483: Social Distancing for Rehab Therapists

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, hospitals can I have clinics ops site but they still fall under the hospital umbrella. You submit claims, NAU B zero four claim form in place of service codes are not used, most likely what you're going to have to use, which we didn't really talk about today. When you go to CPT codes you plugging up to put you to modify your GT or a modifier nine five on the CPT codes and that indicates that it was tele-health provided through a synchronous communication.

Rick Gawenda (00:58:32):

Now I know the follow up question is going to be which modifier do I use? It depends on the insurance company. You know, some insurance companies may tell you to use modifier nine five some may say to use GT if you're not a private practice. So again, unfortunately you just have to check with every insurance company you want to do tele-health with. And that's why I'm stressing so much to make sure you've got your policies and procedures in place and you've checked this through risk-management your attorneys to make sure you got your I's dotted, T's crossed and all of that.

Tannus Quatre (00:59:08):

Excellent. Thank you. Okay, so one here about part B in home. So Hilary if you can unmute. How is reimbursement different for part B in home versus in a free standing outpatient clinic? Right.

Hilary Foreman (00:59:21):

Great question. It is not that is why if a home health agency does choose to implement this program, they are going to have to look into a different way to do their billing. So it is still done by CPT code with modifiers just like a traditional outpatient setting.

Tannus Quatre (00:59:41):

Great. Thank you. Hillary. Another one about part B and home, how long does it take to launch part B in the home? If I only have done freestanding outpatient therapy?

Hilary Foreman (00:59:55):

It would depend on two things. One, if you were going to go a group practice or rehab agency route group practice is much quicker to get up and running, but there are some restrictions, especially depending on the state that you're in. A rehab agency is a much longer process and does require some additional filings. Some of them depending on the state you're in, you can do some retro billing in some cases. So you are able to start before everything is completed, but it's very state specific. If you, whoever asked if you want to reach out and let me know the state, I'd be happy to point you in the right direction for those answers.

Tannus Quatre (01:00:36):

Great. Thank you, Hillary. Okay. Another one here for Rick regarding eVisits. So per webinar a previous webinar or attended Medicare calls, e-visit a non face to face consultation, therefore Skype and such may not be required can be done via email or phone call. Is this accurate?

Rick Gawenda (01:00:57):

I'm sorry, what? I'm not understanding the question. Are they asking, is Skype and FaceTime allowed for a e-visit?

Tannus Quatre (01:01:03):

I'm interpreting this as is it required. So this, I'm going to go ahead and restate it. So Medicare calls e-visit and non face to face consultation, therefore Skype and such not required, can be done via email or phone call.

Rick Gawenda (01:01:21):

Well again, as I said during the presentation when CMS discussed Skype and FaceTime in that publication they released, they were using Skype and FaceTime for quote telehealth services not for an E visit. So right now an E visit needs to occur via email or a secure online patient portal. We are waiting for clarification with CMS regarding a phone call. You know what a phone constitute that cause right now as you know, a phone is not considered an online secure patient portal. So right now I can't tell you to use a phone to do an E visit. So right now I would say use encrypted email or use a secure online patient portal such as charm or you know, other online patient portals that are available to you.

Tannus Quatre (01:02:17):

All right, thank you Rick. Okay. Another one on E visits. When asking for an evisit do they have to, so the patient, does the patient have to directly address it as this or can they electronically ask a question? So for example, through a communication portal for us to then address outside of the clinic and we can count this as a patient contact.

Rick Gawenda (01:02:41):

Yeah, it's a great question because you know, again, this is like not what these codes are designed for. So obviously if a patient sends you an email asking a question I guess my recommendation if you want to play it safest, which is what I really have to do right now on this kind of call, is do you respond to the patient and say, you know, would you like me to respond to your question via an encrypted email via a secure patient portal, as an E visit? And if that patient then responds, yes, I would, you know, then I think that that's the request. And then you, I think you then save that email and then you go and address their question or questions that they had. In my opinion only is I think CMS is going to kind of be lenient on this right now.

Rick Gawenda (01:03:34):

I think other payers would be lenient on this right now, but again, you just in case something were to happen, you kind of need to cover your rear end and have that documentation there. I also think that since these codes don't really pay a whole heck of a lot of money you know, when you look at that G 20, 63, you're spending, you know, 21 or more minutes with them during a seven day period, you know, that payment's going to be somewhere between 32 to $36 depending on what state you're in, what locality you're in. So I don't see CMS really doing a bunch of audits on all of this stuff, but it's more just from a legal perspective and to protect yourself in case something happened where it happened with the patient.

Tannus Quatre (01:04:19):

Great. Thank you. So I've got one here. I'm gonna pose this to Hillary and then Sarah, you may want to chime in on this as well. Are you tracking COVID-19 related cancellations? How are you doing this in your EMR?

Hilary Foreman (01:04:36):

We are tracking missed visits in our EMR. We just haven't placed in the notes section. And we're just trying to look at it. We unfortunately are seeing quite a few many more and the home health side then on the senior living side. But I think as we go we are starting to see more and more people I want to say get more comfortable with infection control both on their side and on our side. So we expect to see that pick back up. Our customers are able to, for some of our products create custom questions or custom cancellation reasons so that they can just click that that was the reason and then they can run some cancellation reports on cancellations due to COVID-19.

Tannus Quatre (01:05:30):

Great. Related, do you know or have an estimate of how many PT clinics are still open versus temporarily closing doors due to COVID-19. Anybody want to take a stab at that?

Hilary Foreman (01:05:47):

I can speak for healthpro heritage that's very state specific. We have some States where it was ordered that they all closed, voluntarily closed due to whether or not they were treating a very immunocompromised caseload. They voluntarily chose to close for safety reasons. But I would say maybe half and half at this point for us.

Rick Gawenda (01:06:19):

And this is Rick, I think, is this an educated guess? I agree. I think it is state specific. I would also say it's probably also region specific within a state and the number of cases going on. And as I said already, the types of patients you're seeing in terms of diagnosis and also the age of the patient, their comorbidities, their risk for COVID-19. You know, obviously, did you have a patient that was now diagnosed with COVID-19 and they were already in your clinic yesterday or two days ago, three days ago. Is that going to force you then shut down and quarantine your staff? I think it's going to be a tough number to really figure out until months down the road.

Tannus Quatre (01:07:02):

Yeah. And some of the tracking that I've had some visibility into from a new claim flow perspective, I'm seeing we're seeing about 40 to 60% kind of in that range, regional specific decrease in the flow of new claims. And so you can kind of extrapolate from there in terms of what utilization is looking like in some private outpatient practices. So thank you. Okay, so this one's for Rick. When billing the G codes on a CMS 1500 form, would we bill just the CR modifier or would we bill GP CR or a PT E visit?

Rick Gawenda (01:07:45):

That is a great, great question. And you're going to love my answer. I think everybody knows my answer by now. We're seeking clarification of CMS on this and now if you are familiar with what CMS calls always therapy or sometimes therapies, CPT codes, those are the ones that always have to have the GP, the G O or the G. And modifier attach them when submitted to Medicare if done under a PT OT SLP plan of care, we're in the 2020 version of always in. Sometimes there'd be codes G 2061 G 2062 G 2063 are not listed in that file, which means right now as we talk today, they're not considered always or sometimes therapy codes, which technically means then GP, G O G N would not be required. However, we are hearing rumors from CMS that for some strange reason they're going to actually add G 2061 G 2062 G 2063 as sometimes therapy CPT codes. Then that would require GP, G N G O modifier, which then means they would actually apply to the annual therapy dollars threshold. Now that's what we're hearing rumors that they're going to do again, so we don't know right now, you know, because we're waiting for clarification. You know, obviously people like me, we've submitted all these questions to CMS trying to get clarification, but as you can imagine, they're swamped. They're trying to figure things out and we're just waiting for those answers to come out.

Tannus Quatre (01:09:28):

Thank you. Rick. got one here for Rick or perhaps Sheila. Do some of these probable changes in Medicare also apply to Medicaid?

Rick Gawenda (01:09:39):

Well it's number one. No. so you think Medicare changes is for Medicare and again, as I always say as I use the word Medicare, that is traditional Medicare doesn't include Medicare advantage. Now would that be in said by law, Medicare advantage plans at minimum have to offer and cover the same services that traditional Medicare does while since traditional Medicare is now covering. So they say those threeG codes, 2061 2062 2063. That means the Medicare advantage plan is also supposed to cover those codes as well. But this is not applied to Medicaid because Medicaid is state specific.

Tannus Quatre (01:10:27):

Great. Thank you. Okay. Hillary how many patients per day can a typical therapist see in part B in home care versus traditional settings?

Hilary Foreman (01:10:42):

Oh, it'll be significantly less. It depends on if you are doing the party in the home. On a senior living campus where the residents are much closer together or if it is in the larger community. So it is very different than a traditional clinic. It would be much more aligned to a home health type where you're counting more visits per day. So when doing modeling for that if you have access to what traditional, depending on your geography productivity expectations on the home health side, where they would be much closer to that. So it could be again, depending on your geography could be 50 to 60% of what a traditional outpatient would be. Thank you. Rick. Regarding initiation and consent by patient, does this have to be written or can it be verbal?

Rick Gawenda (01:11:41):

Well, it's going to be verbal. You almost find a recorded. So I would get it written just to cover yourself. So that again, I, you know, any time you're on this, these kinds of calls and as a consultant, you always gotta, you know, give I guess the most stringent advice or whatever. So I would say to have it written. And it could be something too that, you know, do you send them a document out and once they request a visit, do you create a document that you can send to them? Again, I'm not endorsing this product, you know, via DocuSign or some other format where this is all typed out and you had the patient, you know, electronically sign and date, you sign and date and then you say, that document is what I would do because you also gonna need to figure it out if you're going to be doing tele-health because how you get an EMU consent forms and all of that, that they're going to be consented to telehealth if they can be consented to being videoed and it'd be recorded and all of that.

Rick Gawenda (01:12:41):

So I will always say to try to have as much written down that a patient signs or they sent you an email, something like that that you can save to show just in case you got called out on it.

Tannus Quatre (01:12:55):

Great advice. Okay. What is synchronous versus asynchronous?

Rick Gawenda (01:13:03):

You know, asynchronous would be like that online patient portal. So again, I'm not endorsing the product called charm, so it's kind of a one way communication. It's kind of delayed. We're not live together. My doctor sends me an email, she maybe sends it at 11 o'clock in the morning. I comes into my email box. I may not sign into my account to eight o'clock tonight. I go lead, but she says I may or may not respond to her today. I may wait till tomorrow. Send her a question back or say thank you for sending. When should I come see you were synchronous talk communication, which is really what I think I hope you're going to be doing. If you're doing tele-health. It's live simultaneous two way audio, visual communication. So you know, think of face time. Okay. But you know, there's, and again, as I say some of these platforms and not endorsing them, like doxy, zoom. I know Google has something out there. There's a lot of platforms out there, think of FaceTime. So I can see Ben, Ben can see me. I can demonstrate exercise to Ben, I can watch, do the exercises, correct him. So it's live, simultaneous audio, visual communication.

Tannus Quatre (01:14:20):

Great. Thank you.

Rick Gawenda (01:14:21):

And again, I love Google. Just go to Google and type in asynchronous versus synchronous communication and all that will come up and you can also find different platforms you can use as well.

Tannus Quatre (01:14:35):

Okay. Awesome. okay. Hillary. I'm a physical therapist in private practice. Am I allowed to do in-home part B or is it only for a group practice and or rehab agency?

Hilary Foreman (01:14:48):

It would be for a rehab agency or a group practice. So there are ways to convert into those to be able to, there's some filings, again, depending on the state you're in that can easily allow for that. But you do have to go through some of those hoops to get there.

Tannus Quatre (01:15:07):

Okay. Thank you. Rick. Okay. So this one says just clarifying that we cannot do an evisit to qualify as a fifth or 10th visit.

Rick Gawenda (01:15:20):

Correct. So as we understand it an e-visit is not going to count as a visit towards the Medicare 10th visit progress report. So, for example, you know, you had a patient you know, come in and they had already had eight visits and then you shut the clinic down. A patient is apprehensive about coming in for an actual visit and now you do two eVisits, that's the next, you know, on March 26 and March 31st that's not visit nine and visit 10 towards a 10th visit progress report. So as we understand it today, e-visits do not count towards the 10th visit progress report. They don't count as an actual visit where a patient came in to see you.

Tannus Quatre (01:16:12):

Okay. Thank you. Okay. And I'm doing a time check here. We're going to continue for a few more minutes. We got a lot of questions coming in so we will do some followup from here. But, but I am going to kind of roll through a few final questions here. So this one can be, this may be Hillary, Sheila, Sarah. What PPE do you recommend or are you seeing in use for an asymptomatic home therapy patient?

Sheila Cougras (01:16:41):

This is Sheila. Hi. I would definitely recommend that you check with your local carrier or not your local carrier, but your local facility protocols and what supplies are available and what they have set up. It's been strongly recommended that protocols are set up at the local levels and what your state, local health departments are recommending. That would be your first place to check because I'm not sure which state you're in, but there is a website for all the States and you can check your local Health department.

Tannus Quatre (01:17:19):

Yes. absolutely. So we can work that into our followup communications. Here's another one. Can you elaborate? This is for Hillary. Can you elaborate a little more on the differences between home health provided via home health agency versus rehab company or provide a good resource, which explains the difference.

Hilary Foreman (01:17:39):

I'm sure I could actually provide we have a side by side that I could provide that you could share as part of the followups from this. A lot of it has to do with the billing process. Some of it has to do with credentialing of the therapists. For example, in a group practice, there's eight 55 B forms where therapists have their own PTN numbers. Only therapists can provide services under a rehab agency. Different States, different filings. Assistants might be able to provide those services to do the part B in the home. So there are the state specifics and then there's the therapist specifics. And then there's the billing specifics. So those are probably the three big buckets. But like I said, we have a side by side that I'll make sure that you have to send out.

Tannus Quatre (01:18:32):

Thank you. Hillary. Rick, are eVisits covered at the same 80, 20 percentage as a typical outpatient visit where the patient is responsible for a 20% co-insurance or that 20% gets sent along to their supplemental or secondary insurance.

Rick Gawenda (01:18:49):

Yes. CMS did say that the, you know, the G 2061 2062 2063 that they would count towards, you know, any deductibles, any co-insurance would apply. So again, the Medicare program and on my last slide where I gave you the pricing for Detroit, Michigan, the Medicare program with the 80% of that allowed amount and if they have a supplemental plan your that their Medigap plan, hopefully they would pick up the other 20%. They don't have a supplemental plan and then the patient would be responsible for the other 20%.

Tannus Quatre (01:19:26):

Thank you Rick. Are work comp carriers, paying for telemedicine for PT.

Rick Gawenda (01:19:34):

And my favorite answer, yes. No maybe so it depends and again, I noticed the answer people hate. Unfortunately back when I graduated PT school way back in 1991, it was pretty easy for us back then because every state just had one worker's comp. We've had Michigan worker's comp, Nebraska work comp California work comp, but now we have all these middlemen like align network, one call, med risk, etc. You have unfortunately have to do due diligence and check with every insurance company. And I'll be honest, you could call an insurance company and we're just going to make it Ben and you talk to Ben Monday, Tuesday, Wednesday, Thursday, Friday. And you asked them the exact same questions. I have days in a row and Ben gives you five different answers on five different days. Now that's not because he has five different personalities, more, no offense to the people on the insurance lines right now.

Rick Gawenda (01:20:27):

They have an impossible job right now there that they're not knowledgeable on COVID-19 and all of these changes that are going on and things like that. Because I'm hearing people all the time say, why called United health care? And they tell me they pay for telehealth with therapy. Where did you get the link? Did you get the citation somewhere on their website? No identity. Because if you go to the UHC website, UHC, that paid for telehealth. So again, what you're being told on the phone may or may not be correct. So again, very important to know how you're asking the question. And maybe kind of go for the answer you want to get, you know, kind of phrase the question. So the answer may be your way, but you have to answer your way. Ask them for the citation, you know, ask them on your website. Where is it, you know, can you walk me to a site? I can see it in writing cause it was not in writing. It may or may not be true what they're telling you on the telephone.

Tannus Quatre (01:21:27):

Thank you. Okay. So we're going to do three more questions and then we'll go ahead and wrap up at that point in time. So I just want to do a time check here. We're mindful of everyone's time. Hilary, how are you documenting new patient screening calls prior to initiating care?

Hilary Foreman (01:21:47):

In a variety of our systems we were able to add an additional note. In some systems we actually added the screening questions. So either we would do the screening questions and then the patient note would be together. So then once we did the visit, they would be together. And in some cases we've done the screening questions followed by a withheld or a refusal. If something in that screening then indicated that we should not be seeing the patient that day or they refuse that day or whatever those challenges might be. But we actually had added those to the system for that exact reason.

Tannus Quatre (01:22:28):

Thank you. Sarah, do you have anything to add on that? I'm not sure if there's anything that you're seeing with customers documenting screening calls.

Sarah Irey (01:22:36):

I would agree definitely with Hillary. The only thing is, you know, check with your organization.

Sheila Cougras (01:22:42):

Depending on, you know, your organization might want you to put it in your registration software if you have a hospital interface versus the actual act up documentation application. But definitely important to document those screens.

Tannus Quatre (01:22:58):

Okay. Thank you. Okay. Rick, are there any differences for critical access hospitals with telehealth? Evisits billing or reimbursement?

Rick Gawenda (01:23:10):

You know, again, with the e-visits we are waiting for clarification and CMS on, you know, can non-private practices, you know, go for the G codes, be paid for the G codes. So once we get that answer, of course that would apply, you know, whether you're a hospital or a regular hospital a while. So, you know, put a class that's health was, you are not paid under the Medicare physician fee schedule. You are paid any cost ratio basis. That's the other code unknown. And again with Keller house, do you want to check your conditions or participation with the Medicare program as a telehealth provider? Again, Medicare does not pay for telehealth, then they have to meet the two contracts with the other insurance companies that you've signed. So again, I think whether you're a critical access hospital, a regular hospital, your home health agency, do you impart, be in the home, you're a private practice. It's kind of doing your due diligence and check in with all those other insurance companies.

Tannus Quatre (01:24:09):

Okay. Thank you. So, Sheila, I'm going to direct this one to you. And this is in, and then more broadly, we're getting a lot of questions have come in about specific guidelines with regard to protecting employees and patients and use of masks and PPE. So, the one question that I think encapsulates it here, do employees have the right to refuse to treat positive COVID-19 patients if PPE is not available? We know that PPE is in short supply and not available in some areas. And so the way that I think that we should frame this up is do you have a recommendation for resources that our audience can use locally that can help guide them in the right direction for some of these broad questions about safety of caregivers and how they're treating patients in this COVID-19 period.

Sheila Cougras (01:25:04):

Yes, that's a really tough question. There are some resources like you said, that they could check with our state practice acts as well as looking at their local professional chapters and seeing if they can provide guidance there as well as their local health departments. And what are their rights? Is employees and receiving that PPE, I am hearing that quite a bit. And it's all over the news. That PPE, is it a high demand and there's shortage everywhere across the country. So that's a really hard one for me to give guidance or advice on, but there definitely are resources where you could check where are your rights in protecting yourself when you're employed. So I would start with your state practice act as well as your professional organizations and your local health departments.

Tannus Quatre (01:26:01):

Great. Thank you. Okay. So we're about to wrap it. There have been some questions coming in about access to these materials including the slide deck. Yes, we will make this all available to you. The recording. I think it's going to come out to you automatically and we will find a way to get you the slide deck as well, whether that's an included in a link in that email or some other means. So yes, we'll make sure that you've got all of the information here. I want to thank our presenters. This is just you know, we spun this up very quickly you know, over the past few days, I really appreciate you taking the time and investing in our ability to help our rehab professionals get this valuable information.

Tannus Quatre (01:26:47):

So special thank you to Rick Gawenda and Hilary Foreman. Also Sarah and Sheila for helping us put this together and to all of you that are out there on the front lines adapting your business models to continue the rehab care that is needed in your communities. We just really appreciate you. Thank you and are thinking about you constantly. We will have additional webinars that are coming out of the net health organization by you registering for this webinar. We will be able to make contact with you and let you know about those if you would like to attend more sessions and once again thank you so much for attending be safe and be well.

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