Telehealth

• Check with your professional liability insurance carrier to ensure your policy covers providing care via telemedicine. The professional liability insurance offered through the Academy's Member Advantage Program (Proliability administered by Mercer Consumer) does not exclude telehealth/telemedicine services.
• Familiarize yourself with the interim telehealth policies with any payers for whom you are a network provider. If telehealth policies do not specifically identify RDNs or MNT, seek clarification from provider services/provider relations (not customer service, which is for health plan members) or relevant department.
• Ensure that you are providing services in accordance with your state laws and regulations.
• Licensure:
  • If you are licensed in the state where the patient is located, there are no additional requirements.
  • If you are not licensed in the state where the patient is located, you are likely to be required to become licensed either (1) to provide MNT at all to clients or patients in that state or (2) to be eligible to provide nutrition care services via telehealth in that state. View the Academy’s interactive Licensure Map for help in answering the question, “Can I practice in this state?”
  • To support the delivery of nutrition services across state lines and via telehealth by RDNs during the COVID-19 national emergency, the Academy has itemized certain licensure requirements and exemptions in a state-by-state table.
  • Information will continue to be updated as policies and interpretive guidance evolve. In addition, there are often specific rules requiring a license to provide telehealth services to Medicaid beneficiaries. Medicaid waivers to these requirements must be requested by the individual state that wants to use them. Although many states have temporarily relaxed regulations related to the provision of certain telemedicine services, we recommend you contact your state department of health, state dietetics board, or state medical association for up-to-the-minute information in your state.

This content is designed to provide information only and not intended to endorse any specific products or services.

You will need to use communications technology that complies with payer requirements to provide MNT to your patients remotely. Medicare and several payers have relaxed requirements during the public health emergency. Services delivered via the telephone may not be included as state laws and payer policies typically require audio-video interactions. Medicare is permitting audio-only delivery for MNT services (97802-4, G0270), as of March 1, 2020. Make sure to get clarification from private payers and state Medicaid programs regarding the ability to provide MNT telephonically.

• If you are currently using a practice management system or electronic health record, check with the vendor about telehealth functionality.
• Carefully review Business Associate Agreements for any telehealth platforms you are considering. Understand who has access to, and owns any data generated during a patient visit.
• Ask colleagues what telehealth platforms they are using. Inquire with other Academy members via DPG list servs and the Reimbursement online community.
• Consider ease-of-use for both the RDN and clients.
• Consider whether you need a document sharing feature in a telehealth product.
• Get clear on the pricing structure (e.g., monthly rate, subscription, per visit fees).
• Confirm you have internet service that is optimal for supporting any telehealth platforms or any approved temporary communications technologies. The amount and speed of the internet connection, along with Wi-Fi signal strength where utilized, will impact the video quality and amount and speed of data transfers.
• Compare the technical support available from telehealth vendors.

Non-public Facing Communications Technology to Provide Services via Telehealth

Medicare is allowing temporary use of non-public facing communications technology to provide services via telehealth. The Department of Health and Human Services Office for Civil Rights will temporarily waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday non-public facing remote communications technologies during the emergency. Keep in mind you may still have state requirements to meet.

Under Medicare, RDNs may temporarily use popular applications that allow for video chats. RDNs should notify patients that these third-party applications potentially introduce privacy risks. Take all steps to use available encryption and privacy modes when using the following applications. These include:

• Apple FaceTime
• Facebook Messenger video chat
• Google Hangouts video
• Whatsapp video chat
• Zoom
• Skype

Text messaging may temporarily be used to communicate with patients, including to provide online assessment and management services (G2061-G2063), using the following commonly used applications:

• Signal
• Jabber
• Facebook Messenger
• Google Hangouts
• Whatsapp
• iMessage

The following applications should not be used as they are public facing:

• Facebook Live
• Twitch
• TikTok and similar video communication
• Chat rooms such as Slack

Additional notes about selecting technology platoforms:

• RDNs should seek clarification with commercial payers and Medicaid programs regarding rules and standards.
• Be aware that if you are using personal devices to access any of the temporarily approved communications technologies, clients/patients may have access to your personal telephone numbers. There are apps available, such as Doximity, that allow clinicians to securely contact patients while also masking your own cell phone number and replacing it with your office number in the caller ID.
• Ensure you and your client/patient have adequate battery/power and bandwidth if using cell phones or tablets.
• RDNs who wish to provide MNT via telehealth beyond the time frame of the public health crisis will want to identify a telehealth platform that meets standard HIPAA and payer requirements. The list below includes some vendors that represent that they provide HIPAA-compliant video communication products and that they will enter into a HIPAA BAA:
  • Skype for Business / Microsoft Teams
  • Updox
  • VSee
  • Zoom for Healthcare
  • Doxy.me
  • Google G Suite Hangouts Meet
  • Cisco Webex Meetings / Webex Teams
  • Amazon Chime
  • GoToMeeting
  • Spruce Health Care Messenger

Review and update all processes associated with appointments:

• Determine whether scheduling modifications are needed.
• Confirm/understand the location eligibility (setting for the client/patient) for each payer.
• Train team members, schedulers, and others as applicable.
• Determine how client insurance information will be obtained (e.g., insurance cards).
• Review the Office of Civil Rights announcements regarding temporary adjustments under HIPAA.
• Determine processes for sharing patient policies and complete forms (e.g., HIPAA policy and acknowledgement form, telehealth consent, financial policy, authorizations for release of medical information, and any other forms relative to your practice).
• Obtain and document patient consent for telehealth interventions. Check to see if your telehealth vendor can support electronic consent.
• Consent requirements for providing services via telehealth have been relaxed during the public health emergency. Consent to provide services via telehealth should still be obtained. Provided are sample telehealth consent forms form the Agency for Healthcare Research and Quality and the American Academy of Pediatrics.
• If you are unable to obtain written consent, verbal consent is temporarily permitted. Be sure to document how and when consent was obtained as part of the patient/client record.
• Check to see if your telehealth vendor can support electronic consent.
• Determine how you will collect payment from patients. Refer to payer policies regarding patient copayments and cost sharing during the COVID-19 public health emergency specifically, as many payers are waiving copayments for services provided via telehealth.
• Determine how you will issue receipts, including consideration for receipts that may require protected information (e.g. IRS requirements for Flex Spending Accounts, Healthcare Savings Accounts).
• Review and update financial policy if applicable.
• Conduct a practice session before you use any new platform.
• Update voicemail, website, and social media to let your patients know your practice is now offering telehealth services.
• Provide instructions on how to access telehealth visits based on your practice's technology and workflow to maximize appointment time and avoid disruptions to care.
• Identify and set up a quiet and professional space. Notice what your patients/clients will see.
• Familiarize yourself with where the camera is positioned on your device, and practice looking directly into the camera to ensure good client interaction.
• Identify teaching aides (labels, food/product photos) for telehealth purposes.
• Determine how information (e.g. action plan, recommendations, written educational materials) will be provided to the client (e.g., email, provider portal, website) if not using a telehealth platform that enables document sharing.
• Consider employing multiple monitors to accommodate client visibility as well as documentation requirements.
• Ensure you are still properly documenting visits as you normally would with an in-person visit.
• Consider taking screen shots as one way to document the time spent with patients while using time temporarily approved non-public facing communications technology.

Medicare pays RDN Medicare providers for covered services furnished to beneficiaries in all areas of the country in most settings.

• Coverage and payment for telehealth is no longer limited to rural areas during this public health emergency.
• Temporary rules allow RDNs to provide MNT and other Medicare Part B covered services via telehealth to patients in expanded settings. The clients/patients can use temporarily approved communications technologies from their homes
• RDN Medicare providers who shift their practice location to their home do not need to update their Medicare enrollment file to include their homes as the place of service. They can continue to bill from their currently enrolled location.
• Temporary rules allow RDNs to provide the following services using the telephone (audio-only technology) for services rendered as of March 1, 2020, when audio and video are not possible: MNT (97802, 97803, 97804, G0270), DSMT (G0108, G0109), and IBT for obesity services (G0447). As a reminder, RDNs are not recognized billing providers by Medicare for IBT.
• Medicare will temporarily reimburse RDNs for providing telephone assessment and management services (98966-98968) with new or established patients, after at least seven days following an MNT visit. These codes are not to be used when providing MNT.
• CMS is temporarily offering expedited enrollment for new Medicare providers to receive temporary billing privileges. RDNs can call the toll-free hotline for the Medicare Administrative Contractor that services their geographic area and enroll over the phone. They will be notified of their approval or rejection during the phone conversation.
• The temporary changes (CMS waivers) and the CARES Act allow Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to temporarily act as distant site providers for Medicare telehealth services. This means that RDNs who work in FQHCs can provide MNT to patients of their own health centers, and patients can be in their homes. Providers can deliver services from their home if they are working from home on behalf of the health center. CMS still needs to issue further guidance around how they will be implementing these changes.
• Services are not limited to patients with COVID-19.
• For suppliers and beneficiaries enrolled in a Medicare Diabetes Prevention Program (MDPP) as of March 1, 2020, CMS is making the following temporary changes to MDPP:
  • The limit to the number of virtual make-up sessions is waived.
  • MDPP beneficiaries may receive a maximum of one regular session per day and a maximum of one virtual make-up session per week during the core session period. Beneficiaries may receive one make-up session on the same day as a regularly scheduled session.
  • Virtual make-up sessions may only be furnished to achieve attendance goals and may not be furnished to achieve weight-loss goals.
  • An MDPP supplier may offer to an MDPP beneficiary no more than:
    • 16 virtual make-up session offered weekly during the core session period
    • 6 virtual make-up sessions offered monthly during the core maintenance session interval periods
    • 12 virtual make-up sessions offered monthly during the ongoing maintenance session interval periods
  • MDPP beneficiaries who were receiving services as of March 1, 2020 and whose sessions were paused or cancelled during the public health emergency are permitted to obtain the set of MDPP services more than once per lifetime.
  • Virtual services must be furnished in a manner that is consistent with the CDC Diabetes Prevention Recognition Program (DPRP) standards for virtual sessions, follow the CDC-approved DPP curriculum requirements, and be provided upon the individual MDPP beneficiary's request.
  • The requirement for in-person attendance at the first core service remains in effect.

• MNT provided via telehealth is still MNT. The CPT^® codes used to submit claims to Medicare (most private payers and Medicaid) for in-person visits are the same codes used for telehealth: 97802, 97803, 97804, G0270. Find more information about CPT^® and G codes for RDNs.
• CMS1500 Claims: During the COVID-19 emergency you do not need to use Place of Service code 02 - Telehealth when submitting claims to Medicare. Continue to use the same Place of Service code you would use if the service had been provided in-person. Modifier 95 should be applied to claim lines that describe services furnished via telehealth, regardless of whether the MNT or DSMT was provide using approved audio-visual technology or audio-only communication (telephone).
• Outpatient (hospital): On April 30, 2020 CMS announced that MNT and DSMT can be provided in the hospital outpatient setting (Provider-Based Departments) remotely to a patient in their home, effective for services rendered March 1, 2020. Services should be billed the same as if they were provided in-person. Patients must be registered as hospital outpatients. RDNs can seek further direction from and collaborate with compliance/regulatory and billing staff at their hospitals. For more information read the CMS Guidance.
• Get clarification from private payers and state Medicaid programs for how to submit claims for MNT provided via telehealth.
  • Place of service code, if other than (02), and/or
  • Use of any modifiers. For example, modifier 95 describes synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.
• Rural Health Centers (RHCs): When RDNs in RHCs provide MNT via telehealth to Medicare beneficiaries, the RHC will be paid $92.03 for the telehealth interaction. The All-Inclusive Rate (AIR) will be paid, but these claims will automatically be reprocessed in July with the new payment rate.
  • Use the HCPCS code G2025 with modifier “CG” on the claim for services furnished via telehealth through June 30, 2020. After July 1, 2020, the CG modifier does not need to be used.
  • The home became an eligible originating site on March 6, 2020.
  • For more information read the CMS guidance.
  • Confirm policies for Medicaid and private payers.
• Federally Qualified Health Centers (FQHCs): When RDNs in FQHCs provide MNT via telehealth to Medicare beneficiaries, the FQHC will be paid$92.03 for the telehealth interaction. The Prospective Payment System (PPS) rate will be paid, but these claims will automatically be reprocessed in July with the new payment rate
  • Claims should include the following information:
    • Provide the respective PPS specific payment system codes (GO466, G0467), and
    • The HCPCS/CPT code that describes the services furnished via telehealth (e.g., MNT; 97802, 97803, G0270, or DSMT G0108) with modifier 95; and
    • HCPCS G2025 with modifier 95
  • Beginning July 1, 2020, FQHCs will only be required to submit G2025 where modifier 95 may be appended but is not required.
  • The home became an eligible originating site on March 6, 2020
  • For more information read the CMS guidance.
  • Confirm policies for Medicaid and private payers.
• Medicare will temporarily reimburse RDNs for providing telephonic assessment and management services (98966-98968). CMS is temporarily relaxing enforcement of the restriction of use of these codes to established patients. As a reminder, the assessment and management codes are not to be used when providing MNT. Rather, they should be used for telephone interactions with patients, families and caregivers to address questions that arise between visits.
• There are new codes for which RDNs may be reimbursed for electronic communication with established patients. The new online assessment and management services for established patients (G2061, G2062 and G2063) are payable under Medicare when requirements for using the codes are met. Check with private payers to confirm adoption of and payment for the equivalent CPT codes (98970, 98971 and 98972). For more in-depth information, read the November 2019 issue of the MNT Provider CMS is temporarily relaxing enforcement of the restriction of use of these codes to established patients.
• Medicare pays for MNT provided via telehealth at the same rate as in-person visits. See the Medicare physician fee schedule for more information. The Coronavirus Aid, Relief and Economic Security (CARES) Act increases payments to RDNs and other Medicare providers by two percent by temporarily suspending sequestration. Clarify rates with private payers and Medicaid as they may or may not pay for telehealth services at the same rate as an in-person encounter.
  • For more information on state payment parity laws, refer to the Center for Connected Health Policy.
• Certified providers of accredited Diabetes Self-Management and Training programs can provide DSMT and submit claims to Medicare using codes G0108 and G0109. Services can be provided by any provider type under the accredited and recognized DSMT program (RDNs, RNs, pharmacists, etc.). Programs contracted with private payers and Medicaid programs should seek clarification regarding telehealth policies.
• RDNs providing MNT to Medicare Advantage (Medicare Part C) enrollees should contact Medicare Part C plans directly as CMS has issued guidance allowing these plans to provide enrollees access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries' homes.
• Current telehealth policy information may be accessed through provider portals.
• If you are out of network with a client/patient's health insurance company or other provider network, do not assume that temporary telehealth policies apply.
• The America's Health Insurance Plans website provides broad summaries of private payer policies in response to COVID-19.
• The Blue Cross Blue Shield Association website has an interactive map to connect with state franchise policies in response to COVID-19.
• The Center for Connected Health Policy website provides a quick glance at state telehealth actions in response to COVID-19 with links to further information.

Key questions to ask private payers and Medicaid about billing for services provided via telehealth (Make sure to contact provider services and not customer service):

• Is the fee schedule for MNT delivered using telehealth the same as in-person visits?
• What place of service code should I use?
• Is a modifier required? If so, which modifier?
• What communications technologies are allowed?
• Can services be provided telephonically? (e.g., if client does not have access to technology or internet).

• National Telehealth Resource Center
• Center for Connected Health Policy
• COVID 19 Updates from the Academy of Nutrition and Dietetics