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Optimizing Telehealth Pain Care After COVID-19

The COVID-19 pandemic has presented major challenges to pain care, as pain clinicians face severe restrictions in their ability to provide usual in-person assessments and treatments. COVID-19 has also exposed prepandemic problems in providing comprehensive pain care. Yet, despite this crisis, there have been encouraging developments for long-term delivery of pain services, most notably the explosive growth in the adoption of telehealth technology and clinical resourcefulness in its applications. Read more.

NAM Action Collaborative on Countering the U.S. Opioid Epidemic Publishes Priorities, Strategies to Preserve the Health and Well-Being of Individuals with Substance Use Disorders and Chronic Pain during COVID-19

The COVID-19 pandemic has brought unprecedented challenges. The pandemic is also exacerbating other ongoing public health emergencies, including the addiction crisis in the United States. During these challenging times, the National Academy of Medicine’s (NAM) Action Collaborative on Countering the U.S. Opioid Epidemic remains wholly committed to supporting the health and well-being of individuals with substance use disorders (SUDs), including opioid use disorder, and chronic pain. These individuals are among the most at risk and susceptible to COVID-19, and their care and treatment is among the most disrupted by physical distancing and other measures that have been put into place to prevent the spread of the virus. It is critical that steps be taken to ensure that their health, safety, and care are protected in the near and longer term.

To this end, the Action Collaborative’s Steering Committee have identified and published a series of priorities and strategies for providers, health systems, researchers, policymakers, regulators, and health leaders alike to preserve the health and well-being of individuals with SUDs and chronic pain. 

Key priorities highlighted include: 

    1. Plan for deliberate evaluations of implementation and response strategies and policies enacted during COVID-19
    2. Utilize telehealth to support the needs of patient populations with SUDs or chronic pain during COVID-19 and beyond  
    3.  Reinforce safety net programs that help protect certain high-risk populations  
    4.  Maintain high-quality care for individuals with pain  
    5.  Address immediate research, data, and surveillance needs and enhance reporting  
    6.  Monitor and take steps to prevent a rise in SUDs and overdoses  

Read the full list of priorities and strategies

AAPM is a Network Organization of the NAM Action Collaborative on Countering the U.S. Opioid Epidemic. AAPM Past President Jianguo Cheng, MD PhD represents the Academy serving on two of the collaborative’s work groups, the Health Professional Education and Training Working Group and the Research, Data, and Metrics Needs Working Group. View the AAPM commitment statement.

Virtual Services During the Time of COVID-19

Public and private insurers have taken steps to increase telehealth services during the public health emergency due to COVID-19. CMS is expanding its Virtual Services benefits on a temporary and emergency basis. The expanded benefit is retroactive to March 1, 2020 and allows patients to receive care at their place of residence rather than in a physician office or a hospital. The most recent expansion included payment for telephone calls with patients.

Part of the expanded benefits include allowing telehealth services to be reported by a variety of non-public facing technologies. The requirement for synchronous audio/visual requirements remains. Services can be reported for both new and established patients and should be reported using the same code (i.e. 99201-99215) that would have been reported if the patient was seen for an in-person visit. Reimbursement will be the same as if the patient was seen in the office or other appropriate setting. Levels of service for office visit codes can be based on either time or medical decision-making. It is not necessary to meet the documentation requirements related to the key components (history, exam, medical decision-making) when selecting a level of service.

Based on input from the medical community, CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020. The codes for telephone services (99441-99443) are time-based services and have restrictions on reporting when they are provided in conjunction with other patient encounters. It is important to read the CPT instructions for reporting telephone services to understand the requirements and limitations associated with these codes.

AAPM offered a webinar “Coding Services in the Wake of COVID-19” on April 15 that addresses the appropriate coding and reporting of telehealth services and other virtual services covered by Medicare. The webinar can be accessed here.

AAPM also convened a panel of pain medicine experts to present a webinar, “Pain Management Best Practices During the COVID-19 Pandemic and Public Health Crises: A Discussion of the New Guidelines.” This webinar is also available and can be viewed here.

Guidelines are changing as payers attempt to revise policies and adjust their systems to meet policy changes. You should visit your Medicare, Medicaid and private payers’ websites and/or read all payer communications to determine coverage and specific instructions. 

AMA Seeks Clarification, State Action to Protect Patients with Chronic Pain

The AMA joined the Indiana State Medical Association in seeking clarification from the state medical licensing board whether existing patients with chronic pain can be evaluated via telephone-only communication to satisfy state-specific controlled substances prescribing rules.

The new flexibility “may have been satisfied by Executive Orders (EO) 20-12 and 20-13, but we seek clarification – along with the Indiana State Medical Association – as to whether those EOs specifically supersede 844 Indiana Administrative Code 5-6-6,” wrote AMA Executive Vice President and CEO James L. Madara, MD, in a letter to the Indiana Medical Licensing Board (MLB). 

Dr. Madara also encouraged the Indiana MLB to “adopt, in full, guidance provided by the U.S. Drug Enforcement Administration (DEA) to help ensure patients with pain receive the medications they need while simultaneously helping support public health measures to protect patient safety, reduce unnecessary travel and potential exposure to the COVID-19 virus.” This includes urging the MLB to allow for “multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a Schedule II controlled substance, subject to specific conditions being met.”

If you have specific examples of states/institutions taking action to help patients with chronic pain, please consider it sharing it with the AMA. Information can be sent to [email protected].

Message from the AAPM President about COVID-19

​AAPM has been monitoring CDC guidance related to COVID-19. Today AAPM President Ajay D. Wasan, MD MSc issued the following message to members.

Dear Colleagues:

By now I am sure that you have received many lengthy COVID emails and so I will get to the point. AAPM has been monitoring CDC guidance related to COVID-19, and we offer the following thoughts to our members:

The CDC suggests delaying and not having patients come into the office for elective medical care. Certainly, it is a difficult issue to determine to what extent pain care is ‘elective’ vs. medically necessary, and the consideration for limiting outpatient pain care also depends on the extent of COVID-19 and the risk of acquiring it in your area.

At the very least it seems prudent to reschedule elective procedures/injections, initial evaluations, and follow-up visits in those patients at a high risk of complications from COVID-19. These subgroups include those 65 years old or older, those with important medical comorbidities (such as cardiac disease, pulmonary disease, or diabetes), the immunocompromised, and patients coming from nursing homes or long-term care facilities.

The CDC and the Trump administration have encouraged telemedicine visits in place of in-person follow up visits for elective medical care. The DEA has confirmed that it is reasonable in this crisis to renew controlled substance prescriptions after a telemedicine evaluation or telephone discussion with the patient when appropriate and if consistent with state law (such as by electronic prescribing to avoid a high risk patient coming in for a routine opioid follow up visit).

CMS has also relaxed the requirements for using telemedicine codes for billing and they have pledged to pay for these codes equivalent to in person visits. There are weblinks below that explain further how to use these codes effectively in your practice.

We are all struggling to adjust—both professionally and personally. In the coming weeks, our American Academy of Pain Medicine (AAPM) will work to keep us abreast of developments that are specific to our practice areas. Initially, we are providing updated billing and coding guidance that are consistent with the latest messaging coming from CMS regarding the expanded use of telemedicine codes. These insights were prepared under the guidance of the AAPM’s Coding and Reimbursement Committee, which represents our specialty at the CPT and RUC, and regularly provides information to AAPM members in the bi-monthly AAPM e-Newsletter.

Our AAPM will continue to monitor developments that are particular to pain medicine. Thank you for your continuing efforts on behalf of our patients.

Ajay D. Wasan, MD MSc
President AAPM

Pain Medicine Journal
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American Academy of Pain Medicine