Getting Started with Telehealth

Note: This content is informational only and not intended to endorse any specific products or services.

First Steps

• Check with your professional liability insurance carrier to ensure your policy covers providing MNT via telemedicine. (The professional liability insurance offered through the Academy's Member Advantage Program — Proliability administered by Association Member Benefits Advisors — does not exclude telehealth/telemedicine services.)
• Determine your needs for cyber and data breach coverage. The use of telehealth exposes providers and organizations to additional risk of cyber theft and data breaches of sensitive client information. General and professional liability insurance does not protect providers from damages that may result from cyber/data breaches.
• Familiarize yourself with the telehealth policies of any payers for whom you are a network provider.
• 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, unless an exemption applies, you are likely required to become licensed either:
    (1) to provide MNT to clients or patients in that state or
    (2) to be eligible to provide nutrition care services via telehealth in that state.
  • You should review the laws and requirements of each state where your patients are located.
  • 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. Contact your state department of health, state dietetics board, or state medical association for the most current information available in your state.

Telehealth Platform/Vendor Selection

You will need to use communications technology that complies with payer requirements to provide MNT to your patients remotely. While Medicare and several payers may have relaxed requirements during the public health emergency, it will be important to verify any policy updates related to communications technology as the Office of Civil Rights ended Enforcement Discretion on May 11, 2023.

Services delivered via 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), when audio and visual are not possible, through December 31, 2024. 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.
• Inquire with other Academy members via the Payment and Reimbursement Affinity Group and by connecting with members through DPG communities.
• Consider ease-of-use for both the RDN and clients.
• Determine if you need a document sharing function in a telehealth product.
• Understand the telehealth product's 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.

Understanding Telehealth Technology Options

Health care providers are required to provide telehealth services through technology vendors that are compliant with the Health Insurance Portability and Accountability Act, also known as HIPAA. The Department of Health and Human Services has additional resources on telehealth compliance with HIPAA. RDNs should seek clarification with commercial payers and Medicaid programs regarding rules and standards for approved telehealth platforms.

When considering a telehealth platform, RDNs should assess several key factors:

1. Security and Compliance: In selecting a telehealth platform, prioritize features that comply with data security regulations (such as HIPAA), safeguard patient data and ensure secure communication channels.
   • Platforms should employ robust authentication methods and use end-to-end encryption methods that restrict communication to intended parties only, enhancing privacy and confidentiality.
   • Platforms should be able to enter into a Business Associates Agreement. Business Associates are regulated under HIPAA and include any vendor hired to provide a service that involves protected health information (PHI).
2. User-Friendliness and Patient Experience: Seek a platform that is intuitive for both providers and patients, facilitating easy navigation and usage which can impact engagement and successful telehealth visits.
3. Integration Capabilities: Ensure the platform integrates with existing electronic health records systems for seamless data sharing.
4. Technical Support: Seek reliable customer support and technical assistance to address any issues promptly. Consider if support is available 24/7 versus only at certain times, or if support is available "on demand" rather than a support ticket system.
5. Accessibility: Confirm the platform's accessibility across different devices (desktops, mobile phones, Apple products, Android products, etc.) to cater to patient needs.
6. Functionality and Features: Assess the platform's capabilities like screen sharing, messaging and file sharing to meet your practice's specific needs.
7. Cost and Affordability: Consider the platform's pricing model, ensuring it aligns with your practice's budget and offers value for the services provided.

Workflow and Patient Care

Review and update all processes associated with appointments. Try to use the same processes for in-person and telehealth visits (e.g., registration, obtain insurance information, share policies, obtain consent, documentation, issue receipts and superbills, and collect payments).

• Investigate options for HIPAA-compliant electronic communication if not already established.
  • Review the Office of Civil Rights for more information on telehealth and HIPAA compliance.
• Obtain client consent to provide services using telehealth. The Center for Connected Health Policy's online Policy Finder has information about state requirements regarding consent to provide services using telehealth visit.
  • Check to see if your telehealth vendor can support electronic consent.
  • Sample telehealth consent forms are available to Academy members and from the Agency for Healthcare Research and Quality.
• Confirm that MNT provided via telehealth is a covered benefit (in addition to verifying benefits and the coverage details for MNT) under each patient's individual insurance policy.
  • Clarify patient co-payments and cost-sharing for MNT or any other services you provide via telehealth.
  • Billing instructions may differ (with the same insurance company) based on the type of individual plan a patient has (commercial, self-funded, Medicare Advantage, or other type). Clarifying billing instructions for services provided via telehealth can help to ensure accurate payments.
• Review and update practice policies as applicable.
• Conduct a practice session before using any new platform.
• Update voicemail, website and social media to let your patients know your practice is now offering telehealth services.
• Provide instructions or "tips" to help your clients access telehealth services based on your practice's technology to maximize appointment time and avoid disruptions to care.
• Consider data collection for the purposes of demonstrating effectiveness of your services when they are provided using telehealth.
  • If you are already collecting data for outcomes evaluation in your practice and using both in-person and telehealth modalities to provide MNT, consider taking steps that will allow you to sort, analyze and compare outcomes based on the delivery modality. Practice level data may be helpful in your own contract negotiations.
  • Academy members have free access to ANDHII, a registry that enables RDNs to track nutrition care outcomes and advance evidence-based nutrition practice research. ANDHII can help you track outcomes in your own practice and support the collective efforts to demonstrate effectiveness and value.
• Identify and set up a quiet and professional space to use for your telehealth appointments, taking into consideration what your patients/clients will see from their perspective.
• Consider employing multiple monitors to accommodate client visibility as well as documentation requirements
• Review legal considerations and other provider tips for secure telehealth sessions.
• Ensure you are still properly documenting visits as you normally would with an in-person visit.
  • Remember to document all individuals present even if they are off screen or just observing.
• 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.

Coding Billing and Payment: MNT/DSMT Delivered via Telehealth

• MNT provided via telehealth is still MNT. Remember telehealth is how you are delivering 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.
  • Watch the Power of Payment video, Introduction to CPT^® Codes, for more information on CPT^® codes and G-codes.
• Medicare: Many of the telehealth flexibilities that providers, including RDNs, have grown accustomed to have been extended for the 2024 calendar year. The extended flexibilities include:
  • Waived geographic restrictions
  • Allowing a beneficiary’s home to remain as an eligible originating site for telehealth services
  • Extended coverage of telehealth services at FQHC and RHCs
  • The continuation of coverage and payment for telehealth services via audio-only communications systems
• Updates to Medicare billing and claims filing based on Place of Service are detailed as follows:
  • CMS1500 Claims: Beginning January 1, 2024, providers should utilize either Place of Service code 02-Telehealth Provided Other than in Patient's Home or POS 10- Telehealth Provided in Patient's Home for submitting claims to Medicare regardless if the MNT was provided using audio video technology or audio only. Claims billed with POS 10 will be paid at the non-facility PFS rate and claims billed with POS 02 will be paid the PFS facility rate for CY 2024. CMS will continue to allow providers to use their currently enrolled locations (typically a practice address) instead of a home address when providing services via telehealth for CY 2024.I
  • Outpatient (hospital) – UB-04 Form: 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, through December 31, 2024. Services should be billed with Revenue code 780 and modifier 95. Beneficiaries' homes will no longer need to be registered as provider-based departments of the hospital to allow hospitals to bill for MNT services. Critical Access Hospitals using Method II payment will continue billing as normal using modifiers GT/GQ as appropriate. RDNs should seek further direction from and collaborate with compliance/regulatory and billing staff at their hospitals to understand their organizations specific billing policies and procedures.
• Rural Health Centers (RHCs): Medicare pays RHCs an All-Inclusive Rate for medically necessary and preventative services such as MNT.
  • RHCs and FQHCs were given authority to provide distant site telehealth services to Medicare patients during the COVID-19 PHE; Section 4113 of the Consolidated Appropriations Act, 2023, extends this authority through December 31, 2024.
  • Use the HCPCS code G2025 with an optional modifier "95" for claims. 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): CMS generally pays FQHCs a flat rate of 80% of the Prospective Payment System
  • View more information on the FQHC billing model.
  • 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.
• Diabetes Self-Management
  • 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.
  • All DSMT services may be furnished via telehealth.
  • DSMT services may be provided by institutional providers through the end of CY 2024. For hospitals, beneficiaries’ homes will no longer need to be registered as provider-based departments.
• Medicare Part C- Medicare Advantage Plans
  • 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.

Private/Commercial Payers

Medical Nutrition Therapy

• Providers should stay up to date with any changes regarding telehealth policy information, as well as review current telehealth policy information that may be accessed through provider portals.
• Get clarification from private payers and state Medicaid programs for how to submit claims for MNT provided via telehealth.
• Providers should inquire about the appropriate POS code, POS 02 or POS 10, 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.
• 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.
• Key questions to ask private payers and Medicaid when checking benefits and billing for covered 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).

Online Digital Assessment and Management Codes

• Online digital assessment and management services codes (98970, 98971, 98972) for which RDNs may be reimbursed by private payers for electronic communication with established patients. Note: In the Medicare Physician Fee Schedule CY21 Final Rule, CMS noted RDNs are not eligible to bill for these codes for Medicare patients. Examples of use with non-Medicare patients:
  • 98970 A 70-year-old male with insulin dependent diabetes submits an online query through his registered dietitian nutritionist's (RDN) EHR portal reporting nausea and vomiting due to the flu and seeking guidance on diabetes self-management.
  • 98971 A 65-year-old male with congestive heart failure submits an online query through HIPAA-compliant encrypted email to his RDN regarding a recent 7-lb weight gain.
  • 98972 A 40-year-old female with newly diagnosed type 2 diabetes submits an online query through her registered dietitian nutritionist's EHR portal after noticing her morning fasting blood glucose levels were gradually increasing.

Payment Parity versus Service Parity:

• Payment parity refers to regulation or practices ensuring that providers receive equal compensation for services delivered through telehealth as they would for equivalent in-person care. Medicare pays for MNT provided via telehealth at the same rate as in-person visits. See the Medicare physician fee schedule for more information. 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.
• Service parity are laws or policies that ensure the scope and quality of health care services delivered through telehealth are equivalent to those provided in traditional in-person settings. It seeks to maintain consistent standards of care, encompassing both the range of services offered and their effectiveness, regardless of the mode of delivery.
• For more information on state parity laws, refer to the Center for Connected Health Policy.