As the COVID - 19 pandemic rapidly evolves, this article will be updated accordingly
The current health crisis has made social distancing the most important public health measure in preventing the further spread of the COVID-19 virus. These recent developments primarily challenge how we practice physical therapy; specifically in the outpatient orthopedic, geriatric, neurological, and pediatric settings. If an individual cannot physically attend a session in a clinic, how do we reach these individuals appropriately and effectively?
Physical Therapists still play a pivotal role in the management of individuals with musculoskeletal pain complaints and other movement-related impairments/dysfunction. Physical therapists function to help not only those individuals right now that are in the front lines of healthcare but all the essential workers keeping our country afloat.
Telehealth, commonly known as telemedicine, was introduced as a method in which we can effectively interact with clients through secure telecommunication devices in order to provide our Physical Therapy services. This article outlines the basics of telehealth in PT, billing questions, and how PTs can manage to bring their current clients into the fold.
What is telemedicine/telehealth?
Telehealth is generally described as providing treatments or specific interventions electronically, while Telemedicine allows the transfer of personal medical information electronically. Previously, the use of telehealth amassed a reputation as being cost-effective, efficient, and able to reach those individuals who might not have ready access to a PT clinic.
Telehealth Physical Therapy encompasses all the treatments physical therapists can provide except for manual therapy, some equipment, and tactile cueing provided during your normal in-clinic sessions.
An example: An individual with a child with CP who lives in upstate NY might want to interact with a specialized PT who works in Long Island, NY. The impact the physical therapist can have is still profound and should be stressed when interacting with potential clients. How to communicate and build therapeutic alliances becomes the biggest factor in patient success with telehealth models. Here is another Covalent Careers article that will give you 10 steps to starting a telehealth physical therapy practice and other resources.
Telehealth Models for Physical Therapy
Live Video (Synchronous)
This functions as a way for practitioner and client to interact via audiovisual methods in “real-time”. This plays out just like a normal in-clinic session with one-on-one time, where a goal is set for the meeting and treatment/education is provided. The meeting occurs for an agreed-upon amount of time at a specific time of day.
This method pertains to the creation of pre-recorded video content which can then be sent electronically to an individual as a means of education and treatment. The transfer of content needs to be done securely with HIPAA compliance. Physical therapists can also provide an assessment of an individual's case without interacting synchronously.
Remote Patient Monitoring (RPM)
This method allows for continuous monitoring of certain health information/data that is important pertaining to an individual's rehabilitation program. The data is recorded and sent to the practitioner who can modify the persons' program remotely. Reflexion Health provides their product VERA which is an FDA-cleared Virtual Exercise Rehabilitation Assistant that supports, coaches, and empowers patients as they heal. The patient-facing system allows you to have your movements studied and that information sent to the remote clinician who can modify your program3.
These methods further show how much of an impact telehealth physical therapy can have on the population at large that are affected by the recent changes in socialization and access to PT clinics. Accessibility and adherence will manifest as the two most important factors in the integration of tele-PT into normal treatment paradigms in the PT profession.
10 Telehealth software platforms to ease the transition of practice
These platforms allow for communication that is HIPAA compliant and allows their personal email/mobile phone number to remain private. Some of these software programs (doxy.me) can be used for free but others come at a price. The presence of COVID-19 might have changed the pricing for some of these software programs so contact them to find out more2.
Billing for Telehealth Physical Therapy Services
Federal/state and third-party payer regulations govern how one provides and gets reimbursed for telehealth services and/or E-visits. Medicare is federally run and Medicaid is run individually by each state. This is where it can get confusing for the clinician because of determining which insurances you can take and actually be reimbursed.
It is important to visit your state's physical therapy regulatory board in order to determine how to bill state-run Medicaid insurances and how to code specific to the services and location of services provided. Medicaid has been reimbursing providers who perform tele-rehab services since 2002, although not in all 50 states and in a limited fashion. The importance of understanding each originating payer's regulations is essential to running a successful telehealth practice.
Links below are provided by the APTA and are as follows:
State-mandated executive orders related to telehealth
Federal payer telehealth or e-visit coverage
Parity Laws for Private Payers
MAP OF USA SHOWING STATES WITH PARITY LAWS
At this time, 37 states have parity laws that mandate third-party payers to reimburse for telehealth services (4). These telehealth services must be provided synchronously via live video conference to be deemed reimbursable. There are some states that require the store and forward method to be reimbursed. In addition, many insurers recognize the value of telemedicine and will reimburse for remote visits even if the state does not require them to do so (5).
Reimbursement rates within states with parity law regulations
Most private payers in parity law states give reimbursement rates equal to that of in-person visits. Each private payer has its own rates based on what is provided during the session. Most of the time the state leaves it up to these private payers to determine their own rates.
On March 27th, 2020 Cigna/ASH has announced they will cover virtual care for physical, occupational, and speech therapy services through May 31, 2020, with a retroactive date of March 2nd, 2020. These services will be reimbursed consistent with the standard fee schedule8.
Billing CPT codes for PT visits should be as seen below9:
- 97161-GQ Low complexity new patient (telephonic or synchronous video)
- 97162-GQ Moderate complexity new patient (telephonic or synchronous video)
- 97110-GQ Established patient follow-up (2-unit limit)
Use standard place of service (for example 11) on the CMS 1500 claim forms. These forms should be sent to the ASH group as normally would be transmitted. As with any form of documentation, it is important to note that the method by which the service was provided is paramount. In this case, phone or synchronous video are the formats in which this visit would be accomplished. Furthermore, it is essential that you still follow federal and individual state regulations as that can affect your ability to provide telehealth services.
PLEASE SEE THIS LINK FOR A MORE EXTENSIVE DOCUMENT FROM CIGNA/ASH
United Healthcare (UHC) will be reimbursing telehealth visits for physical therapy starting with a retroactive date of March 18th, 2020 to June 18th, 2020 as a result of the COVID-19 pandemic. The requirements to provide these services include fully licensed PT within the state that the telehealth provider is being given along with HIPAA compliant audio/video interactive technology.
Please follow state laws and regulations in regards to providing telehealth physical therapy services. UnitedHealthcare will reimburse eligible codes when submitted with a place of service code 02 and modifier 9510.
Please see the below link for billing codes as provided by UHC
Medicare Telehealth Services Expanded due to COVID-19
The federal government in response to the burgeoning COVID-19 pandemic has put in sweeping changes to telehealth services for Medicare beneficiaries. The administration is providing temporary regulatory waivers during this time to allow providers to serve medicare beneficiaries while mitigating the risk of spreading the COVID-19 virus. Clinicians can serve these individuals whether or not they are established patients. First and foremost clinicians can waive medicare copayments for those beneficiaries with original medicare. HOWEVER, Physical therapists are still not denoted as a TELEHEALTH PROVIDER according to CMS. ***This means we will still not be reimbursed for our services.
- 97110 Therapeutic exercises Temporary Addition for the PHE for the COVID-19 Pandemic
- 97112 Neuromusulcar reeducation Temporary Addition for the PHE for the COVID-19 Pandemic
- 97116 Gait training therapy Temporary Addition for the PHE for the COVID-19 Pandemic
- 97161 PT Eval low complex 20 min Temporary Addition for the PHE for the COVID-19 Pandemic
- 97162 PT Eval mod complex 30 min Temporary Addition for the PHE for the COVID-19 Pandemic
- 97163 PT Eval high complex 45 min Temporary Addition for the PHE for the COVID-19 Pandemic
- 97164 PT re-eval est plan care Temporary Addition for the PHE for the COVID-19 Pandemic
- 97535 Self-care management training Temporary Addition for the PHE for the COVID-19 Pandemic
- 97750 Physical Performance Test Temporary Addition for the PHE for the COVID-19 Pandemic
- 97755 Assistive Technology Assess Temporary Addition for the PHE for the COVID-19 Pandemic
- 97760 Orthotic mgmt&traing 1st en Temporary Addition for the PHE for the COVID-19 Pandemic
- 97761 Prosthetic training 1st enc Temporary Addition for the PHE for the COVID-19 Pandemic
For more information, CMS.gov provides a DOCUMENT with a list of multiple services impacted by this expansion of telehealth services
Telehealth versus E-visit for Medicare Beneficiaries
Since first writing the article there have been changes to the billing and requirements for telehealth services for Medicare beneficiaries. However, we will still outline the difference here on what constitutes an E-visit which will still be reimbursed by medicare. The provision above also allows E-visits to be performed without having them to be an established client
On March 17th, the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare services to allow PTs, OTs, and SLP to perform “E-visits” for Medicare beneficiaries6. This situation is fluid so please follow updates on CMS.org, the state regulatory board website, or your trusted social media platform.
E-visits are reimbursed at this moment in time but are not considered telehealth under CMS. In order for a clinician or practice to be reimbursed, certain parameters have to be met when initializing and sustaining an e-visit. E-Visit is not the same as Telehealth:
- E-visits as per the above changes can be provided to new and established clients (HCPCS codes G2010, G2012 with GP modifier)
- E-visits can only be initiated by the client. These services can be advertised by the practitioner to the client.
- Online HIPAA compliant software must be used
- E-visits can only occur every 7 consecutive days after the patient-initiated contact.
- Medicare coinsurance and deductible would still apply to an E-visit.
- “E-Visit” does not need to be included in the original POC that was signed by the referring physician.
- You cannot bill an e-visit if you saw the patient in a face-to-face visit fewer than 7 days before the e-visit or if you see the patient in a face-to-face visit fewer than 7 days after the e-visit.
- PT’s need to check with secondary payers if they are waiving copays and deductibles for these services
- Hospital outpatient clinics are now able to use the G codes below for services provided for Medicare beneficiaries during an E-visit.
- Billing Codes as seen below(require GP modifier to designate as being provided by a PT)7:
- G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, the cumulative time during the 7 days; 5–10 minutes
- G2062: non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, the cumulative time during the 7 days; 11–20 minutes
- G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, the cumulative time during the 7 days; 21 or more minutes
For more information please visit this APTA LINK that goes through FAQs on this subject
Cash-Based Telehealth Physical Therapy
Another option clinics have is cash-based telehealth services. One of the best resources that I know of is Aaron LeBauer. He had a free Facebook group with weekly podcasts as well as courses that he had designed. Dr. Jarod Carter also has invested in expanding his own cash-based telehealth physical therapy business and converses with Rob Vining in this PODCAST episode which can help educate individuals on how cash-based telehealth physical therapy might be the best route for you. Rob Vining also goes on to the Healing Pain PODCAST with host Dr. Joe Tatta to talk about all things telehealth physical therapy and again is a good resource for those interested in providing these services.
The Center for Medicare and Medicaid Services still has a stronghold on the efforts of many PTs on how to provide care for millions who have medicare as their insurance program. This affects the livelihood of not only the providers but the beneficiaries as well who rely on the service for improving function and increasing quality of life. Changes to the way telehealth are seen among the populous need to change as well in order for us to have long-lasting changes to the telehealth industry. There need to be more widespread educational opportunities and mediums for the common person to consume information on the benefits of telehealth during this pandemic and into the future.
Telehealth eliminates proximity as a factor for patients choosing a PT provider, expanding the number of options and the reach of your practice, especially for people in areas where there are too few physical therapy providers to meet the demand5.
The ability to see patients without the need to be in the office gives physical therapists an unprecedented degree of flexibility5. Providers can work from home or while traveling and extend hours into the evenings or weekends, improving work/life balance.
Interested in telehealth, but still, have some questions? Check out these groups on Facebook:
- TelehealthDPTs, a group for telehealth PTs
- Concierge Telehealth - PT, a group where telehealth PTs can ask questions and seek advice from their fellow practitioners
IF YOU ARE A PHYSICAL THERAPIST INTERESTED IN VOICING YOUR SUPPORT FOR TELEHEALTH PHYSICAL THERAPY SERVICES TO BE REIMBURSED BY MEDICARE AND TO BE WRITTEN AS A TELEHEALTH PROVIDER PLEASE SEND THE BELOW LETTER
The link above has the instructions and template from which you can add your name to the list of this supporting this initiative.