FAQs on Medicare Telehealth Services and How They Impact CRNA Services Note:  Telehealth services provided must be within state scope of practice.  Ability to provide services via telehealth does not authorize scope of practice elements or prescriptive authority that are not already included in state scope of practice. How has the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services for providers? The use of Telehealth under Medicare has been historically low because it was limited to rural areas, but due to the coronavirus crisis, CMS is expanding this benefit on a temporary and emergency basis under the Section 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act (HR 6704). Under this new waiver, Medicare can pay for office, hospital and other visits furnished via telehealth across the US and including patient’s homes starting on March 6, 2020. CRNAs have been eligible to be telehealth providers prior to this expansion, but this wavier expands the circumstances for CRNAs to provide telehealth. Before this waiver, Medicare would only pay for telehealth on a limited basis such as when the person receiving the service lives in a rural area and then they leave their home to go to a clinic, hospital or certain other types of medical facilities for that service.

Are CRNA telehealth services covered? Under the CMS 1135 Waiver, CRNAs are included in the list of providers that can care for patients using telehealth services. Reimbursement is dependent on your Medicare Administrative Contactor (MAC) and their Local Coverage Determinations (LCDs), on state scope of practice laws, and existing Medicare policy.

What are the five types of telehealth services can be provided to Medicare beneficiaries? There are five types of telehealth services physicians and other professionals (including CRNAs) can provide: Medicare telehealth visits, virtual check-ins, e-consults, remote patient monitoring and e-visits. There are now 171 new telehealth codes that can be billed for under the Medicare Physician Fee Schedule. To the extent that a National Coverage Determination (NCD) or Local Coverage Determination (LCD) would otherwise require a face-to-face visit for evaluations and assessments, clinicians would not have to meet those requirements during the public health emergency.

What are the common telehealth services and codes CRNAs can use to treat patients? Please see the document released by CMS on March 30, 2020 entitled Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, which lists in great detail the services that providers can now provide under the five categories of telehealth services so that clinicians can take care of their patients while mitigating the risk of the spread of the virus. These codes include services such as critical care services, emergency department visits, initial hospital care and hospital discharge day management and initial and continuing intensive care services. Under the public health emergency, all beneficiaries across the country can receive Medicare telehealth and other communications technology-based services wherever they are located. Providers can provide these services to new or established patients. In addition, providers can waive Medicare copayments for these telehealth services for beneficiaries in Medicare.

Where can telehealth services be provided? Telehealth services can be provided to both new and existing beneficiaries in any location, in both urban and rural areas, including a private home. This applies to all existing Medicare telehealth services. The visits can be via telephone call and also the visits do not have to contain both an audio and a visual component as was previously required.

What is the frequency of certain telehealth services that can be provided? The following services no longer have limitations on the number of times they can be provided by Medicare telehealth: a subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days; a subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days; and critical care consult codes may be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation.

How can I find out if I can offer my services in another state? With the 1135 waivers, governors have been making state licensure and telehealth requirements more flexible by allowing out of state providers to treat patients across state lines. The requirements that are waived are at federal level and not at the state level. Providers must look at each state law and executive orders to see what the state licensure requirements are. Check state boards of nursing for these requirements also, because each state is unique and may have different licensure requirements.

What technology can I use to provide telehealth services, if I don’t have dedicated audio/visual equipment? Telehealth visits can be conducted over the phone and do not need to include both an audio and a video component. Furthermore, the OIG is providing flexibility for providers to reduce cost sharing for telehealth. Also, physicians and other practitioners will not be subject to administrative sanctions for reducing or waiving any cost-sharing obligations Federal health care program beneficiaries may owe for telehealth services furnished consistent with then applicable coverage and payment rules.  See OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19)

Could I be subject to penalties under HIPAA for using devices like smartphones to provide telehealth services? The Office of Civil Rights (OCR) will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. A covered health care provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients (e.g. Apple Face Time or Facebook Messenger). See Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency.   Can certain medications be prescribed to patients evaluated using telehealth? DEA registered practitioners may issue prescriptions for controlled substance to patients for who they have not conducted an in-person meeting with. Here is the press release. DEA-registered practitioners may continue this telemedicine practice for as long as the designation is in effect, if all required conditions are met:

  • The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice

  • The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system.

  • The practitioner is acting in accordance with applicable Federal and State law.

Will traditional malpractice insurance cover me if I offer telehealth consultation services during COVID-19? Consult your malpractice insurance carrier. Traditional Medical malpractice insurance coverage depends on your carrier. Have commercial insurance plans expanded their benefits to cover COVID-19 related services? Yes, we have heard that commercial health plans are expanding their benefits and/or relaxing requirements to cover services such as testing, cost sharing, prior authorization requirements, expanding access to telehealth and nurse/provider hotlines.

Can providers be reimbursed under CMS while they are physically in the home (under quarantine)? CMS doesn't limit where providers can practice. They can add their own home address to their Medicare Enrollment by reaching out to their Medicare Administrative Contractor (MAC). It would be effective immediately so providers can provide care without a disruption. See 42 CFR 424.516 for more information. If a CRNA reassigns his/her billing rights to a clinic or group practice that clinic or group practice must add the individuals home address to their Medicare enrollment by reaching out to their MAC.

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