APTA telehealth updates?

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

Do we need to record each telehealth session we provide?

No—and you probably shouldn’t. Collmer does not believe that any payer requires telehealth session recording. In fact, each state has its own surveillance laws, and some even may prohibit session recording without the patient’s informed consent. Furthermore, recording the session may increase the provider’s risk of a HIPAA breach, since it will create additional (and substantial PHI) that must be protected. Collmer advises providers not to record sessions unless the patient asks for a recording—or there is a compelling reason to do so. The provider should have written informed consent from the patient before recording any sessions.

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.

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).

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.

What are your recommendations on cost-effective telehealth platforms?

When choosing a telehealth platform, we recommend creating a list of options, denoting the pros and cons of each, and figuring out which features and drawbacks are absolutely non-negotiable. For example, while the federal government has relaxed its enforcement of HIPAA regulations during the emergency response period, we absolutely recommend using a HIPAA-compliant platform so you can:

1. better protect patient information, and
2. continue using the platform once the national emergency declaration has expired.

As for determining cost effectiveness, you need to estimate how often you’re planning to provide remote care. Some platforms charge a per-visit rate, which could be great for a small, low-volume practice—but detrimental to a large, enterprise organization. Other platforms (like WebPT Virtual Visits) charge a flat monthly rate. There are some free telehealth platforms you can use to provide remote services for the time being, but many of them are not HIPAA-compliant and do not allow providers to enter into a business associate agreement (BAA)—which means you likely cannot use them permanently.

What types of remote care can non-rehab therapy providers (for example, registered dieticians) offer their patients?

Review your state practice act and payer guidelines—and connect with your individual professional associations—to determine the rules and requirements for providing remote services in your discipline.

If you or your patient don’t have access to video, can you provide telehealth through audio only?

No; you cannot provide audio-only telehealth services to a Medicare beneficiary. Telehealth services must occur through live, synchronous video and audio communication. If you can only communicate with the patient through audio, it may be more fitting to bill for a telephone visit, which means you’d use CPT code 98966, 98967, or 98968.

Do these legislative changes apply to Medicare Advantage plans (Part C)? Do they have to follow Medicare rules?

According to the APTA, because these legislative changes are waivers—and because the CARES Act expands telehealth only to Part A and Part B—they do not automatically apply to all Medicare Advantage (MA) plans. Some providers—like Cigna and Aetna—are covering telehealth services at this time, and that extends to those payers’ MA plans. So, you’ll need to check in with your contracted MA plans to see where they stand regarding telehealth coverage and billing protocol.

Can students provide telehealth to Medicare patients?

At this time, CMS has not changed any regulations regarding how students can participate in treatment. Gawenda thinks that, ultimately, it doesn’t make sense for students to provide telehealth. Students can only provide care under stringent supervision—and if you or a therapy assistant can’t stand over the student’s shoulder to direct the appointment, then it doesn’t make sense to involve him or her in that care.

Can a patient come into the office once a week and attend a telehealth appointment multiple times that same week?

Gawenda says yes—this should be totally acceptable. Just be sure to document (and justify) why in-person visits are required. That justification could be as simple as describing why the patient needed a specific modality or manual therapy.

Can mobile outpatient providers bill Medicare for telehealth services?

Yes! These practitioners should bill using POS 12, as they would normally provide services in a home environment.

Miscellaneous

We don’t use WebPT 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?

On March 19, the Cybersecurity & Infrastructure Security Agency (CISA) of the US Department of Homeland Security designated PTs, OTs, and SLPs as “essential critical infrastructure workers.” However, decisions regarding essential providers are determined at the state level.

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.

What does “sometimes therapy” mean?

As noted in this APTA resource, “sometimes therapy” services can be furnished by qualified providers “outside the plan of care of a PT, OT, or SLP.” In other words, the services aren’t restricted to delivery by a physical therapist, occupational therapist, or speech-language pathologist. However, when “sometimes therapy” services “are provided under a PT, OT, or SLP’s plan of care, the codes must be accompanied by the appropriate GP, GO, or GN modifier.”

Are payers still allowing new providers into their networks?

Maybe. Wallace has stated that some payers are doing accelerated credentialing—so it’s worth calling payers you’re interested in and finding out where they stand. It’s highly likely that if you get in now, they’ll keep you on when the pandemic is over. Ultimately, though, you’re going to have to call individual payers.

How do you recommend we cultivate referral relationships when we can’t do face-to-face meetings?

Get creative. Call them, send a note, or schedule a video chat. Check in on their family and see how they’re doing. You can do a lot of relationship-building that doesn’t require in-person interaction. This is a time to reach out to your community—and your referral sources—to see what (and how) they’re doing. It’s also a time to educate others about what you’re doing.

Where can we go to find additional information on what was discussed during the April 16 webinar?

• SBA affiliation rules guidance material
• Lowenstein Sandler: SBA Paycheck Protection Program
• DLA Piper publication on equity-backed company eligibility
• Foley Lardner publication on applying for a CARES loan
• SBA resource on applying for EIDL loans
• Department of Labor website
• OCR risk assessment tool
• WebPT Google my Business blog post
• WebPT HIPAA risk assessment blog posts
• OSHA guidance on preparing workplaces for COVID-19

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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