By Rajnish Mago, MD (bio)
Healthcare delivered by telemedicine has been increasing due to many reasons:
– Due to the availability of broadband internet, video conferencing is now widely available at relatively low cost.
– There is a shortage of clinicians, especially specialists, in many parts of the country. Telepsychiatry can increase access to care while also reducing clinician burnout (Gardener et al., 2020).
– Many studies have shown that psychotherapy for anxiety and depression can also be delivered safely and effectively by telepsychiatry (Tuerk et al., 2018).
– Telemedicine care is so much more convenient than in-person visits. Think of the time it saves patients and/or clinicians if they don’t have to commute.
– Telemedicine care is inexpensive, generally costing less than in-person care.
On this page, we will discuss some of the commonest questions that are asked by mental health clinicians who are considering starting to do part or all of their clinical work through telepsychiatry.
Warning and disclaimer! The contents on this page are provided to clinicians for general informational purposes only. They do not constitute specific advice for a particular clinician or situation. In the US, laws governing telepsychiatry vary from state to state and may change. So, clinicians must check with their state’s board of medicine and with their malpractice carrier before proceeding to use telepsychiatry to see patients.
What constitutes telepsychiatry?
Sorry–for reimbursement purposes, a telephone call alone is not considered telemedicine by either government or private insurances. To get reimbursed for a full visit, the visit HAS to have both audio and video. For a discussion of what tools can be used for telepsychiatry, see the following page: A comparison of telepsychiatry platforms.
Does telepsychiatry work?
Is the care delivered by telepsychiatry substandard? Not at all! Many studies have shown that the outcomes of treatment delivered by telepsychiatry are just as good as those from in-person care if not better (Hubley et al., 2016). Also, both patients and clinicians report high degrees of satisfaction with telepsychiatry visits.
Fancy equipment is NOT essential for telepsychiatry! We shouldn’t get too caught up in buying a special computer, microphone, headset, etc. The webcam and microphone built into the computer are usually good enough.
What is important is the internet speed at BOTH our end and the patient’s end. Both we and the patient can find out our internet speed easily by simply googling the words “test my internet speed”. See the image below.
When you click on “RUN SPEED TEST”, the test runs and in less than a minute, we get the results. See the image below:
One of the great things about telemedicine is that a clinician does not have to be in the same city or even the same state as the patient. But, if the patient and the clinician are in different states, which state does the clinician have to be licensed in?
Note: We may think or wish that the laws were different but they are what they are.
In 49 states (and in District of Columbia, Puerto Rico, and the Virgin Islands), the medical boards require that the physician providing care via telemedicine must be licensed in the state in which the patient is physically present at the time of the telemedicine session. That is typically the state where the patient lives, but it doesn’t have to be.
Because of this, many clinicians whose practice consists of a considerable amount of telemedicine care (or entirely so) get licensed in multiple states. This allows them to use telepsychiatry to see patients living in those states.
Note: We have to be licensed in the state where the patient physically is at the time of the telepsychiatry visit, not where the patient lives. For example, if a patient who lives in New York is visiting family in Florida at the time of the telepsychiatry visit, we would have to be licensed in Florida to be allowed to see the patient by telepsychiatry while they were in Florida.
Also, we, of course, have to be licensed in some state, but we don’t HAVE to physically be in that state at the time of the telepsychiatry session.
But, we should go the website of the state where the patient is and look at any special requirements or options that state may have. For example, in 12 states, the state boards of medicine issue a special purpose license or certificate allowing patients to be seen across state lines by telemedicine (Federation of State Medical Boards, 2019). That is, instead of needing to get a full, unrestricted license, we can get a limited license for seeing patients in that state only through telepsychiatry. In 6 states, the state boards of medicine require physicians to register with the board before practicing across state lines (Federation of State Medical Boards, 2019).
Note: This requirement to be licensed in the state where the patient is at the time of the visit does not apply to clinicians working in federal health care systems (Department of Veteran Affairs, Department of Defence, Indian Health Services). They can generally be licensed in any one state and see patients within that system who are located anywhere in the US. But, these clinicians should look up the rules and regulations of their organization about telepsychiatry to see if the organization has any other requirements.
To emphasize the importance of obtaining licensure before seeing a patient in another state via telepsychiatry, let me quote from a guide on telepsychiatry by PRMS, Inc, a leading malpractice carrier:
“If you are tempted to proceed without requisite licensure consider this. In many states the practice of medicine without a license is considered a criminal act. Should you be involved in a claim or a lawsuit, coverage may be denied as criminal acts are an exclusion under malpractice insurance policies. In a worst case scenario, you might find yourself subjected to criminal prosecution, licensing board actions, and a malpractice lawsuit all without defense coverage.”
Some malpractice insurance companies include coverage of telepsychiatry in their standard policies. But, some others do not and need us to purchase separate coverage to cover our telepsychiatry work.
So, it is VERY important that before seeing any patients through telepsychiatry, we should contact our malpractice insurance company to ask whether telepsychiatry is covered by our current policy.
Standard of care
Clinical care delivered through telepsychiatry is held to the same standards as in-person care. So, EVERYTHING that we would do in an in-person visit needs to be done, one way or another, in a telepsychiatry visit as well. If, for some reason, the quality of clinical care would be compromised if a particular patient is seen via telepsychiatry (this is not common), then that patient should not be seen by telepsychiatry.
Along with informed consent to the evaluation and the treatment, another specific informed consent needs to obtained AND documented—to care by telepsychiatry.
Commonly, getting this consent orally and documentinig it briefly is enough. But, some states may require written informed consent to telepsychiatry. So, when we are looking up state regulations about telepsychiatry, we should look this up as well.
The good news is that we can prescribe any medications that are not controlled substances without EVER seeing the patient in-person.
Under usual circumstances, for prescribing a medication that is a controlled substance, we have to first do an in-person medical examination. This is mandated by an important law called the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, or more commonly, simply the Ryan Haight Act. The law does not specify whether the in-person examination has to be done just once before the very first prescription of the controlled substance or has to be repeated. It has been suggested that an in-person examination should probably be conducted at least once every two years to be in compliance with the Ryan Haight Act (American Psychiatric Association Telepsychiatry Toolkit).
There are some exceptions to the requirement to do an in-person examination before prescribing a controlled substance. For example (not a complete list):
– Prescribers who are covering for another prescriber (thank God!)
– When the patient is currently in a hospital or other facility that is registered with the Drug Enforcement Administration (DEA) AND the prescribing clinician has a DEA license in the state where the patient currently is.
But, the Controlled Substances Act contains certain exceptions to the requirement to conduct an in-person medical examination for prescribing a controlled substance through telemedicine. For example, that requirement is waived when the Secretary of Health and Human Services declares a public health emergency. On January 31, 2020, the Secretary of Health and Human Services did declare such a public health emergency. The DEA notes that “For as long as the Secretary’s designation of a public health emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation” (source)
Coverage by Medicare
So far, Medicare would only pay for telemedicine care for established patients, that is, a patient who has been seen at least once by that clinician, and in certain situations, e.g., for patients living in rural areas. Also, patients had to travel to a local medical facility to get telehealth services and could not receive telehealth services in their homes.
But, during the COVID-19 crisis, Medicare will TEMPORARILY pay for telehealth services for patients without their having to travel to a healthcare facility. The CMS website notes: “A range of healthcare providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to Medicare beneficiaries. Beneficiaries will be able to receive telehealth services in any healthcare facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.”
Also, CMS has specifically said that during the emergency, it will NOT enforce the previous “established relationship” requirement for telemedicine. That is, Medicare will pay for telemedicine care even if the patient was not previously seen in-person by that clinician (source).
The Fact Sheet on this announcement is available at the following link: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
Frequently Asked Questions about this announcement are answered at the following link: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
Coverage by private Insurances
Private insurances may or may not pay for telepsychiatry visits; some do and some don’t.
In 40 states and the District of Columbia, there are state laws regulating the telemedicine reimbursement policies of private insurances (Federation of State Medical Boards, 2019). States that have NOT passed laws to improve reimbursement for telemedicine care include New Mexico, South Carolina, West Virginia, Ohio and Michigan (American Telemedicine Association, 2019).
Some states go further and have private payer parity laws (Federation of State Medical Boards, 2019). These include California, Maine, Michigan, New Jersey, New York, Texas, and Virginia. These laws require private insurance companies to pay the same for medical care provided via telemedicine visits as for in-person visits. This information is best looked up on the website of the board medicine of the state where the patient is. But, another website to get information on this and other state laws related to telepsychiatry is www.cchpa.org.
In general, for both government and private insurances, the SAME billing codes are used for telepsychiatry as would be used for an in-person visit, e.g., E & M codes.
But, there are two special things that we need to do with regard to billing codes:
1. When billing is submitted, there also a code for place of service. For example, if the patient is seen in an outpatient office, the place of service code is 11.
2. There has to be some additional code to show that the visit was done using telemedicine. Previously, Medicare required the use of the GT modifier, that is, the addition of the letters “GT” after the code, e.g., 99213GT, to indicate that the visit was done “via interactive audio and video telecommunications systems”. But, this was eliminated and instead, the “use of the telehealth Place of Service (POS) Code 02 certifies that the service meets the telehealth requirements” (source). But, many private insurers want the GT modifier to be added on to the billing code. An alternative to the GT modifier the addition of “95” to the billing code.
CPT procedure codes a new patient evaluation or E&M visits for non-COVID-19 patients are listed under “Scenario 10” (scroll down to get to Scenario 10) on the AMA’s website. On-line visits via a patient portal or e-mail are listed under “Scenario 11”. Both are available at this link.
A full list of Medicare billing codes for telehealth is available at the following link:Covered Telehealth Services CY 2019 and CY 2020 (Updated 11/01/19) (ZIP)
To be able to act in an emergency, for every telepsychiatry visit, we should make sure we know:
1. Exactly where the patient is right now (the street address).
2. The patient’s phone number, in case we have to contact the patient by phone if the telepsychiatry platform fails.
Along with this, it has been recommended that, when possible, a “patient support person” should be identified who can help the patient with various things if needed. If such a support person is available, we should have that persons’ phone number as well.
A simple thing to remember is that if the police need to be called and dispatched to where the patient is, we should not call 911 because that call is routed locally to near where we are located. Instead, we would have to identify the police station closest to where the patient is located. One way to do this is to Google “police station near xxxxx” where xxxxx is the address where the patient is located.
Telemedicine platforms or vendors
Please see the following article on this website:
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