Home Forums Coronavirus and the private practice

Well, this will be a good forum to post on, because many users will be solo providers or in private practice. Not sure how it has been for others as far as your health department, local hospital or your state CDC, but in Maine it is like I don't exist.

I am sure we all here on the news how poorly the U.S. has responded to this possible pandemic. With new cases and deaths every day, it seems as though it will be an epidemic here. But, most of the news coverage is based on the lack of testing kits. But, this is not nearly the only issue.

A few weeks ago, when there were only a few cases reported but many more expected, I sat back and waited for what I thought would be a coordinated response from our CDC as to what would be expected by my pediatric outpatient setting, what PPE we would need, when would we test, how would we test, etc. It made some sense that there would be centralized testing in clinical settings set up specifically to handle testing, etc. But, I have received ONE email from our hospital saying only one thing. If you are going to send a test here, call us first.

I emailed the Chief of Pediatrics, the CEO of the hospital, the head of the micro lab, the director of the lab, infectious disease. One response. We aren't sure yet, but we can send you some pdfs. So, they did. So, I read them.

No one has talked to us about N95 masks, gowns, goggles or gloves. No one has talked to us about checking the fit of the mask. No one has come over to go over the ideal way to be in a room with someone who meets the criteria of having possible Coronavirus. My guess is the hospital has done all of this with all of their staff and clinics. I am sure that our local FQHC has had the government's CDC advising them. I am sure all of them get this equipment at no cost. All the pediatricians can stand to be out 14 days. I have asked the hospital what I am supposed to do if I am exposed. My reading has stated I can self-monitor and check for fevers.

The state CDC has been absolutely useless. When I asked if they were going to provide information to private practice providers and go over the protocols, she asked what hospital are you affiliated with. I said I am not affiliated with any hospital. And, she says, "Oh, that's a problem. I don't know what answer to give you." Yes, she said, she had no idea.

Then there is the issue of testing kits. From the news, we are woefully deficient in testing kits. But, we have over 100 in stock. Our lab and the CDC can run the test on our Influenza and RSV kits. Although it was a big secret to me. I had to look at that also.

While I have finally located disposable and reusable N95 masks, thank God for Home Depot before that.

Just wondering what everyone else is doing. We have no cases in Maine, so I am seeing tons of normal viruses and Influenza B. We have 60 negative tests done as of today. I have no idea when I am supposed to start testing.

I run a solo internal medicine practice in Florida. We have gotten a lot of emails from the health department. However we have no sample kits yet. And the health department is being very stingy with who they test.

We have some PPE left over from the SARS era. We would like more ear loop masks for coughing patients but our order for 250 masks from Mckesson was cancelled.

I am worried about having to temporarily close office if staff gets sick and there are not enough people to work.

Does anybody have suggestion on which platform to use for temporary virtual visits? Maybe just use the phone?

Yes, the CDC, the state and local governments, the administration lol, the whoe friggin' stupid government who can't even decide how to deal with a cruise ship.

Skype and other forms of communication would make great sense. The news keeps talking about test kits, etc. The country has no idea what the deal is.

Oh, and just now. I received 20 more test kits. We have 70 now.

Today I was bombarded with information. CDC. Hospital. State health department. Mike Pence. A local daffodil farmer. They were great. I am now on:

1. The email they send out with any updates.
2. The weekly conference call to labs, hospitals and other practices that I was left off.
3. Will be getting free N95 masks, gowns, gloves and face shields.
4. Information as to how to test patients.

Travel history to China. That's like saying you road up travelled in a bus from NYC to LA in a bus where everyone else had Influenza A and RSV. Try South Korea, Italy, etc. I would think that once there are four or five confirmed cases in a state especially within 50 miles radius that cough and fever would suffice. Hell we test for RSV in infants six months and younger and Influenza in those with cough, fever and malaise, aches and pains (many diagnosed clinically). Not a lot of deaths in those cohorts. I would say that once there are confirmed cases, it will be hard to talk parents out of a Covid-19 test in their children if they are symptomatic.

Ken,

If you use Updox texting, you should be able to do virtual visits, by HIPAA compliant secure video chat. I had to install a logitech video camera on my computer, but have this option, which I might be using a lot more of soon when the coronavirus reaches Montana.

Bert,

How do you go about getting the free N95 masks, gowns, gloves and face shields?

Hi everyone,

This is mind boggling. About 8 cases in Maryland, all around Baltimore, about the same in Pennsylvania, all eastern Pa/Philadelphia area. No confirmed cases West Virginia. The local college just cancelled classes and closed dorms for the next 2 weeks.

I am really at a loss. What do we do if patients come in coughing? If one staff member tests positive?

Anyone able to predict the future?

Thanks

Gene

Gene,

I have been reading a lot of conversations on Twitter under #COVID2019 and reading docs that are in the Coronavirus zones of dealing with it now and what works and what doesn't, and it is continually evolving.
Right now, screening by nurse, and trying to keep out of office and my first high likely patient hasn't called yet but if so we have to have a negative viral PCR before testing for COVID-19, but I am thinking of gowning up and testing from their vehicle out in parking lot or one designated room in office that we don't use as a regular exam room.
Not sure how to handle positive staff member other than staying at home till cough clears then wait 24 hours before returning, hospitalized patient I think have to have 2 negative RNA tests separated by 24 hours before getting out of isolation ( I think)

The county just north of me now has 5 confirmed cases and 4 of them have no travel history so it is here, community spread.
Guess tomorrow call the dept of health to find out about where testing available, we have been instructed to not send anyone to hospital unless clearly lower resp tract involved and are 'sick'.
Let the fun begin, I like the 'stay in your car and I'll do the swab in the parking lot' technique.

Koby,

You might want to check with your Quest lab rep, we can get the presumptive nasopharyngeal swab RNA test (SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR), up to 20 per doc, we have ordered 50 from Quest, which will be a send out test. But we have to do the collection. Results in 3-4 days from pickup. If positive, then patient referred to City County Health. The whole state of Montana thru City County Health offices only have 200 statewide currently, so hopefully we will be ahead of the game when it moves into our community.
Also it sounds like there will be little if any out of pocket with the Quest test vs the City County Health test (more out of pocket) for patient.

Pretty busy and missed a lot of this stuff. And, what I know will be different than everyone else.

First, just the fact that we have five (and lots more) doctors here that know a helluva lot about medicine and testing. The problem is (and I am not that pissed at CDC for screwing up the kits -- they were moving fast and everyone is human -- OK except president t). The news media and the pundits can talk about not enough test kits and the administration not talking it seriously, but the shame is the federal CDC and the state CDC/state health departments. As I said, I had to pretty much knock down doors.

Whether we have no kits or gowns or anything is one thing, but then every CDC should be mailing, emailing, texting, dropping by and tell what the deal is.

We have been told by the CDC and the hospital lab that we can use the regular RSV/Influenza test kits that I think Jimmie was referring to.

Here's the deal. We haven no "confirmed" cases in Maine. I figure by the time we get one confirmed, there will be 20 that are not confirmed. I am seeing patients in masks and goggles and gowns and gloves. The CDC is sending us 50 masks per week and goggles. They are sending us gowns. We have tons of gloves. The getup works. Getting it off is what is dangerous.

But, I am seeing patients this week. Starting next week, our office will schedule patients and triage them as usual. If they have fever and cough, fairly bad cough, fatigue; they are going to walk-in care or the ED. They can decide to test them there or not. The way I see it hardly anyone is helping me. If one doctor goes down in the ED, there are 20 more to step up. Even if 10 are sick or quarantined. Even if the entire ED closes (patients are screwed), but the hospital can get by without the money. Same with walk-in care. With one doctor, my entire practice is down. I can't afford to lose an MA. The patients or the hospital can yell at me all they want, but unless they are going to me while I am out, then no way. The patients will just be turned away. When they ask why, I will just tell them. We aren't equipped to handle possible coronavirus cases. We have one waiting room. We do not have negative pressure rooms.

It will come and go. And, I know it will be tough to turn patients away. And, with every patient who tests positive, I will have the nightmare of the CDC coming around to quarantine everyone.

Quest fee $199. for the test has to be frozen only 72 hr stability(and from here-CT) they send it to California

I have started video visits. When I try to code using E&M code with changing the place of service amazing charts on clicking place of service to change it is kicking me back to the note. I could use a GT modifier but reading things it looks like private insurers want us to change place of service. Has anyone been successfully billing e visits?
What CPT do you use?
On the testing front if the CDC and state lab tests are ELISA (I believe) and the Labcorp (RNA) and Quest (NAA)
I have been having patients work with department of health if they qualify for testing (none yet) and telling others that dont qualify not to have testing done.

Hi Krisinc,

Welcome to the AC Users Forum. I have never experienced that. Do you have any way of just adding that to the note manually?

I am interested more in the Skype option. This is a way our government could really help. Make it mandatory that all insurance companies accept Skype visits with very few restrictions.

New CPT® codes for online digital E/M

99421 Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes

99422 11—20 minutes

99423 21 or more minutes

These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

I am considering trying these codes. Unfortunately, AC does not recognize them so I can't bill through AC. I am on 10.1.3. Maybe they have updated on later version??
Bill

Bill. Thanks for those new online digital E/M codes. I did not know about those. I just looked up the reimbursement for non-facility Florida Medicare and they are
99421 (5-10 min), $15.49, 99422 (11-20 min) $31.15, 99423 (21+ min) $50.31. I also note that this does not seem to require videoconferencing. Cumulative time back and forth on the portal seems to qualify? Cannot use these codes with chronic care management codes on same patient for the month.
...Ken


"Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). Online digital E/M services require physician or other QHP's evaluation, assessment, and management of the patient. These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. While the patient's problem may be new to the physician or other QHP, the patient is an established patient. Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP."

I am experimenting with a free hippa secure telemedicine product. https://doxy.me/ Seems to be working pretty well.

Bill,
That doxy.me platform looks pretty easy. No software download or password required for patients. I just tested out with a relative and had no issues. We will offer it to patients who are leary of coming in office for well visits.

Once again, screwed by the insurance company. So, 20 minutes for $31.15. That's a joke. Let them go to the ED for Medicare to pay $250 and give everyone Covid-19. My idea, although, probably stupid I think is just as safe and I will be able to have a better idea how sick the patient is. Have them wait in their car, fill out a history. Take their temp. Look at them. Write them a script for amoxicillin and Tessalon Perles. Then, make them sign a disclaimer and that they will go to the nearest ED or call if they get 1% sicker or 0.1 degree hotter. I should be able to write this up and get a decent CPT code. One good thing about Medicaid or MaineCare is they tend not to audit solo practitioners, and I think this shows a greater amount of care and time.

I am not knocking video visits. Just wonder if my CMA hands them a sheet, takes an oral temp, and I read the sheet, ask a few questions, and document it at the end of the day.

I think one of the toughest parts will be having a healthy wcc with three siblings and both parents. They need to be home or outside.

A few months ago I was looking into telemedicine. I believe you can just use the place of service code 02 with EM codes 99213, 99214 and the reimbursement would be the same. I looked into for Texas Medicaid, so I don't know about for private insurance. But I do know that for my personal BCBS insurance, they do not cover telemedicine unless it's through LiveMD.

The Updox videoconferencing service is $100/month. Updox had presented a webinar that I watched with two practices that use their service - one pediatrics, the other some kind of specialty I forget. It was very informative. I'm sure they have a recording.

We decided against it because I could not get a straight answer from all the Medicaid HMOs on whether it's covered or not. (Even though Texas HHSC says they cover it, I didn't want to deal with the HMOs if they were not aware or set up for it.) But now we are looking at doing it again, especially if the payers start to clarify their policies in light of all this interest in telemedicine.

We are doing telemedicine visits... we essentially have no choice. Perhaps it is pie in the sky, but I am hoping some insurers decide to cover this (or the government plus Medicare mandate it) in view of the crisis.

For now... has anyone been paid for tele visits?
Any hints for the rest of us?

We could bill 99422 it’s 30$ 11-20 min. That works for just portal communication too. Medicare red white blue is the only definite payor. MA will vary by payor meaning probably not covered. Commercial same.

We need 99211-3 via telehealth but not there yet:

https://www.pyapc.com/insights/despite-waiver-of-telehealth-restrictions-coverage-appears-unchanged/

Cash is probably easiest for now. We probably ought to document a verbal waiver that we are not billing insurance for this. There is probably a clause in some insurance contracts saying we must bill insurance for covered services. Problem is most (but not all) don’t cover it.

One caveat: evisit for routine communication of lab results or simple follow up to recent in-office visits would run afoul of Medicare as that’s included in 99213-4.

We might be canceling or curtailing routine visits for a while from our side or patient side. Keep overhead low and use evisits for more things-even some stuff we previously handled by phone ( un reimbursed and better handled with a quick e visit). Today patients were grateful to have me take the time to video call them, $40 was not a concern. I liked being able to take my time on a call and not feel it’s unreimbursed.

I might try doxy.me they have a payment setup and a “waiting room”. Updox video doesn’t have either.

This might change how I practice onward. Fortunately we can just do it without endless approval meetings. More personal doc-patient contact likely strengthens the relationship ala concierge medicine. I talked to a guy on vacation about mild allergies/asthma (maybe would’ve been free via nurse relayed messages before), and I could feel how good his wife felt about the ability to reach out and get personal call.

Just tried doxy.me. Seems to work well. We are going to start using it. Will report back if/when claims start getting paid.

Researching on how to bill for Telemedicine is confusing me. I'm seeing two different ways to do it. One is billing CPT codes 99421-99423. I don't know if my brain is on overload but I'm also seeing this from CMS:

TELEHEALTH SERVICES BILLING AND PAYMENT
Submit professional telehealth service claims using the appropriate CPT or HCPCS code.
If you performed telehealth services “through an asynchronous telecommunications system”, add the
telehealth GQ modifier with the professional service CPT or HCPCS code (for example, 99201 GQ).
You are certifying the asynchronous medical file was collected and transmitted to you at the distant
site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii.
Submit telehealth services claims, using Place of Service (POS) 02-Telehealth, to indicate you
furnished the billed service as a professional telehealth service from a distant site. As of January 1,
2018, distant site practitioners billing telehealth services under the CAH Optional Payment Method II
must submit institutional claims using the GT modifier.
Bill covered telehealth services to your Medicare Administrative Contractor (MAC). They pay you
the appropriate telehealth services amount under the Medicare Physician Fee Schedule (PFS). If
you are located in, and you reassigned your billing rights to, a CAH and elected the Optional Payment
Method II for outpatients, the CAH bills the telehealth services to the MAC. The payment is 80 percent
of the Medicare PFS facility amount for the distant site service.
TELEHEALTH ORIGINATING SITES BILLING AND PAYMENT
HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your MAC for
the separately billable Part B originating site facility fee.
Note: The originating site facility fee does not count toward the number of services used to determine
payment for partial hospitalization services when a CMHC serves as an originating site.

I understand the modifier and place of service code, but what CPT codes do we bill? 99421-99423 or 99212-99214?

Charlene that's my confusion too. It seems 99421-99423 are covered by some insurance plans but the medicare rate for them are very little, much less than 9913. From the Updox webinar that I watched, the practices billed 99213 with POS 02 and modifier GT for interactive communication. It seems the components/documentation requirements for 99421 are much less than 99213, so maybe it depends on what was done during the visit.

Here's UHC policy. It doesn't talk about 99213/99214 only 99421-99423. https://www.uhcprovider.com/en/resource-library/news/provider-telehealth-policies.html

Just saw this, table at bottom of the page talks about differences between the codes. So still very confusing. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

99213-214 via telehealth only allowable to designated remote shortage/rural sites without access to docs. This restriction has not been waived for the rest of us yet. So i wouldn't try that. Even if it goes through it's likely audit material.


from https://www.pyapc.com/insights/despite-waiver-of-telehealth-restrictions-coverage-appears-unchanged/


-------------->
In the March 5 fact sheet, CMS also notes that such services furnished to rural Medicare beneficiaries may be eligible for reimbursement as telehealth services in specific circumstances. As such, these services are reimbursed at the same rate as the comparable face-to-face service:

In addition, Medicare beneficiaries living in rural areas may use communication technology to have full visits with their physicians. The law requires that these visits take place at specified sites of service, known as telehealth originating sites, and receive services using a real-time audio and video communication system at the site to communicate with a remotely located doctor or certain other types of practitioners. Medicare pays for many medical visits through this telehealth benefit.

Following the March 13 declaration of a national emergency, CMS has temporarily waived requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state.[5] Thus, a provider now may provide telehealth services, as well as virtual check-ins and eVisits, to an individual residing in a state in which that provider is not licensed to practice. Still, all other restrictions on Medicare reimbursement for telehealth services remain in place.

Despite having clear congressional authority to extend telehealth coverage to patients in non-rural areas and to services furnished to patients in their homes, CMS apparently believes significantly lower reimbursement for virtual check-ins and eVisits for Medicare beneficiaries is adequate now. With circumstances changing daily with respect to the virus’ continued spread, CMS’ current perspective on all reimbursement matters pertaining to beneficiary coverage is likely to evolve. Stay tuned…

Thank you Serene and Larry. You've been very helpful!

Now we are trying to figure out which video chat program to use.

According to the press conference today, Medicaid and Medicare are going to make it easy for reimbursement. Florida already has it. In Maine, we can do telephone calls only, which I will do. I don't plan on doing video since I see no value in it compared to phone calls.

We will mostly see patients and test all of them. Spread out wccs.

I don't think telemedicine in any form pays as much as a 99213. We can't afford not to see patients.

The answer would be for all non-hospital associated private practice to receive two bonus checks of around $30,000 a year. We already get two. Then Skype on top of that.

Breaking news: For medicare, Can bill 99211-99215 among lots of other codes, using place of service 2, and be paid at same rate as if patient were in office.
Also, don't have to worry about HIPAA audits for using facetime, skype, etc.

https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

Exactly, Ken. That takes care of Medicare... do a video visit and bill just as you would in the office (new and old visits, 99202-5 and 99212-5).

Now let's see if private insurers do the same...

Yes! and again change location to an 02 - correct? and it is now working for me:)
GT modifier not needed
doxy.me really is working well for me

Yes great news with Medicare!!!! In the state of Montana can do the same with private insurance.
I have billed secure video chat successfully with Blue Cross patients and just use the same code I would use like an office visit usually 99213 for simple stuff.
I do like the integration of Updox as everything on one platform, e-fax, secure text, secure video chat and patient portal. Can either use the email or cell phone to secure video chat so some patients only have the portal or secure text but most have both.
Just did a secure video chat via patient's cell phone/my office computer with logitech camera on patient with fever, cough, had him meet me out in parking lot 5 minutes later, swabbed his nasopharynx and Quest lab tech should get it out tomorrow, answer in 3-4 days for Corona Virus. Worked quite well, then sent f/u summary and handout from up to date with Corona Virus info via portal. All one easy platform that plays well with AC. Well worth the 177 $ per month in my opinion.

AC just sent information regarding partnering with DrFirst for telemedicine.

I sent in a request for information but videos on the DrFirst site don't help (may be too new) explain how they integrate with AC

I'm going to try doxy.me there is a free version then a paid version $35/mo no contracts got to see about copy/paste note into AC. Will post how it goes.

I have used the doxy.me telehealth for the last couple of days. It works fairly well depending on internet connectivity. It is nice to see the patient and for the patient to see me but honestly, for most things a phone call is clearer. I upgraded to the professional version of Doxy.me. It is free for the first month so why not? I get texted when a pt is in the waiting room so if I am seeing a pt in person I know someone is waiting. Glad to hear we can bill regular E/M codes. Thanks everyone as always.

The CMS FAQ posted by KenP is great - answers a lot of questions. They are even waiving the requirement for HIPAA compliance video system. You can use skype and facetime! Also I saw that Updox is offering the video option for $20/month now.

I just saw that the biggest Medicaid HMO in our county will be reimbursing for telephone calls with codes 99211-99214. They clearly state it here http://www.thecheckup.org/2020/03/1...dicine-telehealth-services-and-covid-19/

Maryland Medicaid is covering, too.
https://phpa.health.maryland.gov/Documents/COVID-19.1_Telehealth%20Guidance_Neall.pdf

Yeah, in Maine we can do telemedicine and not worry about the Skype or video. Regular E & M codes. This is the first time we are getting reimbursed for messages, which is the worst part of our day.

All messages are now being sent in a chart as if the patient is in the room. My MA is taking a very long and thorough HPI and then I add to it. CC is Telemedicine encounter. There is a place on the CPT window for telehealth.

Turning all messages except things like constipation into regular visits.

NOW JBS COULD CHARGE FOR CONSTIPATION.

One other nice feature of Updox is to be able to blast message all patients with a portal or secure text option. I just sent a portal message to all of my patients, 1052 with a portal regarding triage at the front door of the office checking temp and symptoms and that I will be offering secure video chat appointment and there will be a charge covered by insurance or medicare for this service, works slick!

Just some feedback on televisits. We have been doing them for two days. I have to say three things:

1. They are saving the practice. Without them, we would be seeing five to eight patients a day. Now, we are averaging around 15.
2. We checked with MaineCare (Maine's version of Medicaid). They paid every claim from yesterday (1st day) at $69.22. We are working hard to see at least five patients a day to show a contrast. I don't want MaineCare or other insurance companies to think we only see telemed.
3. It is balanced somewhat by the fear of Coronavirus or what would happen if my staff or I contracted it with the fact that this is the first time I have enjoyed being a doctor in years. It just feels like concierge medicine. I am not running around crazy all day. I have time to relax. I have time to read and WE ARE NOT DOING 15 REFERRALS A WEEK.

Not sure what the private insurers will be paying. Of course, they don't look at the notes, so I don't know how they would know. But, we do make it clear the patient was not present and it was a telehealth visit.