AAPPM CHECKLIST TO PREPARE PHYSICIAN OFFICES FOR COVID-19 - July 1, 2020
PICA COVID-19 OFFICE REOPENING CHECKLIST – May 12, 2020
APMA COVID-19 HEALTH RESOURCES – May 8, 2020

The APMA has compiled a list of resources on the subject of clinician well-being and burnout. Take some time to learn more about burnout, the importance of work-life balance, and how to talk about substance abuse, suicide, and other difficult topics.

These resources are available at: https://www.apma.org/wellbeing

ADDITIONAL HHS PROVIDER RELIEF FUNDS MADE AVAILABLE – May 8, 2020

HHS announced additional plans for distributing funds from the CARES Act Provider Relief Fund, stating that $50 billion would be a “General Distribution” based proportionately on the provider’s 2018 net patient revenue. Providers have already received $30 billion via this fund. Of the remaining $20 billion, approximately $10 billion was scheduled to be released on April 24 to providers who have already shared key data with HHS.

Providers who already have received funds from the initial $30 billion must sign into the general distribution portal to provide revenue data if they would like to receive additional funds. https://covid19.linkhealth.com/docusign/#/step/1 Providers must attest to each payment associated with their billing Taxpayer Identification Number(s), if they have not already done so. Providers will also need to attest to the Terms and Conditions for the first $30 billion if they have not already done so. HHS has extended the deadline for providers to attest to receipt of funds under the CARES Act Provider Relief Fund and accept the program’s terms and conditions. Previously set at 30 days from the date of receiving funds, providers now have 45 days from this date to complete their attestation. 

HHS has released a user guide to assist with this data submission process. One key element of the cost reporting is information from the provider’s tax returns. Additionally, providers will need their W-9 and Medicare or Medicaid ID number. 

APMA’s understanding is that the total funds being provided in this round will take into account any funds the provider previously received as part of the $30 billion distribution. Subsequent to the funds being deposited, within 30 days of receipt of the funds, the provider is requested to log onto the CARES Act Provider Relief Fund attestation portal to confirm receipt and agree to the terms and conditions. Please note that these terms and conditions are not identical to those for the $30 billion distribution. Additionally, according to HHS, if providers receive a payment from funds appropriated in the Public Health and Social Services Emergency Fund for provider relief (“Relief Fund”) and retain that payment for at least 30 days without contacting HHS regarding remittance of those funds, they are deemed to have accepted the terms and conditions. 

For more information, visit www.hhs.gov or call the CARES Provider Relief line at 866-569-3522.

APMA OFFERS LOAN PROGRAM WITH BANKERS HEALTHCARE GROUP – May 8, 2020

APMA has teamed up with Bankers Healthcare Group to offer members an Assistance Loan Program that can help you get the money you need now, and you won’t make your first payment for up to 89 days from loan closing. This loan features an affordably low monthly payment, and unlike other lenders, BHG’s repayment term goes up to 10 years.

BHG Assistance Loan Program At-A-Glance:

  • Up to $250,000
  • Approval in 24 hours and funding in as few as 3 days
  • Minimal paperwork required; we do all the work
  • Repayment terms up to 10 years
  • Loan will not appear on your personal credit
  • First payment up to 89 days from loan closing
  • No personal collateral required

Learn more about BHG’s loan solutions and begin the application process at www.apma.bhgchoice.com.

IMPORTANT CLARIFICATIONS ON DHHS PAYMENTS – April 14, 2020

As a result of the concerns raised by APMA, AMA, and other medical societies, HHS has updated the terms and conditions of the provider relief fund as well as the guidance provided on its website. 

The relevant language in the terms and conditions now states that “[t]he Recipient certifies that it…provides or provided after January 31, 2020 diagnoses, testing, or care for individuals with possible or actual cases of COVID-19…” (Emphasis added). According to HHS guidance, offices that closed are eligible to receive the funds, and HHS takes a broad view that every patient could be a possible COVID-19 patient for purposes of providers being eligible for these funds.

Specifically, HHS states, “If you ceased operation as a result of the COVID-19 pandemic, you are still eligible to receive funds so long as you provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. Care does not have to be specific to treating COVID-19. HHS broadly views every patient as a possible case of COVID-19.”

The AAPPM and APMA believe that this clarification should satisfy many of the questions and concerns raised by members about the attestation requirements. We encourage members to read the terms and conditions closely before attesting, and seek guidance from their legal counsel if necessary. The attestation portal should be made available this week at www.hhs.gov/providerrelief.

Updated HHS guidance: https://www.hhs.gov/provider-relief/index.html

Updated Terms and Conditions: https://www.hhs.gov/sites/default/files/relief-fund-payment-terms-and-conditions-04132020.pdf

DHHS PAYMENTS FOR PODIATRIC PRACTICES – April 10, 2020

Part of the bipartisan CARES legislation provides $100 billion in relief funds to hospitals and other healthcare providers, including Podiatric practices, on the front lines of the coronavirus response. Recognizing the importance of delivering funds in a fast and transparent manner, the Department of Health and Human Services (HHS) is distributing $30 billion of the relief funds immediately. These are payments to healthcare providers, not loans, and will not need to be repaid. The AAPPM wanted to inform of this as practices are already receiving automated payments.

How are payment amounts determined?

Providers will receive a portion of the initial $30 billion distribution based on their share of total Medicare FFS reimbursements in 2019. Providers can obtain their 2019 Medicare FFS billings from their organization’s revenue management system.

How will payments be distributed?

You will receive payment within two weeks via Automated Clearing House (ACH). Note: practices began receiving payments today. The automatic payments will come via Optum Bank with “HHSPAYMENT” as the payment description. Payments to practices that are part of larger medical groups will be sent to the group’s central billing office. All relief payments are made to provider billing organizations based on their Taxpayer Identification Numbers (TINs).

What action should I take?

Within 30 days of receiving the payment, you must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. Terms and conditions can be found on www.hhs.gov/providerrelief. The CARES Provider Relief Payment Portal for signing the attestation will be open the week of April 13, 2020, and will be linked from www.hhs.gov/providerrelief.

Whom can I contact for more information?

For additional information, please visit www.hhs.gov/providerrelief or call the CARES Provider Relief line at (866) 569-3522.

COVID RESPONSE: SMALL BUSINESS RESOURCES AVAILABLE The AAPPM recommends all members consider BOTH of these options – April 7, 2020

In response to the COVID-19 pandemic, the CARES ACT expanded loan options for small businesses. The AAPPM highly recommends all members take advantage of BOTH loan options available to you and your practice.

Paycheck Protection Program (PPP)

The Paycheck Protection Program provides small businesses with funds to pay up to 8 weeks of payroll costs including benefits. Funds can also be used to pay interest on mortgages, rent, and utilities.

Funds are provided in the form of loans that will be fully forgiven when used for payroll costs, interest on mortgages, rent, and utilities (due to likely high subscription, at least 75% of the forgiven amount must have been used for payroll). Loan payments will also be deferred for six months. No collateral or personal guarantees are required. Neither the government nor lenders will charge small businesses any fees.

Forgiveness is based on the employer maintaining or quickly rehiring employees and maintaining salary levels. Forgiveness will be reduced if full-time headcount declines, or if salaries and wages decrease.

Small businesses with 500 or fewer employees—including nonprofits, veterans organizations, tribal concerns, self-employed individuals, sole proprietorships, and independent contractors— are eligible. Businesses with more than 500 employees are eligible in certain industries.

Starting April 3, 2020, small businesses and sole proprietorships can apply. Starting April 10, 2020, independent contractors and self-employed individuals can apply. We encourage you to apply as quickly as you can because there is a funding cap.

You can apply through any existing SBA 7(a) lender or through any federally insured depository institution, federally insured credit union, and Farm Credit System institution that is participating. Other regulated lenders will be available to make these loans once they are approved and enrolled in the program. You should consult with your local lender as to whether it is participating. All loans will have the same terms regardless of lender or borrower. A list of participating lenders, as well as additional information and full terms, can be found at www.sba.gov.

The Department of Treasury and SBA has issued guidance for lenders on the Paycheck Protection Program which can be found in its entirety at https://bergman.house.gov/uploadedfiles/ppp_ifrn_final.pdf?utm_campaign=1664-424.

Economic Injury Disaster Loan (EIDL)

To qualify for an EIDL, the applicant must have suffered “substantial economic injury” from COVID-19. Substantial economic injury generally means a decrease in income from operations or working capital with the result that the business is unable to meet its obligations and pay ordinary and necessary operating expenses in the normal course of business. Eligible recipients can receive up to $2 million in assistance, which can include a $10,000 Emergency EIDL (cash advance grant). EIDL loans under the CARES Act are based on a company’s actual economic injury determined by the SBA (less any recoveries such as insurance proceeds). Unlike PPP, EIDLs generally do not have any loan forgiveness provisions. However, applicants that already applied for an EIDL loan can refinance their EIDL under the PPP. Additionally, the Emergency EIDL loan (next section) of up to $10,000 is not expected to be repaid, even if you are subsequently rejected for an EIDL. 

For questions, please contact the SBA disaster assistance customer service center at 1-800-659-2955 (TTY: 1-800-877-8339) or e-mail disastercustomerservice@sba.gov. Additionally, one of your AAPPM leaders provided this document for assistance. 

Finally, here are additional resources that might help:

https://www.sba.gov/disaster-assistance/coronavirus-covid-19

https://www.apma.org/covid19sba#3

Your Practice & COVID-19

As the effects of the COVID-19 pandemic continues, the AAPPM wanted to share some important messages with you and your practice. Our goal is not to add to the hysteria or suggest a reason to panic; instead, the AAPPM simply offers the following as reasonable guidance for your practice operations during this challenging time. These are only suggestions and you can decide if or how they may benefit your practice.
First and foremost, as a health care professional, it is essential that you remain healthy yourself and abide by the health department restrictions. As health care professionals, we need to lead by example and be cognizant of the perceptions and precautions associated with the present COVID-19 situation.
How Are You Handling Patient Interaction in Your Office? 
If you have not done so already, the AAPPM would recommend communication with your patients. For instance, are you planning to maintain regular office hours? Additionally, communicate with them about your standards of care and sterilization. As health care professionals, remind them that you already maintain the highest standards for sterilization and disinfection at all times. Remind your patients that your standards for every patient, every procedure, requires full sterilization, sanitizing, and disinfecting every critical item and surface every time. The coronavirus is killed by your sterilization and sanitizing techniques.
Also, remind your patients that the Coronavirus is low risk for children, young and moderately aged healthy individuals. However, your patients over the age of 70 and those patients with immunocompromised systems are at higher risk for severe sickness. The “social distancing” recommendations by governmental authorities seem wise to slow the spread and avoid the medical system being overloaded by severe cases. That said, you obviously know what is best for your patients and the care they may need from you.
Some suggestions on patient communications include: 
  • Obviously, patients who have Coronavirus or patients that have been exposed to individuals who have or are being tested for Coronavirus should cancel/reschedule visits. 
  • Any patients exhibiting any signs of fever, significant cough, and/or flu-like symptoms such as body aches, headache, weakness, fatigue, should cancel/reschedule visits. 
  • Any patients over 70 years old should consider postponing non-emergency visits. Or offer to work with those patients for alternative treatment and patient care. 
  • Inform patients to not bring any unnecessary extra people with them to an appointment. 
  • Inform patients that minors should be accompanied by an adult as usual, and any minors not receiving care should have arrangements made for their care so that those minors are not in your office unnecessarily. 
  • Patients requiring special caregivers or relatives that assist them are welcome to bring accompanying individuals as always. However, remind everyone visiting your office that they should also be free of symptoms and not have had high risk recent history (travel from high risk areas, interaction with sick individuals, not exhibiting any signs of flu or flu like symtoms). 
  • If you have patients come to your office to pay bills, consider telling them to pay via credit card or online payments to limit exposure and lines in your office. 
  • Remind patients in your office to practice “social distancing” to keep themselves 6 feet away from other patients. 
  • If your waiting area is not large enough, consider telling patients to wait in their vehicles until you are able to treat them. 
  • Practice sterilization in your office constantly. Use clean pens for each patient. After use, treat your pens with antiseptic agents before being distributed for use again. Alternatively, patients could be instructed to bring their own pens, both for intake and for signatures on consent forms. Clipboards and all countertops should be cleaned and wiped between direct patient contact. Chairs, armrests, doorknobs, etc. should all be disinfected periodically (once an hour perhaps). 
  • Though it is still cold outside, if possible, consider propping doors to open. As the weather warms, this may be feasible, so as to discourage touching doorknobs or door handles. 
  • Encourage patients to wash hands. Patients should be encouraged to wash hands thoroughly upon arrival and departure from your office.
How Are You Handling Patient Care at Nursing Homes or Assisted Living Facilities? 
As the President noted last week, he and his health care advisors are recommending that only necessary health care professionals be in contact with and treat those in nursing care, assisted living or elder care homes. With that in mind, if you have not done so already, the AAPPM recommends you reach out to the administrators at each of the facilities you aid and ask how they would like to proceed. You may also want to reach out to PICA or your liability insurance provider and see if they have any steps or precautions for you take during this challenging time.
From a perception standpoint, as you would in an office setting take extra steps to remind the administrators and your patients that you maintain the highest standards for sterilization and disinfection. Perhaps, make it a point to perform extra hygienic steps you might be taking in front of your nursing home patients. While your standard of care and hygiene was no doubt top notch already, it might help ease any lingering fears if they see you taking extra hygienic care in front of them.
The following recommendations for assisted living facilities, adult day care programs, and senior living facilities are from the Centers for Disease Control (CDC). If you treat patients within any of these types of facilities, then you should be prepared to follow and use these protocols yourself: 
  • Encourage personal protective measures among residents, clients, and staff, including handwashing and covering coughs and sneezes. 
  • Encourage residents, clients, and staff to stay home (or in their private quarters) when sick and to notify program administrators of illness. 
  • Regularly clean and disinfect frequently touched surfaces, like doorknobs, keyboards, cell phones, and light switches. 
  • Ensure hand hygiene supplies are readily accessible throughout the facility. 
  • If caring for an individual living in a care facility, monitor the situation, ask about the health of the other residents frequently, and know the protocol if there is an outbreak. 
  • Implement social distancing measures as feasible, such as reducing large gatherings, altering meal schedules to reduce mixing, and limiting programs with external staff. 
  • Limit visitors to only those who are absolutely necessary and implement screening of visitors for temperature and respiratory symptoms. 
  • Maintain contact with individuals at risk of severe illness who are no longer able to attend day care programs.
Patient Care at Patient Homes 
If you can avoid patient care at their homes, consider limiting exposure to patient homes in non-emergency situations. When in home treatment is needed, the AAPPM reminds you to demonstrate the highest standards of sterilization and disinfection. Limit your patient exposure as much as possible, and practice sound hygiene to limit liability and exposures. Again, it may be worthwhile to reach out to your liability insurance provider and see if they have any steps or precautions for you take.
How Are You Handling Employee Situations? 
The flu may already have impacted many AAPPM members throughout the fall and winter. Should employee absenteeism increase as a result of COVID, are you ready?
As schools and daycares close as a result of COVID, are you and your employees prepared with those effects on your practice and your patient care?
There may be no “right” answers to these questions but it’s important to ask them before the moment comes. Please consider how your company and its employees will respond to the potential workforce impacts of a COVID-19 outbreak.
Additionally, make sure your staff practice some of the same measures as you ask your patients. Practice social distancing amongst co-workers. Staff surfaces that are frequently used (like cellphones, mainline phones, light switches, keyboards, computer mouse, break room), should be wiped clean at the beginning of the day, throughout the day, and finally at the end of each day. Door handles and office countertops should be wiped clean with antiseptic agents after EVERY patient. If you have access to face masks, employees should be encouraged to wear face masks during office hours, to prevent touching of their faces, and potential transmission of asymptomatic infection to co-workers and patients.
Finally, as the situation continues to unfold, the AAPPM recommends you play close attention to the CDC recommendations and/or recommendations from your state health department.
The AAPPM is proud of each and every member. The AAPPM has complete confidence in each and every member and its employees. Again, please take this message as simply sharing ideas and tips for you and your practice to consider during this challenge.

Telehealth Response

 As the effects of the COVID-19 pandemic continues, the AAPPM continues to receive questions from members, and we welcome all questions from members. We are happy to try and be a resource for you and your practice at this unprecedented time.   
 
Most recently, the AAPPM received questions about telemedicine and billing for telemedicine. Following is a response that we hope will help you as your practice makes any transitions into telemedicine. 
 
In the meantime, during this COVID crisis, effective immediately, all providers including podiatrists will be allowed to conduct telehealth visits with patients on non-HIPAA compliant “everyday technologies” such as Skype or FaceTime. This is a short-term response to the critical situation our society faces right now with COVID. We anticipate practices will still need a long-term solution in order to provide compliant telemedicine visits once the crisis is over. 
 
(After the crisis subsides, you need to ensure that your state allows for telemedicine for podiatry.) 
 
To your question directly, there are three options for services you can provide remotely to your patients: 
  1. Use CPT 99202-99215 for Medicare Part B patients when these services are provided remotely as long as the Public Health Emergency lasts 
  2. Telephone E/M services for any insurance patient, but these often do not reimburse 
  3. Online digital E/M services for any insurance patient, but these often do not reimburse 
Regular E and M codes will be allowed during the waiver. Documentation must be similar to all other times. G codes and 99421 etc. are for virtual call-ins or portal based visits, not the face to face time.  
 
Option 1 is your best option if you have the tools needed and it is a Medicare Part B patient. 
 
Details of all three options follow: 
1. Office E/M Codes for Medicare Part B Patients 
On March 17, CMS announced that we can submit CPT 99201-99215 when providing these services remotely. We can be in any location and the patient can be in any location. These are the guidelines: 
  • Must use a communication tool that has interactive audio and video 
  • Communication tool must allow real time communication 
  • FaceTime and Skype were given as examples 
  • We are permitted to reduce or waive cost-sharing for these services if we wish 
  • Typical HIPAA guidance does not apply to these services as long as we are providing these services in good faith. 
  • No modifiers needed 
  • Use Place of Service “02” 
  • These will be paid at facility rate 
  • This is in place as long as the Public Health Emergency lasts 
  • CMS Fact Sheet
 
2. Telephone E/M 
This is an E/M service & documentation must support an E/M just like any other E/M type. Must have history, as much of an evaluation as you can elicit and some form of medical management. 
  • Must be an established patient 
  • Must be initiated by established patient or their guardian 
  • CANNOT report if call results in decision to see patient “within 24 hours or next available urgent appointment” 
  • CANNOT report if call refers to E/M service performed by you within previous 7 days 
  • CANNOT report if call refers to a problem for which a patient is in a global period 
  • CANNOT report if you performed a Telephone E/M or Online Digital E/M for same patient for same problem in the last seven days 
  • CANNOT report if the call is part of Home Care Oversight Services, Care Plan Oversight Services, Home / Outpatient INR Monitoring, Complex Care Management Services, or Transitional Care Management Services 
  • CPT 99441 – Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion 
  • CPT 99442 – ; 11-20 minutes of medical discussion 
  • CPT 99443 – ; 21-30 minutes of medical discussion 
 
3. Online Digital E/M Services 
This is an E/M service & documentation must support an E/M just like any other E/M type. Must have history, as much of an evaluation as you can elicit and some form of medical management 
  • Examples of “Digital” platforms: 
  • HIPAA-compliant HER 
  • HIPAA-compliant email 
  • Other HIPAA-compliant two-way digital communication 
  • Must be an established patient 
  • Must be initiated by established patient via a digital platform 
  • CANNOT report if service refers to a problem for which a patient is in a global period 
  • CANNOT report service is initiated within 7 days of any E/M for same problem. 
  • CANNOT report if performed on same day as in-person E/M service 
  • CANNOT report if service is part of Home Care Oversight Services, Care Plan Oversight Services, Home / Outpatient INR Monitoring, Complex Care Management Services, or Transitional Care Management Services 
  • Time spent is cumulative time over 7 days starting with review of the request 
  • Can only report once per 7 day period
  • Time includes: 
  • Review of inquiry 
  • Review of patient records 
  • Interaction with other staff 
  • Development of management plan 
  • Rx 
  • Ordering tests 
  • Communication with patient 
  • Add time if multiple providers in same practice perform this service for same patient over same 7 day period 
  • If within seven  days of the initiation of an online digital E/M service, a separately reported E/M visit occurs, then the physician or other QHP work devoted to the online digital E/M service is incorporated into the separately reported E/M visit 
  • CPT 99421 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 
  • CPT 99422 ; 11-20 minutes 
  • CPT 99423 ; 21 or more minutes 
 
Lastly, APMA has recorded a webinar on the topic which can be viewed here.