Q. What are the signs and symptoms of COVID-19?
A. Centers for Disease Control (CDC) says the following symptoms may appear two to fourteen days after exposure to coronavirus: fever, cough, shortness of breath. Please read and monitor clinical information available through the CDC, your state department of health, and your medical specialty societies and associations.
Q. Are coronavirus tests available in all states?
A. State health departments may use their discretion to administer tests for coronavirus through public laboratories and to instruct hospitals, physicians, and their practices to conserve tests and testing supplies. Private laboratories may also administer tests. Currently, there is no public repository or databank of the number of tests available in each state in public and private laboratories.
Q. Are there risk stratifications for the types of exposure, for example casual contact or prolonged contact, and recommendations corresponding to risk levels for health care professionals who have or may have been in contact with a COVID-19 patient?
A. Centers for Disease Control (CDC) has stratified the risks. However, CDC published a guideline for assessing and monitoring risk, and work restriction decisions for health care professionals with potential exposure to COVID-19. Professional clinical judgment is required to use the guideline to assign a risk category and determine the need for work restrictions. The guideline is available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.
Q. Are quarantine procedures applicable to travel to a state with more confirmed cases than the state in which the patient lives?
A. Centers for Disease Control (CDC) does not generally issue travel advisories and has not issued travel advisories or restrictions within the U.S. but the CDC does address in detail considerations for U.S. travel at https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-in-the-us.html and https://www.cdc.gov/coronavirus/2019-ncov/travelers/faqs.html. The US State Department issued a Level “4” “do not travel” advisory on March 19, 2020 recommending against global travel. . Please continue to check these documents and the US State Department for international travel. for changes and before making decisions related to international and interstate related travel.
Q. What should a physician or practice do when they cannot find personal protective equipment and have high-risk patients coming to the practice?
A. Older adults, age 65 and older; and people with asthma, lung disease, heart disease, and diabetes may be at higher risk for severe COVID-19. Physicians may consider the following when deciding on in-person, telehealth, telemedicine, or telephone visits:
- physician’s own risk factors, such as age and health status, as they relate to transmissibility of coronavirus and potential severity of COVID-19;
- practice staff’s risk factors, such as age and health status, as they relate to transmissibility of coronavirus and potential severity of COVID-19;
- patients’ risk factors and potential treatment needs;
- availability of personal protective equipment (gowns, coveralls, gloves, respirators, facemasks or surgical masks, goggles, and face shields);
- availability of telemedicine or telehealth platforms to the practice and to patients of the practice;
- availability of other physicians, health care professionals, and clinics for referrals for in-person visits;
- availability of physicians or other health care professionals already engaged in telemedicine; and
- availability of locum tenens physicians and temporary staff for in-person visits.
Q. Are all doctors switching to telemedicine? What platforms are acceptable?
A. Office of Civil Rights (OCR) announced the agency will use its discretion when enforcing the Health Insurance Portability and Accountability Act (HIPAA) and related regulations and not impose penalties for noncompliance where the physician or other health care professional
- acts in good faith to provide telehealth or telemedicine;
- through non-public facing audio or video chat applications, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype;
- during this public health emergency.
Several vendors claim they provide HIPAA-compliant video communication products, but OCR has not reviewed and does not endorse, certify, or recommend these products: Skype for Business/Microsoft Teams, Updox, VSee, Zoom for Healthcare, Doxy.me, Google G Suite Hangouts Meet.
OCR says the agency will also use its enforcement discretion as it applies to telehealth or telemedicine for any reason and regardless of whether the telehealth technology is related to the diagnosis or treatment of COVID-19. Facebook Live, Twitch, TikTok, and similar public facing video applications should not be used for telehealth or telemedicine at any time.
For further information and additional links to OCR bulletins on further flexibilities available in a crisis, see, https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.
Q. I read the federal government waived licensure requirements for treating patients in other states. I am in one state but have patients in another who always came to appointments in my office but now want to have telemedicine visits across state lines. I guess this waiver means I do not have to get a license in the state where they live, right?
A. The federal government did not waive the licensure requirements of state licensing agencies regulating the practice of medicine in their states. A section of the Social Security Act allows the federal government to waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program requirements under a declaration of an emergency or public health emergency. In an emergency, the waivers promote beneficiaries’ access to care and physicians’ and other health care practitioners’ eligibility for reimbursement for services. The President declared a national emergency March 13, 2020, giving the Centers for Medicare and Medicaid Services (CMS) the authority to waive certain Medicare and Medicaid requirements. CMS waived several requirements, including requirements that out-of-state physicians and health care professionals obtain licenses in the state where they are providing services, so long as the providers have equivalent licensing in another state. The licensure waiver means Medicare in urban areas can participate in telemedicine and any Medicare beneficiary can participate from their home, as opposed to a designate location or site. The waiver also means physicians and other health care professionals are no longer limited to real-time audio and video technology to be eligible for reimbursement. The waiver recognizes the use of smartphones, with audio and video capability, as reimbursable. Physicians and health care professionals must continue to abide by the licensing requirements for the practice of telemedicine in the state in which the patient is receiving care if different than the state in which the physician is located.
For more information on licensure requirements, please contact the state board of medicine or medical examiners:
Arizona Medical Board
Direct (480) 551-2700
Toll Free (877) 255-2212
Colorado Medical Board
Direct (303) 894-7690
Nevada State Board of Medical Examiners
Direct (775) 688-2559
Toll Free (888) 890-8210 (in state)
Utah Department of Commerce Division of Occupational and Professional Licensing
Direct (801) 530-6628
Toll Free (866) 275-3675 (in state)
For assistance with coding and billing and information about reimbursement, please contact the applicable third-party payor. For more information on the Medicare telemedicine broadened access for beneficiaries see:
Q. Is there a consent form we should have patients sign for telemedicine or telehealth? Is verbal consent enough?
A. MICA recommends obtaining the patient’s or representative’s verbal informed consent to telemedicine (which does not include telephone medicine) services and documenting the process in the patient’s medical record OR obtaining the patient’s or representative’s written informed consent to telemedicine services and documenting the process in the patient’s medical record. DocuSign and your electronic health record patient portal are two considerations for obtaining an electronic signature. See MICA Telemedicine Consent by logging into the MICA website, going to the Policyholder Home Page, clicking on “Order Risk Management Products” to the right side of the screen, then scrolling down to Telemedicine.
Discussion or notification should include:
- Possible risks of telephone/telemedicine/telehealth visits, such as insufficient transmission of an image or data, delays in diagnosis or treatment related to equipment problems or failures, and breach of confidentiality or privacy related to transmission of an image or data
- Possible benefits, which may include improved patient access to medical care and decreased risk of spreading or encountering an infectious disease or condition
- Possible alternatives, which may include conducting the visit in-person or through another telemedicine technology when medically indicated
- Patient’s or patient’s representative’s right to inspect information documented during the telemedicine visit
- Physician or health care professional does not guarantee or assure a specific outcome or result of the telemedicine visit
- Patient or patient’s representative authorizes and consents to the use of telephone or telemedicine technology
- Patient or patient’s representative may withhold or withdraw consent to telemedicine
- Date of the patient’s or patient representative’s signature, if applicable
- Date verbal consent was obtained, if applicable.
In Arizona, informed consent requirements for telemedicine do not apply to emergencies where
- the patient or patient’s representative is unable to consent to the service,
- the patient is not physically present during the telemedicine encounter or visit,
- the physician or other health care professional transmits images to another physician or health care professional serving as a consultant, or
- the consulting physician is reporting to the treating physician or health care professional the imaging results.
Colorado physicians and health care professionals must obtain the patient’s or patient’s representative’s informed consent for telehealth encounters. Appropriate informed consent includes the following:
- identification of the patient;
- identification of the physician and the physician’s credentials;
- types of transmissions permitted, for example, scheduling appointments, patient education, prescription refills;
- patient’s agreement the physician determines whether telemedicine is appropriate for the condition being diagnosed or treated;
- security measures, such as encrypting data, password-protected screen savers and data, applicable authenticating process, and the risks to the patient’s privacy notwithstanding these measures;
- patient’s agreement and consent to forwarding patient-identifiable information to a third party; and
- clause in which patient agrees to hold the physician harmless for information lost due to technical failures.
In Nevada, osteopathic physicians must obtain the patient’s or patient’s representative’s informed consent to engage in telemedicine. The osteopathic physician must document consent in the patient’s medical record and include the following:
- that the physician informed the patient or patient’s representative;
- the patient may withdraw consent at any time;
- the potential risks, consequences, and benefits of telemedicine;
- whether the osteopathic physician has a financial interest in the website or vendor used to engage in telemedicine or in the products or services provided to the patient via telemedicine; and
- the transmission of confidential medical information while engaged in telemedicine is subject to applicable federal and state laws on the protection of and access to the confidential medical information.
In the event of an emergency, a Nevada osteopathic physician is not required to establish a bona fide patient relationship before engaging in telemedicine and does not have to obtain the patient’s or patient’s representative’s informed consent to telemedicine.
Q. I have established patients already overdue to make appointments asking for additional refills on medications, but not opioids or other controlled substances, so they do not have to come to my office during the coronavirus crisis. In some cases, I have not seen the patient in over a year. What should I do?
The Governor of Arizona issued an Executive Order 2020-15 March 25, 2020 waiving the physical examination before prescribing regulation. The Order states: No Arizona regulatory board shall enforce any statute, rule, or regulation that would require a medical professional who is licensed by that board and who is authorized to write prescriptions to conduct an in-person examination of a patient prior to the issuance of a prescription. The Order expires upon the termination of the Governor’s declaration of a public health emergency issued March 11, 2020. See https://azgovernor.gov/sites/default/files/eo_2020-15_expansion_of_telemedicine_0.pdf.
When this Order expires, licensed physicians and other prescribers are expected follow the regulations and policy statements of the Arizona Medical Board. The Arizona Medical Board Substantive Policy Statement #12 Internet Prescribing states that before prescribing any medication or device a physician must obtain a reliable history, conduct an appropriate physical examination, and establish a proper diagnosis supporting the prescription. A questionnaire completed by the patient and submitted over the internet does not meet these requirements and telemedicine does not eliminate the requirements for an established physician-patient relationship and appropriate physical examination before prescribing. https://www.azmd.gov/Files/LawsRules/SPS_12_PolicyStmt.pdf.
Colorado physicians may exercise their professional medical judgment when deciding to prescribe with or without an in-person physical examination. The Colorado Medical Board says:
An appropriate medical evaluation and review of relevant clinical history . . . should be performed prior to providing treatment, including issuing prescriptions, electronically or otherwise. Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (encounter in person) settings. Treatment, including issuing a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care. https://drive.google.com/file/d/0BzKoVwvexVATMGFNdW9SX0IyLTA/view.
Prescribing medications, in-person or via telehealth technologies, is at the professional discretion of the provider. The indication, appropriateness, and safety considerations for each telehealth visit prescription must be evaluated by the provider in accordance with current standards of practice and consequently carry the same professional accountability as prescriptions delivered during an encounter in person. . . providers may exercise their judgment and prescribe medications as part of telehealth encounters.
In Nevada, the definition of the practice of medicine includes prescribing by “any means or instrumentality,” which may include telemedicine or telehealth. NRS §630.020(1) https://www.leg.state.nv.us/NRS/NRS-630.html. For more specific information and answers, please contact your personal attorney.
In general, the practice of medicine in Utah includes prescribing by “any means or instrumentality.” https://le.utah.gov/xcode/Title58/Chapter67/58-67-S102.html?v=C58-67-S102_1800010118000101. Furthermore, the Utah Telehealth Act defines the scope of telehealth practice to include diagnosing, identifying underlying conditions and contraindications for recommended treatment, obtaining a relevant clinical history from the patient or patient’s other physicians, and documenting the relevant clinical history and the patient’s symptoms. Utah Code §26-60-103(b)(i) and (ii). https://le.utah.gov/xcode/Title26/Chapter60/C26-60_2017050920170509.pdf.
Q. We are implementing telehealth. Can we refill prescriptions for controlled substances, such as medications for attention deficit disorder or anxiety and chronic pain medication?
A. One exception to the federal Controlled Substances Act in-person medical evaluation prior to prescribing requirement is the declaration of a public health emergency by the Secretary of Health and Human Services. The Secretary declared an emergency January 31, 2020. On March 16, 2020, the Secretary designated the telemedicine prescribing allowance applies to Schedule II-V controlled substances. As long as the public health emergency remains in effect, physician and other prescribers registered with the Drug Enforcement Agency may prescribe schedule II-V controlled substances to patient for whom they have not conducted an in-person medical evaluation, as long as the following conditions are met:
- the prescription is issued for a legitimate medical purpose by a physician or other practitioner acting in the usual course of professional practice;
- the telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and
- the physician or other practitioner is acting in accordance with applicable state and federal laws.
If the physician or other prescriber has previously conducted an in-person medical evaluation of the patient, the physician or other prescriber may issue a prescription for a controlled substance after communication with the patient by telemedicine or other means regardless of whether a public health emergency has been declared as long as the prescription is issued for a legitimate medical purpose, the physician or other prescriber is acting in the usual course of his/her professional practice, and the physician or other prescriber is acting in accordance with applicable Federal and State laws. See https://www.deadiversion.usdoj.gov/coronavirus.html.