• Teleophthalmology: How to Get Started


    Prompted by the COVID-19 pandemic, the Centers for Medicare & Medicaid Services has allowed health care practices to provide outpatient telehealth services to patients in a remote location.

    You and your practice can now provide telehealth services to new and established patients. However, the policies on what is covered and how to code for services change frequently and coverage varies by payer. Monitor web page on telehealth for the most up-to-date information.

    Some key items to remember:

    • Coding. The Academy has issued guidance about how to code your claims for telehealth services.
    • Health Insurance Portability and Accountability Act (HIPAA). CMS has waived HIPAA and site-of-service requirements and temporarily allowed the inclusion of new patients during the COVID-19 crisis. (See more about HIPAA below.)
    • Payments. Commercial insurers and Medicaid programs may vary.
    • Consent. In all cases, patients must be informed that a charge will be submitted to their insurance plans.

    Synchronous Audio and Video Visits

    Visits are covered under CPT codes 99201-99215.

    Smartphone or web interface (not electronic health record portal). Common platforms include FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, Go-To-Meeting and Skype.

    • Connect with the patient using one of these audio-video connections.
    • Document patient consent.
    • Start your timer.
    • Complete medical history and history of present illness (HPI) updates, update medical record.
    • You can watch or perform visual acuity testing, and the patient (or other person) can position the camera to view the external structures, as well as attempt to visualize a red reflex.

    Testing Visual Acuity Using a Chart or Web-based System

    The Academy has printable instructions on how patients can test their vision at home. Here are the charts they can use:

    Adults (PDF) Amsler Grid (PDF) |  Children (PDF)

    • Perform the external exam, pupils, eye movements and alignment and pen light anterior segment with a camera. The patient can share additional selfie images separately for documentation but they are not separately billable.
    • Conduct medical discussion, including questions from the patient and family.
    • Document the time of the visit.

    For EHR built-in systems that support videoconferencing: Practices with sophisticated EHRs can use the patient portal.

    There are specific rules for each EHR system, including scheduling and access for the patient including consent, patient location (currently waived restriction) and then logging in to the EHR portal. This can be challenging for patients.

    Testing Visual Acuity Using a Local Chart or Other Available Platform

    • Perform the external exam, pupils, eye movements and alignment and pen light anterior segment with a camera. The patient can share additional selfie images separately for documentation but they are not separately billable.
    • Medical discussion including questions from patient and family.
    • Document time of visit.

    Virtual Check-ins

    As a HCPCS code, G2012 may be a Medicare-only service that does not require adherence to the evaluation and management (E/M) documentation guidelines. A brief, five to 10-minute check-in with physician via telephone or other telecommunications platforms. Document patient consent and time in the record.

    Important: There is currently no Medicare payment for calls that are shorter than five minutes.

    Asynchronous Visits

    These services include reviewing photos and other images with a reply to patient (G2010) or communication through a portal or email (99421, 99422, 99423). Typically, there would be a telephonic or electronic check-in with the patient reported to review these services (G2012 can be used).

    Nonpublic facing remote communication products would include, for example, platforms such as: Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, or Skype.

    Text Check-ins

    CMS has added texting to the list of asynchronous communications (see question 10 under the Department of Health and Human Services Office for Civil Rights' frequently asked questions) on texting programs such as Signal, Jabber, Facebook Messenger, Google Hangouts, Whatsapp or iMessage.

    Interprofessional Contacts/Consults

    These consultations may be billed under certain circumstances. Reference the Academy's coding guidance. They include:

    • Email, text
    • Other system platforms

    Remote Inpatient Consults

    Details for remote inpatient consults are still being developed.

    Licensing

    Requirements are being relaxed. But they do vary widely by state and are less relaxed than reported. Find the latest information on licensing on the Federation of State Medical Boards website.

    HIPAA Requirements

    In light of the COVID-19 nationwide public health emergency, the Department of Health and Human Services Office for Civil Rights (OCR) is exercising its enforcement discretion and will not impose penalties on physicians using telehealth in the event of noncompliance with the regulatory requirements under HIPAA as long as the platform used is not public-facing.

    Allowed platforms that are not HIPAA compliant include FaceTime, Facebook Messenger video chat, Google Hangouts video, Skype and text. Public facing platforms that are not allowed are Facebook Live, Twitch, and TikTok because they let others to view an exchange.

    Liability/Legal

    The best practice is to obtain consent and remind patient this communication is not the same as a face-to-face exam with appropriate legal verbiage. For example, you could document the consent by reporting, “Patient initiated a request for care and consented to care by phone.”

    State Requirements for Telehealth

    The Center for Connected Health Policy is posting national as well as state-by-state fact sheets.

    Contact

    Have questions? Send comments and questions to healthpolicy@aao.org.

    Further Resources

    FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency. Department of Health and Human Services. Office for Civil Rights.