Telemedicine/Telehealth Services

COVID-19 TELEMEDICINE FLEXIBILITIES

Medicare

The federal COVID PHE ended May 11, 2023. The Consolidated Appropriations Act 2023 extends many of the prominent Medicare telemedicine flexibilities through Dec. 31, 2024. For more information review the MLN Fact Sheet, the TMA chart outlining the current flexibility deadlines for telemedicine services, and CMS Flexibilities to Fight COVID-19. Some of the extended Medicare flexibilities include: 
  • The ability to see a patient in their own home regardless of geographic location
  • An expanded list of eligible practitioners
  • The ability for federally qualified health centers and rural health clinics to be distant site providers 
  • The ability to provide audio-only visits to patients
  • The delay of the in-person visit requirement before a patient receives mental health visits

HIPAA

Enforcement discretion issued under HIPAA and HITECH during the COVID-19 PHE expired on August 9, 2023. As such, physicians must ensure that the communications platforms used for providing telehealth services support HIPAA compliance. Even when ‘HIPAA-compliant’ platforms are used for telehealth there are still privacy and security risks that must be addressed and reduced to a low and acceptable level. The OCR has issued guidance for healthcare providers on HIPAA and audio-only telehealth services. The U.S. Department of Health and Human Services (HHS) provides a resource guide aimed at assisting telehealth physicians in explaining the privacy and security risks to patients that engage in telehealth. Importantly, the guidance makes clear physicians are not required by HIPAA to provide this education, but is provided to assist physicians who would like to explain to patients the privacy and security risks to their protected health information when using telehealth services .

Controlled Substances Prescriptions

The DEA issued another temporary extension of telemedicine flexibilities for the prescribing of controlled medications originally adopted in March 2020 that permitted physicians to prescribe controlled medications to a patient via telemedicine (audio-video), even when the physician had not conducted an initial in-person visit with that patient. This extension allows for the full set of telemedicine flexibilities regarding prescription of controlled medications as were in place during the COVID–19 PHE, through December 31, 2024.  It also authorizes all DEA-registered practitioners to prescribe schedule II-V controlled medications via telemedicine whether or not the patient and practitioner established a telemedicine relationship on or before November 11, 2023, The temporary rule:  
  • Extends through December 31, 2024 the full set of telemedicine flexibilities regarding prescription of controlled medications that were in place during the COVID-19 PHE.
  • Applies to existing and newly formed patient-physician relationships.
  • Allows for prescribing a 30-day supply of buprenorphine to treat opioid use disorder without an in-person evaluation or referral.*

*Please note, this temporary extension was made permanent on Jan. 31, 2024 as HHS finalized a rule allowing for initiation of buprenorphine at an Opioid Treatment Program (OTP), by the OTP physician, if an OTP physician determines that an adequate evaluation of the patient can be, or was, accomplished via audio-only or audio-visual telehealth technology.  The final rule is also somewhat applicable to methadone treatment in that treatment via audio-visual telemedicine is permitted. However, treatment is NOT permitted via audio-only telemedicine in assessing new patients who will be treated by the OTP with methadone as methadone, in comparison to buprenorphine, holds higher risks to the patient.

IMPLEMENTING TELEMEDICINE IN YOUR PRACTICE

If your organization is considering implementing a telemedicine program but you currently have limited experience with telemedicine systems, please review the following information to assist you and your practice in this process. 

Contract Language:

Contracts are a necessary part of any telemedicine venture. A telemedicine service contract will share many of the same contracting concerns as an EHR, such as who owns the equipment, who owns the data, and expectations around service call timing, up-time, software updates and turnaround times. Agreements made with telemedicine providers or technology vendors should be reviewed to ensure that insurance provisions include mutual hold-harmless and indemnification language and that adequate insurance coverage is required. Confer with legal counsel to determine which state laws apply to the organization’s telemedicine services, monitor changes in applicable regulations and take steps to ensure that procedures for education and compliance are in place. The American Society for Health Care Risk Management has developed a white paper discussing Telemedicine Risk Management Considerations

The Coker Group offers TMA/HCMS physician members free technology contract review services. Coker Group is a member of TMA-approved Group Discount Programs.

Policy and Procedures:

Although telemedicine has the potential to improve several aspects of medical care, such as facilitating physician-patient communication and monitoring treatment of chronic conditions, telemedicine poses unique challenges in ensuring patient-safety and privacy of health information. Therefore, it is prudent for telemedicine providers to develop a comprehensive set of policies and procedures (P&P).
The TMA has developed templates to assist practices in developing their own P&P. These can be found under the section titled “Policies, Procedures and Forms for Telemedicine Services” on their own P&P. These can be found under the section titled “Policies, Procedures and Forms for Telemedicine Services” on their Telemedicine in Texas web page.

Additionally, organizations considering telemedicine or adding new telemedicine technologies to an already existing panel of services must consider how the new or added services will be incorporated into privacy and security policies, procedures, and workflows. For example:
  • Incorporate telemedicine into the Notice of Privacy Practices. 
  • Include telemedicine equipment in the organization’s Security Management Plan and annual Security Risk Assessment. 
  • Ensure all staff and providers who participate in telemedicine services have received telemedicine specific healthcare privacy and security training. 
  • Determine the need for Business Associate Agreements. Evaluate all parties, including any vendors involved in the provision of services, for compliance with federal and state privacy and confidentiality regulations, and require the ability to provide proof compliance if asked. Require telemedicine vendors to hold their subcontractors accountable as well.

Vendors:

After reviewing and understanding payor policies (see above for COVID policies and below for standard policies) and ensuring you will receive proper payment for conducting telemedicine services, below are resources to help identify a vendor that fits your needs. 

Educational Resources/Webinars:

The TMA Telemedicine in Texas web page provides resources to assist in the implementation of telemedicine with various guides, webinars, and CME's all free to members.

The AMA developed a Quick Guide to Telemedicine in Practice that includes a "Telemedicine Implementation Playbook" designed to support physicians and practices in expediting the implementation of telemedicine. The AMA also has Digital Health and Telehealth resource center: Guides & reports web pages offering free resources.

The American Telemedicine Association is a non-profit association with a membership network of thousands of industry leaders and healthcare professionals. Visit their website for resources, educational courses, and events.

RULES AND LEGISLATION

Texas Requirements

For the current TMB telemedicine rules, please review the Texas Administrative Code. Additional information is available on the TMA General Counsel's white paper "Texas Laws and Regulations Relating to Telemedicine".

Out-of-State licensure requirements

A number of states have passed legislation to permanently allow out-of-state physicians to practice telehealth in their state if they follow the state’s requirements. Some states allow out-of-state physicians and other providers to practice telehealth in their state if they are already licensed in another state. Other states require out-of-state telehealth license recipients to pass an exam. You’ll need to refer to state licensing boards to determine if that state offers a telehealth registration option, and if so, what are the requirements. Details can be found at HHS.

PAYOR POLICIES

Commercial

In general, most Texas telemedicine legislation applies only to fully-insured plans (TDI or DOI on front of patients insurance card), thus coverage for telemedicine varies by plan and the patient's benefits. The TMA Telemedicine Billing and Coding Guide provides information by payor. However, coverage, benefits, and coding requirements should be verified prior to rendering telemedicine services. 

Medicare

Medicare covers various telemedicine services, each with their own stipulations and requirements. Consult the MLN Fact Sheet for a list of services, billing guidance, etc. More information is available at Telehealth.HHS.gov. Visit the TMA Telemedicine in Texas web page for billing and coding information and other resources applicable to Texas. There are three main types of Medicare virtual services available to Medicare beneficiaries, and one temporary service -- telephone (audio- only):

1. Telehealth/Telemedicine Visits: Telemedicine is the use of electronic information and telecommunications technologies to provide care. Technologies for telehealth include videoconferencing, store-and-forward imaging, streaming media, and terrestrial and wireless communications. Beginning Jan. 1, 2024, bill POS 02-Telehealth to indicate telemedicine services were provided to a patient in an originating site other than the patient’s home. Bill POS 10-Telehealth for services provided to patients in their home.
 
2. Virtual Check-Ins: Virtual check-ins are brief phone calls or video chats to see whether patients need to have an in-person visit. New and established patients in all geographical locations may receive this service from their homes and have a brief communication with physicians using various applications including telephones, or exchange information through video or images. The communication cannot be related to a medical visit within the previous seven days and may not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. 

3. E-Visits: E-visits are non-face-to-face patient-initiated communications through an online patient portal. Available in all locations, including the patient’s home, and all geographical areas, for established patients only. Medicare patients may have non-face-to-face patient-initiated communications with their physicians using online patient portals. Patients must generate the initial inquiry, and communications can occur over a seven-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable.

4. Telephone (audio-only, temporary): Through December 31, 2024 only, some services are available to new or established patients and may be furnished using audio-only devices to include audio-only telephone E/M, behavioral health, and educational services. After December 31, 2024, CMS does not intend to cover audio-only services except for mental health. Codes that have audio-only waivers are noted in the list of telehealth services

Medicare Advantage

Medicare Advantage plans are required to cover all Part A and Part B benefits covered under traditional Medicare. Medicare Advantage plans also have the flexibility to offer additional telemedicine benefits not routinely covered by traditional Medicare. Telemedicine benefits should be verified prior to rendering services for each patient to ascertain coverage, reimbursement, and coding requirements.

Medicaid

Consult the current provider manual under the Telecommunication Services Handbook for Texas Medicaid fee-for-service benefits. Also consult the TMHP COVID-19 page for updates (see the Recent News column on the right side of the page for specific notices) that may provide current flexibilities beyond the information in the provider manual, and the Texas HHS Medicaid and CHIP Teleservices web page. For information about managed care benefits please contact the patient's plan. Medicaid, Medicaid managed care organizations (MCOs), and the Healthy Texas Women Program continuously update their coverage polices. Texas Medicaid managed care organizations must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims filing may differ from traditional Medicaid and from MCO to MCO. Providers should contact the client's specific plan for coverage and billing guidance.

**The information provided on this page is subject to change and should be verified independently.**