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Social Distancing for Rehab Therapists
Leveraging Part-B In-Home Care and Telehealth in Your COVID-19 Response
Recorded Thursday, March 26, 2020 | 2:00PM EST
In light of the recent COVID-19 pandemic, the CDC has recommended ‘social distancing’ as a key tactic to help reduce the spread of the virus. In this webinar, our guest speakers will discuss two options to help rehab therapists continue delivering care during COVID-19.
Hilary Forman, PT, Chief Clinical Strategies Officer for HealthPro-Heritage, a leading consulting and therapy management firm, will share best practices for effectively and safely delivering care through Part-B in-home care. Additionally, consultant Rick Gawenda, PT, President of Gawenda Seminars & Consulting, will discuss telehealth legislation now in effect, which supports the practice of ‘social distancing’ while continuing to deliver necessary outpatient rehab care.
Included in the webinar are details related to:
COVID-19 pandemic and CDC recommendations Risks associated with traditional therapy ‘clinic’ settings during COVID-19 Benefits and best practices associated with delivery of Part-B in-home care Telehealth legislation and application for rehab therapists
The continuation of outpatient rehab care plans during this unprecedented time requires careful thought as to how we adhere to new recommendations while providing the quality of care traditionally delivered in public locations such as outpatient clinics and gyms. This webinar is designed to help you as you seek ways to adapt your care delivery in today's new environment.
Resources:
Gawenda Seminars Website
Healthpro Heritage Website
Rick Gawenda Twitter
Hilary Foreman LinkedIn
For more information on Hilary:
Hilary is an experienced, sought-after health care reform expert with a dynamic approach to advising providers within the post-acute care industry. As a solutions-oriented leader and consultant, she meets the challenges of a rapidly changing health care environment with innovative clinical and financial strategies. With more than 15 years of experience in rehab management, Hilary has worked with hundreds of clients to optimize marketplace strategy, clinical program development, and compliance integrity.
Hilary has presented at several association meetings to share up-todate information and insights as well as her thought- provoking approach to meeting the challenges of health care reform initiatives.
She has established a reputation for facilitating meaningful partnerships between post-acute care (PAC) providers and upstream and downstream cohorts. Hilary’s philosophy encourages open collaboration, proactive communication, and honest dialogue regarding outcomes, safe care transitions, and financial opportunities/pitfalls.
With a keen sense of humor and a no-nonsense approach to solving problems, Hilary has the ability to assist groups in thinking strategically, challenge the status quo, and ultimately succeed in leveraging positive outcomes.
For more information on Rick:
Mr. Gawenda has presented nationally since 2004 and currently presents approximately 100 dates per year around the United States.
He has provided valuable education and consulting to hospitals, private practices, skilled nursing facilities, and rehabilitation agencies in the areas of CPT coding, ICD-10 coding, billing, documentation compliance, revenue enhancement, practice management, and denial management as they relate to outpatient therapy services.
Read the full transcript below:
Tannus Quatre (00:00:02):
Welcome everyone. My name is Tannus Quatre and today I'll be kicking us off with our webinar on social distancing for rehab therapists. Before getting into our topic I'd like to take a moment to acknowledge and appreciate each of you that are on the call today, as well as the teams that you work with to serve patients in your communities. As a physical therapist myself and as part of an organization that proudly serves rehab therapists, this is a really heart wrenching time as we watched this coronavirus pandemic unfold and impact lives across the world, including the interruption of the care that you provide to your communities. As part of our effort to help rehab professionals continue to deliver care in your communities during a time of putting my hands in quotes here, social distancing and sheltering in place, phrases that are new to us, we've assembled a team to present for you two business models today, part B in home care and e-visits.
Tannus Quatre (00:01:03):
And we hope that these will facilitate the continuation of the care that you provide while helping your patients and your staff adhere to guidelines that require that during this time we limit our physical exposure to one another. We've got an amazing speaker lineup for you today. Starting off with Rick Gawenda, physical therapist, compliance and billing expert and president of Gawenda seminars. Rick's going to help us understand some recently expanded legislation regarding telehealth and e-visits for rehab therapists. We have Hilary Foreman, physical therapist and chief clinical strategies officer with HealthPRO heritage. Hillary is going to walk us through health pros, part B in home rehab model and how this model is uniquely positioned to help protect her patients and her team during a time of social distancing. And we have Sheila Cougras, registered nurse and director of compliance at net health, who together with Sarah Irey, also a physical therapist will be setting the stage for us today by introducing us to COVID 19 and considerations that impact us as rehab professionals.
Tannus Quatre (00:02:12):
Now, today's webinar represents our best efforts to help rehab therapists adapt to a very unique circumstance. We're working right alongside you to adjust and learn as things change and I know for all of us things are changing hour by hour at this point. So in our webinar today we'll be sharing some information that is both fairly broad in nature and then we're going to be zooming in to discuss details that are really pretty technical. So we hope that the information will help you stimulate thoughts and ideas that you can use to continue care for your customers, but please do know that the information is changing rapidly and you're going to need to verify if and how this information applies to your particular business. Now finally for me on a housekeeping note, we're going to be pretty fluid with this webinar today and we're going to take the time needed to cover the information that we have planned as well as time for Q and A at the end.
Tannus Quatre (00:03:06):
If you have questions that come up during the presentation, please use the Q and A function that you'll find on your desktop or your phone and we'll get to as many of your questions as we can. At the end of the webinar, we have about a thousand attendees on the call today, so we probably won't be able to get through all questions. So we'll be providing our contact information following the webinar so you can reach out to us for followup if and where that that is needed for you and for those that cannot attend, that may be within your organization or colleagues that you'd like to have attend this webinar after the live version. We will be sharing a recording following the live presentation today, so expect that in your inbox. So with that, I'm going to hand it over to Sheila Cougrass and Sarah Irie to introduce us to COVI- 19 and clinical considerations that apply to rehab therapists.
Sheila Cougras (00:04:00):
Thank you, Tannus. As Tannus mentioned, I'm a registered nurse and a certified wound care nurse that is certified in healthcare compliance. I have been at net health for the past 12 years and serve as the compliance subject matter expert for our products. But before I even get started, I really sincerely want to thank all of you on the front lines who are caring for our patients and communities. What you're doing is really, really appreciated and very much noticed throughout the world. I'm going to also first state that we recognize that all of you are being inundated with a lot of information for COVID-19 that's coming in through, you know, firehoses a lot of information and it only seems so appropriate though that we open with a high level of information we're receiving every day from the CDC to other regulatory and professional agencies across the country. It's also important to note the information is being updated every minute. Even as we speak. I'm reading and learning that new regulations and legislation is introduced at us at a startling pace. We already have over 500 bills and 250 regulations that have been introduced and proposed across the States and the use of the executive order has skyrocketed.
Sheila Cougras (00:05:17):
So we also recognize that this information varies for all of you. Depending on where you provide services, you may be in a home health, you may be in a SNF, acute hospital, private practices, assisted living facilities and with that said you may have a lot of variations with your facility and local policies and federal guidelines. So we want to keep that in mind. As we know, corona virus has been around for a long time. It is a group of related viruses such as SARS that causes disease in humans, in animals, the world health organization, they recently identify COVID-19 is a new virus group, Corona virus which typically respiratory illnesses and most will recover as we know without special treatment. As we've heard, it mostly impacts our elderly population and those that have specific underlying conditions or immunocompromised. We are also hearing about many of the treatments that are off label that are now being made available being introduced today for treatment. But currently there is no vaccinations and treatments are just now starting to be introduced off-label. It is active in all 50 States and I guess it's also active within our surrounding four jurisdictions of our country. And the last we seen reported I know that this is obviously probably updated since, but the last reported by the CDC is 27 are reporting community spread.
Sheila Cougras (00:06:46):
We are hearing that it is also being noted by the new England journal of medicine that COVID-19 is also stable in aerosols and on surfaces that can last from several hours to several days. So we want to keep that in mind when a person sneezes or coughs without proper coverage into their elbow or their sleeve, it creates a bubble of air that contains the virus. It could be suspended for hours and so with that said, if someone walks through that area an hour later, they could potentially pick up the virus.
Sheila Cougras (00:07:23):
So this slide is not only to share with you common recommendations from CDC and the world health organization, but also think about setting up competencies for your staff and educating your patients. We obviously want to maintain that good hand hygiene as being occurring washing for at least 20 seconds with soap and water and hand sanitizer with at least 60% alcohol reasoning is because those soaps we use contains surfactins which neutralizer removes the germs from the pathogens such as COVID-19 that has a crown like structure and outer membrane made of lipid molecules and protein that is then runs down the drain. Do not touch your face. We hear that a lot with unwashed hands is specifically your eyes, your nose in your mouth where there's much entry into your system. Where if face mask, if indicated by your facility policy protocols, we know there's a lot of uncertainty in this area due to the limitation of supplies.
Sheila Cougras (00:08:21):
So please check how and when you are to utilize face mask and the type of mask you should be wearing Disinfect your common touched surface areas. Often whether it be tables or knobs, countertops, desk, phones, keyboards in any other equipment that has commonly touched you. It's also helpful if you increase ventilation by opening windows or adjusting the air conditioning and we also want you to limit food sharing, stay home if you're feeling ill or have an ill family member and most importantly is you're going to hear threaded throughout this presentation and as Tannus mentioned is social distancing maintaining a safe distance three to six feet between you and others. It's so important given how this virus is transmitted. Sarah will speak to this further but before I hand it off to her, I want to share that a I have been listening to other professional organizations speak about ideas and best practices they're sharing.
Sheila Cougras (00:09:14):
I was on a call a couple of days ago with American hospital association in CMS with Sima Burma where she was encouraging the physicians to share ideas. Some are setting up tents outside of their offices to do the screening conducted prior to allowing the patients or staff to enter the building. Some are calling the patients prior to their appointments and asking a series of questions provided by the CDC to triage those patients. And many of you are hearing utilizing telemedicine and you will hear more from our other panel speakers on that topic. Additionally, I heard that in HPCO, which is a hospice professional organization just yesterday. They're getting so creative that they're providing care through windows and standing outside of the patient's home and looking at the patient through the window and addressing the needs with the caregiver at the door. So as we know, this is the time to really get creative and treat your patients safely as much as you can.
Sarah Irey (00:10:07):
Thanks for that great information Sheila. Before we start, I'll let you know a little bit about me. I'm a clinical liaison for net health, but my background is as a physical therapist with nearly 20 years of experience working in various settings including private practice, hospital outpatient and acute care and skilled nursing facilities. I'm lucky enough to use my clinical experience here at net health, but I do some clinical work still now and then. Let's continue to build on what you learned from Sheila. An important part of social distancing includes being able to identify patients and staff who have COVID-19 or who may be a risk of carrying or contracting the disease. Many facilities are now using screening protocols, as Sheila mentioned, to identify these individuals. If you're part of a larger organization, check your organization protocols to determine the process for screening patients and staff and know how to refer them for additional testing if they're possibly infected.
Sarah Irey (00:11:12):
If you don't have a formal protocol, you might want to consider creating one using sources from the CDC website as well as checking with your state. The CDC outlined some recommendations such as using your clinical judgment. Clinicians should use their judgment to determine if a patient has signs and symptoms of COVID-19 and should be tested so the signs and symptoms that you've heard about include fever, cough, and difficulty breathing. Other risk factors are having contact with someone who has or is suspected to have COVID-19 or pneumonia of an unknown cause within the last 14 days. Someone who's recently traveled outside of the United States or in an effected area and someone who has residents in an area with community spread of COVID-19. Like Sheila mentioned, your screening can actually begin before your patients arrive at your clinic. When you're making appointment reminder calls.
Sarah Irey (00:12:09):
You might want to consider asking screening questions and making recommendations for exposure risks in mildly ill or high risk patients to stay home per social distancing guidelines. We realized that many of you may still need to see patients in a clinical setting. So let's consider some ways to keep you and your patients safe while keeping social distancing in mind no matter where you treat your patients. First, follow the screening guidelines we just discussed to decrease your risk in your clinic. You also may want to ask patients to wash their hands prior to starting the treatment session and after you could even maybe consider having them stand on one foot to practice balance while they wash if it's safe, right? Wash your hands as well. Always follow standard precautions and use PPE per your organizational protocols. Be mindful to follow the six foot social distancing guideline in the waiting area and your treatment space.
Sarah Irey (00:13:09):
So you might need to modify your waiting area seating setup or your schedulings practices to support this model. Maybe use private treatment rooms for patient visits instead of the gym area. Avoid group and concurrent therapy treatment and consider treating patients in their rooms if they reside in a skilled nursing or assisted living facility. Also think about if you can change treatment and treatment plans to decrease physical contact with your patients, but still provide quality care. Examples of this might include instruction and self mobilization techniques instead of manual adjustments or mobilization or instructing the patient in use of tools for soft tissue mobilization such as foam rollers and trigger point release balls rather than direct therapist to patient touch. Also consider keeping your patients with one provider per visit instead of sharing care to decrease contact. So you may need to change your scheduling and staffing practices there. Finally consider educating patients on alternative treatment options such as part B in home rehab and eVisits. So let's learn more about part B in home rehab with Hilary foreman from HealthPRO heritage.
Hilary Foreman (00:14:22):
Thank you so much Sarah. And as Sarah said, my name is Hilary foreman. I am the chief clinical strategy officer at HealthPRO heritage. I am a PT by background and I've been lucky enough to be with HealthPRO for about 18 years now. I'm moving from operations into our clinical role. I have the honor of being in charge of our clinical and consulting business lines over our rehab services that span across the post-acute continuum. So as Sarah said, I wanted to talk to you about our first business model, which is part B in home rehab. Though HealthPRO heritage did not start this model in light of the current COVID-19 situation, it now more than ever in this era of social distancing has become one of our standards as it makes more sense as a consideration. This model can be used by both rehab companies and home health agencies to better meet the needs of some of our seniors.
Hilary Foreman (00:15:19):
So let's start with what is part B in home rehab. Very simply, it's the concept of the traditional outpatient therapy model being provided in a patient's home as opposed to a free standing clinic or the gym of a senior living community. Services still remain covered under Medicare part B. They may also be covered by managed B or some commercial payers as well. By being able to deliver this service in a patient's home, it provides a lot less anxiety for a patient and a much happier person. Patients in this scenario are not home bound, but due to other circumstances prefer to stay in their home, whether it be convenience, safety, or cost. One caveat to this model is that because patients aren't home bound, they can also not be receiving any part a benefits as this is a part B benefits. So those two insurances do have to be separated.
Hilary Foreman (00:16:27):
So why would we do part B in the home first? As I said, it would be convenience of care. According to some recent AARP statistics, over 89% of patients over 50 years old would prefer to receive these type of services in their home for many of their own reasons, but now in the era of social distancing, this can be a more protected setting. This can also be a great solution for protecting some of our most vulnerable patients, but continue to provide those essential rehab services with reducing the risk of illness or injury to those patients.
Hilary Foreman (00:17:14):
As we continue down the path of why we would do this, one of the other has to do with a lot of the regulations going into place. Many of us are looking to expand our referral base, so whether you're a rehab company or a home health agency, chances are you're looking for different partnerships in your community. In light of changes with PDPM on the skilled side and PDGM on the home health side and changes and just the level of competition in many markets, you may be looking at different ways to partner with other people in your community. Whether you're looking to expand with physician services, many outpatients we think of as partnering with orthopedic physicians. We all know that orthopedic physicians tend to use their own clinics or hospital based rehab settings. In this model. Healthpro heritage chose to partner more with primary care physician groups in order to better expand into the community.
Hilary Foreman (00:18:17):
These primary care physician groups, we're community-based or we're already partnering with many of the senior living and assisted living communities in the areas. This paired nicely with their house calls programs, so we just like the physicians would start making house calls. It became a very good word of mouth referral source for us as well as a network between different senior living communities who wanted to partner their therapy across all their levels of care. So having therapists provide services through the home health agency as well as part B in the home. This helped the therapist become a standard part of the community, whether it be on that campus or in the greater community. Another reason you may consider why we would do part B in the home is just to reduce overhead for providers. This model reduces costs associated with brick and mortar clinics and the costs associated with keeping those running or even dedicating space within an assisted living or independent living community for patients.
Hilary Foreman (00:19:27):
This reduces a lot of their anxiety. It may also save time, money and effort for them traveling, worrying about parking and worrying about keeping all their appointments straight by having us go to them. It is a lot of their worry. And lastly, in order to follow any of the trends in healthcare, we all have to change, diversify and grow. Most importantly, meeting people where they are and where they want to be. Chances are that is going to be in their homes. We wanted to be able to offer more alternatives to where they could get the essential rehab they needed. Now again, in the era of social distancing, we were able to meet them in their homes and it was a great new business model for us as well. So killing two birds with one stone, but now as Sheila shared in the era of COVID-19 we did have to take some additional rehab considerations.
Hilary Foreman (00:20:28):
So we at HealthPRO heritage, decided to do a few things before we ever entered someone's home. First, we implemented a very strict policy of staff monitoring where staff self-monitor temperature checks twice a day, attest to whether or not they have any signs or symptoms. We even instituted a smell check. Some of the more recent literature indicated that people ahead of coming down with the symptoms of COVID-19 had actually lost their sense of smell. We also reviewed contact or exposure history, looking at what would be a low or high risk exposure and choosing whether or not therapists would see some of our most immunocompromised patients in their homes or not. We also instituted patient screening calls as Sarah suggested, making sure that we not only asked about the patients themselves, but anyone else that might be in the home at the time of the visit.
Hilary Foreman (00:21:28):
So many of our seniors have their spouses or older children home with them. They may be caregivers for grandchildren, so we did want to make sure that in addition to asking just about the patient, we knew about them as well. We did follow the CDC guidelines on what we could and couldn't ask, but it also helped us explain to our patients what infection control steps we would take prior to coming into their home. We did focus a lot on our staff and making sure that they understood what those infection control steps were. We did add additional steps in light of the current situation, especially when it came to clean bag and equipment technique. We wanted to take extra care of everything we did or did not take into a patient's house and how we were able to take care of that.
Hilary Foreman (00:22:19):
The other issue we have run into, and I'm sure many of you on the call have as well, is the availability of PPE. In cases where we do have low risk or high risk situations, patients still may have required care and we did have to make sure that people had the correct availability of PPE and understood proper use and retirement of that PPE well in the home. We did ask our therapists to continue to maintain social distancing rules from others in the house, in the apartment or in that senior living community. We did see that there was a lot of opportunity there as well. We were able to be another set of eyes for our seniors in the community or in the senior living community. Looking for other needs they may have. Being able to address things such as medication that may need to be delivered, additional signs and symptoms of other issues outside of COVID-19 that may increase a patient's risk of rehospitalization and we were able to work better with our senior living communities in that way.
Hilary Foreman (00:23:29):
So now that you know a little bit about our model and now it's time to look to see if this is the right model for you as you're possibly considering this as part of your growth and diversification strategies. There are a few things both pro and con you should consider if you are a home health agency, there are differences between billing part a and part B. You still do have a homebound requirement. You have to look at what those billing differences as well as what the different therapy documentation rules might be because this is part B and the home. It does follow traditional part B documentation and billing guidelines with all of the modifiers attached. A benefit to this is for the home health agency. Being able to provide additional rehab services after perhaps nursing services have ceased as a need, gives you the ability to divert those critical nursing visits to more high risk patients that may be elsewhere in the community. In this case, rehab would focus mostly on safety in the home and basic ADLs. If you're a rehab company, there's a little bit more to consider here. We were able to, in different parts of the country operate this model either under a group practice or a rehab agency. These both models have specific regulations by state that vary and we did need to look into all of those different rules and regulations and setting up the different practices and different locations.
Hilary Foreman (00:25:05):
The other challenge we had was looking at our therapists and their skill sets. This is a unique model because you do blend the skillsets of a home health therapist by being in the home, being more innovative and looking at what you have available to you in a home to provide therapy while mixing it with true outpatient skills. So looking at our therapists being able to work at the top of their license and looking at things from medication management all the way down to manual therapy. As Sarah shared, we did have to make some alterations in the care we've provided recently in light of some of our infection control procedures. But to our patients still receiving that essential therapy was still most beneficial in some cases in making this decision, you may have to actually look for additional consulting services in your area to help you either set up this program or work through the regulations. I hope this gave you a good overview of this possible new business model. And now to talk about our second alternative business model, I pass to our next speaker, Rick Gwenda.
Rick Gawenda (00:26:16):
Thank you very much. My name is Rick Gawenda. I am a physical therapist. My wife, I and another business partner do own two clinics here in Southern California. And then also for the past 17 years I have been a national speaker and national consultant in outpatient physical occupational speech therapy as relates to documentation, CPT coding, diagnosis, coding, payment reimbursement compliance. And all stuff nobody really likes to talk about. So with that, we're going to talk today about telehealth and e-visits. As we go to the next slide. This information I'm going to share with you is current as of 2:00 PM Eastern time today. Cause obviously I used to say things, you know, change weekly or monthly things are changing hourly. We're seeing many state governors mandate insurance plans in their state cover telehealth. We're seeing insurance companies doing this on their own saying they're adding PT OT SLP as telehealth providers. And we are waiting patiently for updates from these centers for Medicare and Medicaid services. So again, everything is current as I speak today. Most likely things would change either tomorrow or early next week. We are in the Medicare program as well as maybe other insurances in many States.
Rick Gawenda (00:27:47):
So speaking with the Medicare program first, so CMS, the centers for Medicare and Medicaid services issued a document over a week ago and they talk about three types of virtual services that you see here on this slide. And the commom mistake I'm hearing people make is they're using the terms eVisits and Telehealth interchangeably synonymously, the same as, and they're not the same. They're completely different. So again, three types of virtual services per the Medicare program right now. Medicare telehealth visits, which we're going to give you the current status of that coming up, virtual check-ins, which were not apply right now to PTs, OTs and or SLPs. And then we're going to talk about eVisits that will apply to PTs, OTs and SLPs.
Rick Gawenda (00:28:45):
So as I speak to you today, now about, I believe it's around 2:30 East coast time, March 26, the Medicare program still does not pay for tele health services for outpatient, physical, occupational and or speech therapy services. They consider this a non-covered service because the Medicare program does not pay for these services for therapy and they consider it non-covered. You right now today can provide tele health services to your Medicare part B beneficiaries and charge them your cash rate for the telehealth services. And an ABN, an advanced beneficiary notice of non-coverage would not be required to be issued to the Medicare beneficiary. You can issue a voluntary ABN to the Medicare beneficiary if you want to and I do recommend you do that but it's not mandated. You issue an ABN to the Medicare beneficiary and the reason why it's not required is an ABN is only issued when normally the services are covered by the Medicare program, but under the circumstance you think Medicare is not going to pay or since right now today, March 26 telehealth services provided by PT OT SLPs or statuary, non-covered and ABN would not be required.
Rick Gawenda (00:30:24):
Also, if you are familiar with the ABN form in section G there's three boxes and the patient's supposed to select one of those three options in section G since your issue in a voluntary ABN, you are not going to ask the patient to choose an option. The patient does not need to sign and date the ABN because you're not going to be submitting the claim to the Medicare program. So people haven't been asking me, well, Rick, what CPT codes do we bill to Medicare for telehealth? You're not going as I speak today, you will not submit a claim to Medicare if you are providing telehealth services for outpatient PT, OT SLP to a Medicare part B beneficiary because it's statutorily non-covered. And since these services are non-covered, the mandatory claim submission is not required. Now I will say there is a barrel that we expect the house to vote on tomorrow called the creating opportunities now for necessary and effective care technologies.
Rick Gawenda (00:31:32):
The acronym is connect, C O N N E C T act, the connect act and in section three seven zero three of that bill. If it gets passed by the house passed by the Senate, everything stays in president Trump signs it. It's going to broaden the authority of the secretary of health and human services to wave tele-health requirements as they currently are. So we're hoping that once the house is supposed to take a voice vote on that sometime tomorrow followed them by the Senate. My opinion only, it should pass pretty easily. Hopefully the president signs it, then hopefully then the secretary of health and human services would then waive the current restrictions house for Medicare beneficiaries and allow PTs, OTs and SLPs divide those services and build the Medicare program for that. Also, as we speak today in the office of management and budget, there is an interim final rule regarding COVID-19 and some updates in that interim.
Rick Gawenda (00:32:43):
Final rule. Unfortunately we have no clue what's in that interim final rule. It could be some things way too. What I'm still going to talk about here today about E-visits could be about tele-health, could be about easing restrictions and supervision, requirements of assistance, could talk about certifications recertifications it could have nothing about therapy and you know, we don't know again, it's still in the office of management budget to OMB. Hopefully it leaves there either later today or tomorrow and then gets published in the federal register. But that's why I add that disclaimer. We expect things to change with the Medicare program here shortly. We expect clarification to come out from CMS on some things we're talking about right now during today's presentation.
Rick Gawenda (00:33:38):
Let's talk about now e-visits. So again, e-visits and tele-health are not the same. The two are completely different things. So CMS did come out over a week ago and say that they would pay for eVisits provided by physical therapists, occupational therapists and speech language pathologists. I cannot stress enough that top bullet point, they must be initiated by the patient for each E visit, which means the patient needs to reach out to you, the provider, either via a phone call, via an email request. In this E visit. Now CMS did clarify you, the provider of therapy services can educate the beneficiary on the availability of this service. So you can send out an email to your current established patients about the option for ae-visit and all of that. So you can quote I guess like a better word, advertise this service. However the patient must initiate this visit now, but we don't know.
Rick Gawenda (00:34:42):
Here's this third bullet point says patient must be an established patient with the provider who is conducting the visit. And what we're hoping to get soon from CMS is clarification and the definition of an established patient. Because these G codes I'm going to talk about in a moment on the next slide, they actually are brand new this year just came out January 1st of 2020 and to be honest with you, they were not designed for what CMS is allowing us to use them for right now. This is not the purpose of these codes. Now these codes are kind of a, a knockoff, kind of a shoot off of the nine eight, nine seven zero CPT code nine eight nine seven one CPT code nine eight nine seven two CPT codes that are used by physicians for evaluation and management services for these visits done through an online patient portal.
Rick Gawenda (00:35:45):
Now when you look at the physicians and the definition of established patient for a position, this is somebody that has, you know, maybe seen that physician within the last three years. We don't know how CMS is using that definition of established as it pertains to PT, OT, SLP. I'll be honest, it could be established patient as in this is a patient that you were currently seeing for therapy services and now they can't come into your clinic right now you've shut down your clinic, you want to do an visit. Is that what they mean by established patient? Could established patient mean this is the patient you've seen sometime in the past three months, the past six months. Are they going to have to go back, you know, quotes three years like they do physicians. We don't know the answer right now. What we do know though is if you're going to do an evisit any Medicare beneficiary that that patient could not have been seen by you for a physical visit within the previous seven days for the same condition.
Rick Gawenda (00:36:48):
And then once you do this evisit they're not coming in to see you within seven days for that problem. Now, CMS does say that you must use an online patient portal. And I'm giving you the definition of an online patient portal by the office of the national coordinator for health information, which is a secure online website that gives patients can be it 24 hour access to personal health information from anywhere with an internet connection. And there's the URL link for you cause people, you know, if you read the CMS information that's come out, you know, you saw, CMS mentioned that they're the lax scene, they're kind of easing the HIPAA rules and regulations. You know, you saw CMS mentioned Skype and mentioned FaceTime, they mentioned Skype and FaceTimes for tele health services, not for E visits. So right now again we're trying to seek clarification from CMS and boy, can you do a phone call, can you use FaceTime, can you use Skype before we get that clarification.
Rick Gawenda (00:37:57):
I've got to, you know, talk here and say you have to use an online patient portal. And again, you can go on the worldwide web, go to any search and you want to go to, I just use Google and type in a search box, you know, types of online patient portals. You know, what is an online patient portal? You know, I know my physician, and again, I'm not endorsing this product. My physician uses the call it, it's called charm, C, H, A, R, M, all capital letters where she can send me my test results. You know, my lab results. She can give me updates on my medications. You know, I create an account, I log in, I see my test results, I see her email, I can respond to her, she gets notification and with things like that. But again, it must be initiated by the patient for each E visit.
Rick Gawenda (00:38:54):
Next slide. So here are the three G codes, G 2061 G 2062 G 2063 and I cannot stress enough those words that are underlined, assessment and management, and then shooting the tib time during the seven days. So let's talk about what are the seven days. When is day one? When is day seven so here's my example. Let’s say on Monday, March 23rd the patient reaches out to you either via a phone call or an email requests in any visit. You don't respond to them until March 25th. March 25th is going to now be day one, which means six days later that's going to end that seven day period. So, so say you know, March 23rd the patient's sent you an email requesting any visit and they had some questions for you maybe about their home exercise program or should I use ice or should I use heat or how many times do you want me to do my exercises a day?
Rick Gawenda (00:40:03):
Things like that. You respond to them on March 25th and as I say, I'm going to make math easy here today. You spend five minutes typing out the instructions, answering their questions. You send that to them on March 25th on March 27th the patient responds, requested another e-visit with additional questions on Friday, March 27th and you spend another five minutes, you know, answering their questions, whatever that may be, send it back to them on Tuesday. March 31st patient requests another E-visit with additional clarification. They want some information from you. You spent another five minutes on March 31st answering their questions via email or via that secure online patient portal. You send it back to them. That's, and that's it. There's no more other e-visits within that seven day period. So I kept math simple. So you did three separate eVisits spent five minutes each time answering their questions via email, sending it back to them.
Rick Gawenda (00:41:12):
When you add up five plus five plus five that is 15 minutes, that's going to fall between 11 to 20 minutes. So on that last day to service, during that seven day period on March 31st you're going to bill one unit of G two zero six two because the QM to time during that seven day period was 15 minutes. And the question I know you want to ask me is, Rick, can we do more than one seven day period? You know, can I bill G 2060 to say from March 25th to March 31st but that from say April 3rd to April 9th, I spend 27 minutes. Can I do G two zero six three and ms dancer, you hate for me today, we don't know. We're seeking clarification from CMS because again, these codes were not developed for this purpose. We did not know COVID 19 epedemic was coming when these codes became effective January one of 2020. So we're not sure if CMS as well as other insurance companies are going to allow us to build these G codes for more than one seven day period. Now you see it says underlying assessment and management as the go to the next slide.
Rick Gawenda (00:42:33):
People always want to know what is a qualified healthcare professional. And this definition comes straight from the American medical association. So if you have a CPT book, you know, especially or more current one, but if you have like a 2018 2019 2020 CPT books at the beginning of the CPT book, a Roman numeral number of pages explains how the book works, where the AMA provides this definition of a qualified healthcare professional. And in really the key is the words or the sentence who performs a professional service within his, her scope of practice in independently reports that professional service. Well, as a physical therapist, an occupational therapist, a speech language pathologist, you meet this definition because in a private practice you enroll with Medicare, you enroll with other insurance companies, you get an NPI number, you can report the CPT codes independently of anybody else that people was asked for.
Rick Gawenda (00:43:35):
Rick, what about a physical therapist assistant or an occupational therapy assistant? Can they report these G codes you just spoke on was to go to the next slide. You can now see the definition of a clinical staff per the American medical association. And you see in that first bullet point is a person who works under the supervision that'd be physician or other qualified healthcare professional that goes on to say, but who does not individually report that professional service. So that would include a physical therapist assistant and an occupational therapy assistant. So right now it's my interpretation. I know APTA interpretation that PT assistants, OT assistants, you know, can't provide the evisit. And also if you get a definition, if you go back to two sides from replays, you know it says assessment and management and really who's assessing the patient, who's managing and changing what's going on with the patient. And that's really within the scope of practice of the therapist, not the assistant. Now again, we're hoping to be CMS allows assistants do these G codes. We don't know waiting for clarification, but right now I don't feel comfortable saying they can do it based on the definition of a qualified healthcare professional as well as the words assessment and management. Because that is done by the therapist, not the assistant.
Rick Gawenda (00:45:09):
Now how about modifiers? Now, CMS did say if you are submitting a claim on a 1500 claim form and if your Smith claims on a 1500 claim from you are a private practice, the Medicare program did say to attach this CR modifier to the applicable G code. If you are a non private practice, you submit claims you be zero for claim form. You would not only attach the C R modifier to the G code but you also need as a condition code the R. So again that R is not a modifier that R is a condition code. Now we are hearing issues and concerns from households around the country that these G codes can't be submitted, can't be built on the UBS or four claim form. We are still waiting for clarification from CMS on this. You know, can hospitals, can facilities that submit claims any UBS four claim form? Can they bill the G codes? A part of me thinks yes, I'll be honest. Part of me thinks no because again, these G codes, a kind of a knockoff of the nine eight nine seven zero (989) 719-8972 CPT codes which are really the physician codes and typically physicians are only been at any 1500 claim form. But again, we are just waiting for clarification with CMS as well as other insurance companies. Can non private practices bill these G codes and get paid by that insurance company.
Rick Gawenda (00:46:56):
Now, documentation for an evisit extremely important that at minimum each E visit you do must have the following documentation. You must document that the patient initiated and or requested the visit. You must document the patient consented to the visit and then you must document these services, the education, the training that you provided during that e-visit. So an example I gave where you did visits one on March 25th one on March 27th one on March 31st you would have a note for each date of service that will contain at minimum these three bullet points, but the billing would not occur to a date service March 31st
Rick Gawenda (00:47:51):
Now let's talk about telehealth and tri care. You know Tri-Care, believe it or not does cover house services and they've done so since July 26 2017 and that top moral point, that sentence is right out of the tri care manual that they cover telehealth services if these services are otherwise covered. Tri care benefits, well since Tri-Care covers outpatient PT, OT, SLP services, this means that they would cover telehealth services for PT, OT and or SLP services and nicely my Tri-Care is they allow payment for telehealth provided both asynchronous and synchronous. Now non-Medicare, it's the answer you hate. You've got to go check with every insurance company. And when I say every insurance company, we estimate they're over 6,000 insurance companies in the United States. Whether they cover telehealth, it's all over the board. If they do cover tele-health, which CPT code or CPT codes they allow or want to see all over the board, which modifier or modifiers do they want and every CPT code all over the board.
Rick Gawenda (00:49:17):
You know, this is changing hourly because we're seeing many state governors issue declarations, issue orders mandating all insurance plans in their state that are overseen by their insurance commission, you know, cover tele-health. That's great. You know, we've seen some insurance companies like Michigan blue cross California blue shield of blue cross blue shield of North Carolina do this voluntarily where they now expanded telehealth for PT, OT SLP on a temporary basis. And again, the CPT codes, IMC and I'll all over the board which ones they want. Just, you know, when to kind of maybe give you some guidance here. The most common codes I'm seeing be and allowed for tele-health a PT and OT are nine seven one one zero 30 exercise nine seven one one two neuro re ed nine seven five three zero safety activities, nine seven five three five self care, home management and for speech is nine two five zero seven.
Rick Gawenda (00:50:30):
The treatment of speech, language, voice communication, Archway processing disorder. You know, don't try billing ultrasound for through telehealth. A manual therapy would also be a no through tele health cause your hands have to be on the patient. The other thing to ask when you check with these insurance companies is are they covering tele-health for only patients that were already established. You know, you've already seen them for therapy. There's already an active, you know, plan of care going on and now they can't come to your clinic. Or are they also covering tele-health for new patients as well? That's something you're going to want to check. If you're in a private practice setting they usually want to see for the place of service code for telehealth be a zero two. So again, extremely important to check with each insurance company and their coverage of telehealth services.
Rick Gawenda (00:51:34):
You know, how do you keep up to date with all this, you know, number one, stay current with your national associations. APTA. Also check your state associations website. You know, most of them now have a dedicated page for COVID-19 many of them are, you know, doing daily updates and information that they find out. You know, why not go bookmark your top four or five, six insurance companies that you deal with in your practice. You know, and again, go to Google and search box. Just type in for example, Georgia Medicaid provider page, tri West provider page, Nebraska blue cross blue shield provider page. In those last two words, stay the same provider page. That's what you want to get to on insurance company's website to provider page. And most of them now have a dedicated COVID-19 page and they've got dedicated page for, you know, quote, telemedicine, tele rehab, tele-health and those three terms don't all mean the same thing we've got. I think we're using them synonymously right now and I'm okay with that. But they are different. But get on those payers websites. If you're not on social media, get on social media, get on Twitter, get on Facebook. Many of us are putting out tons of information hourly on all of the changes.
Rick Gawenda (00:53:02):
Not to get too excited about these G codes. Just so you know, the Medicare program has about 112 different payment localities across the United States on just using each choice, Michigan. And you see the approximate payment amounts here. And before we go to get questions. And one thing I really want to say about tele-health. You know, normally if you're gonna start tele-health in your practice in your organization, it's usually about a four, five, six, seven, eight weeks start up. Yeah, I know a lot of people are trying to start tele-health in 24 hours and 48 hours. Be careful, you know, even though CMS has eased the HIPAA enforcement doesn't mean you can be careless. Just because CMS has eased HIPAA does not mean other insurance companies may not come after you. You know, you got to make sure you have your policies and procedures in place.
Rick Gawenda (00:53:52):
They're going to do telehealth, you know, have you updated your consent forms to include telehealth services, have you gotten your consent forms to your patients for them to sign, you know, how you document in the medical record and keep a track of, is the patient consenting to telehealth, have they consented to be videoed and have that recorded and saved in case they want to look back at it? You know what happens if you are doing a telehealth visit and you're doing it with Tannus and you see Tannus all of a sudden he grabs his chest, becomes short of breath, he falls off his chair, there's an emergency situation. You know, what's your policy? What's your procedure to address those kinds of things because you could have a liability. So again, you need to check with a healthcare attorney to make sure you got the proper policies and procedures in place. Because my hope is those of you that initiate tele-health, like right now when the COVID-19 pandemic is done, I'm hoping you're not done with telehealth. I hope you continue to do tele-health into 2021 2022 2023 as I think this is an important aspect of your business growth. Keep in mind, tele-health is not appropriate, not applicable for all of your patients.
Tannus Quatre (00:55:16):
Outstanding. Thank you so much Rick. Hilary, Sheila, Sarah wonderful presentation. We're going to get into some Q and a now and I will go ahead and moderate this portion of the webinar. And while we're doing this, we have our contact information up on the screen. So for those that would like to get in touch with us, if you have further questions or would like to learn more about what each of us and our organizations are doing to help rehab professionals adapt to COVID-19. We want to have this up on the screen. So with that we've got a lot of questions coming in and I know that we're right up against the hour. Like I said before, we're going to be kind of fluid with this, so if you're able to stay on, we're gonna answer as many of these as we can and then anything that we're not able to get to, we'll figure out a way to follow up with you independently afterwards. So I'm gonna start with I'm going to start with one here. For Rick, would encrypted organization based email be considered a secure patient portal for delivering he visits?
Rick Gawenda (00:56:23):
Yeah. Great question. And again, my opinion, my interpretation as it stands right now today is yes, because the email is encrypted, which usually requires a patient, you know, to create a username and a password to then access that encrypted email.
Tannus Quatre (00:56:24):
Perfect. Another one for Rick here. Are these codes billable by home health organizations or just outpatient organizations?
Rick Gawenda (00:56:54):
Well you know, when you say home health, if you're doing quote part B in the home which we believe you can bill the G codes. Again, we're just saying for clarification where if you're talking to home health under say part a under a home health agency plan of care, the G codes would not be applicable to that setting.
Tannus Quatre (00:57:19):
Excellent. Thank you. And we're going rapid fire here with Rick. I've got another one here for you. What POS code should be used for hospital-based outpatient clinics with any commercial insurers? Should it still be zero two or does it need to be different?
Rick Gawenda (00:57:33):
Yeah, great question. And again, if you are a private practice, and again some hospitals you've got offsite clinics that are set up as a private practice and you submit any 1500 claim form if you do in telehealth services, the place of service code would be a zero two. If you are a non private practice, which again could be, you know, as a hospital outpatient department, you know,
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