greater washington society
for clinical social work

Promoting the highest standards of clinical social work practice through education, advocacy, and community.

GWSCSW TOOLKIT FOR VIRTUAL PRACTICE DURING THE COVID-19 NATIONAL EMERGENCY
APRIL, 2020

Judy Gallant, LCSW-C, Director, GWSCSW Legislation & Advocacy Branch

Please note: This information is not to be construed as legal advice. It is being posted with links to additional information, and further research may be required. [ It is current as of 4/14/20.] * UPDATED ON 4/30/20.*  Changes to the law as a result of the Covid-19 crisis can happen at any time, as Executive Orders issued by the Federal or State governments have been frequent since the national State of Emergency has been declared. If you are aware of any new/different information, please contact judy.gallant@verizon.net. We will do our best to keep this information updated, but cannot guarantee it is up-to-date at any given time.

We work closely with The Clinical Social Work Association, with frequent exchanges of practice-relevant information during this National Crisis. CSWA is also maintaining a helpful Toolkit (available to all) on their website.

CURRENT LAWS AND REGULATIONS

For more detailed Medicare information, see pages 4-5 of this document.

  • ALL LOCAL JURISDICTIONS (MD, VA & DC) ARE INDICATING THAT IT IS OK FOR TELETHERAPY TO OCCUR ACROSS STATE LINES FOR CONTINUITY OF CARE WITH CURRENT CLIENTS DURING THE DECLARED STATE OF EMERGENCY DUE TO THE COVID-19 VIRUS. In Maryland, there is an explicit order from our governor, with our licensing board interpreting how they are proceeding. In DC, explicit guidance has also been developed: if you are practicing from another jurisdiction in DC, there is no problem with providing continuity of care with clients with whom you have a prior relationship; establishing a new relationship gets complicated. In Virginia, the regulatory requirements have now been waived.

For MD, go to https://governor.maryland.gov/wp-content/uploads/2020/03/Executive-Order-Health-Care-Matters.pdf  

The Board of Social Work Examiners (website: https://health.maryland.gov/bswe/Pages/default.aspx) is asking clinicians to submit an application in order to provide ongoing therapy through teletherapy, to already established client(s). It is free to apply, and it is reportedly not too onerous. Contact person to obtain an application: gloria.hammel@maryland.gov

  • For DC: Waiver of Licensure Requirements for Healthcare Providers 20-03-13, and Guidance On Use of Telehealth in the District of Columbia 3-12-2020. We have just heard from a member that after writing to the DC Board to ask about establishing relationships via videoconferencing with new clients, she was given permission to do so prior to her DC license being processed. We  would recommend that you check directly with the DC Board if you would like to do this.

·       For VA: See https://www.dhp.virginia.gov/social/covid19Info.htm

Board of Social Work

COVID-19 Information

Accelerated Temporary License

April 20, 2020

Pursuant to Governor Northam’s Executive Order No. 57 (effective April 17, 2020),  a clinical social worker with an active license issued by another state may be issued an accelerated temporary license by endorsement as a health care practitioner of the same type for which such license is issued in another state upon submission of an application and information requested by the applicable licensing board and the board's verification that the applicant's license issued by another state is active in good standing and there are no current reports in the United States Department of Health and Human Services National Practitioner Data Bank. Such temporary license shall expire ninety (90) days after the state of emergency ends. During such time the practitioner must seek a full Virginia license or transition patients to Virginia-licensed practitioners.

Health care practitioners with an active license issued by another state may provide continuity of care to their current patients who are Virginia residents through telehealth services.  However, if they want to acquire new patients, they must apply for full licensure in Virginia or an Accelerated Temporary License as indicated above.

You can access the applications here: Temporary Licensed Clinical Social Worker Application

·       For any state where your client is located during sessions, make sure that you check with the Board that governs social work practice in that state to see if you need to apply for a waiver, pay a fee, etc.

  • At this writing, audio only telephone appointments are not reimbursable by insurance companies, except by Medicare. And an executive order signed by Gov Hogan approves reimbursement of telehealth sessions provided by telephone for health care providers who participate with Maryland Medicaid only…OR providers who are enrolled with MD Behavioral Health Administration programs. (This is also true for those participating in SAMHSA grant programs.).

PAYMENT, BILLING, CODING, CPT MODIFICATIONS

  •  Most commercial insurance plans will reimburse for telemental health therapy through video platforms, but the details depend on the specific plan. Patients should be asked to confirm with their insurance that reimbursement will be provided, and whether they are restricted to receiving it on a specific platform like Teladoc. BlueCross BlueShield and Aetna have lifted requirements that providers use Teladoc for telehealth sessions during the National Emergency, and will reimburse for sessions on HIPAA compliant platforms. See links below for coding modifiers to use for those insurances. Other insurances seem to be accepting a 95 modifier for the CPT code and 02 as the place of service. Medicare is asking 11 to be used at the place of service with the 95 modifier.
  • Information from Aetna to cover sessions 3/6-6/4 2020: https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/bh-televideo-service-codes-covid-19.pdf?cid=eml-prov17136150&spsub=prov_NTI0NjE5MDgyNjY4S0
  • Information from BCBS re: coding for teletherapy: https://individual.carefirst.com/carefirst-resources/pdf/carefirst-telemedicine-code-modifier.pdf
  • Additionally, CareFirst is amending its Medical Policy on a temporary basis to pay a $20.00 flat fee for phone consultations of 10-15 minutes provided by behavioral health providers in CareFirst’s network. “Psychiatrists and Nurse Practitioners should use CPT 99441. Psychologists, Licensed Certified Social Workers and Licensed Professional Counselors should use code 98966. We selected these codes, as check-ins for all phone visits, regardless of the amount of time. This is in effect through April 17, 2020. At the end of the 30 days
  • CareFirst will re-evaluate whether the policy should be extended for a longer period.” As I understand this, the 98966 code can be used for a phone consultation - not a phone call to deal with scheduling issues, but a consultation where a clinical issue is addressed.

HIPAA PLATFORMS FOR TELEMENTAL HEALTH THERAPY

  • HIPAA regulations are relaxed. As a result of the COVID-19 national emergency declaration, the Office of Civil Rights (OCR), Department of Health and Human Services (DHHS), has affirmed that it will “exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency.” See https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.
  • Although penalties are being waived, we should always strive to maintain client confidentiality to the best of our capacity. Currently, we are aware of three platforms - doxy.me, VSee, and Zoom - that each offer a Business Associates Agreement (BAA) to users as well as offering encryption to make the platforms more secure. Zoom’s platform offering those services is quite costly, but Zoom also offers free and less expensive platforms that do not have the same level of security. Doxy.me and VSee have free platforms that offer security, but which may not be systems that are as smooth to view as paying for additional speed within their platforms. There are likely others which are not included here.
  • major issue to note: although the OCR notification allows non-HIPAA-compliant platforms, it does not allow “public-facing” platforms. Facebook Live, Twitch, TikTok, and similar video communication applications are public-facing, and they should not be used in the provision of telehealth by covered health care providers.

CONSENT FORMS FOR TELEMENTAL HEALTH THERAPY

  • If you are a member of the Clinical Social Work Association, you can download a sample Consent form for Telemental Health therapy at: https://www.clinicalsocialworkassociation.org/Informed-Consent-for-Telemental-Health
  • We have found sample consent forms on other websites to be inadequate, lacking a place to record contact information for a local hospital or Crisis Center Hotline. Having a personal emergency contact is not enough, as you may be the person who needs to make contact for emergency services to be delivered during a teletherapy session.

ONLINE PAYMENT FOR PSYCHOTHERAPY

  • Paypal and Venmo are not generally seen as secure even in privacy mode.
  • Zelle is a bank-to-bank transfer, and requires the client’s bank to use this system, as well as your bank. You need only give your client a cell phone number or email address, no information about bank accounts is exchanged with your client.
  • Ivy Pay is a system is exclusively for therapists’ use. There is a 2.75% fee. You charge the client’s debit, credit, HSA or FSA card on file. It is HIPAA compliant.
  • Square is a secure platform that permits you to accept credit card payments. Fees are 2.75% per swipe or 3.75% plus 15 cents for manually entered transactions.
  • A credit card can be kept on file and billed directly. Credit card fees vary.
  • Bills may be sent via mail and clients may pay by check.

INFORMATION ON MEDICARE

  • LCSWs can now be reimbursed by Medicare for audio only psychotherapy sessions which have taken place as of 3/1/20 on.  More details can be found at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf
  • CPT codes are the same as the ones that we use for in-person and videoconferencing sessions, e.g., 98034, 98037, 90791, etc. Any telephonic session that you have conducted since March 1 can be submitted for reimbursement.
  • The POS code should continue to be 11 for Medicare claims.  During the Public Health Emergency, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services furnished via telehealth.
  • This is the decision that CMS has made for Medicare coverage.  As we know, private insurers often follow the lead of Medicare policy, so there is a chance that we will see more coverage of audio only sessions by private insurers.  Do not take it for granted though, that this is the case. Continue to check the plan that each patient has if you wish to conduct treatment in an audio only format.
  • This also will not automatically apply to ERISA, or self-insured, plans.  We are continuing to pursue audio only coverage for those plans as well.
  • New information and news releases can be found at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

SOME CLINICAL ISSUES TO CONSIDER

Numerous clinical issues have emerged regarding the way we practice psychotherapy via telehealth. This list is by no means exhaustive, but it can be useful in thinking through ways to understand the impact these issues may have on our patients and ourselves and help us think about what we can anticipate and discuss with clients. We can reach out to our fellow therapists as part of our own support and taking care of ourselves. For our clients, it may all be worthy of exploration and is “grist for the mill.”

Seeing each other’s home environment

  • In a virtual session, we are "seeing" clients in different places – we see them in their houses and they see you in yours. How do we feel about the loss of privacy we usually have with our clients? How do they feel about our having this visual window into their world? We and our clients can make some choices about what we want each other to see, with the option of exploring related therapeutic issues.

Boundaries

  • What is the background view our clients see behind us on-line? What pictures or pets might they see, what noises might they hear, what is the potential for interruptions from family members? How might those things make your clients feel? How would you feel about them seeing those things?
  • Try to protect the space you use at home from interruptions by posting a sign on the door – “In session. DO NOT ENTER” – and informing family beforehand that you will not be available during this time, and ask clients to do the same.

Feelings and concrete issues patients might have about receiving telemental health therapy

  • Which of our clients might not want to receive psychotherapy in this format?  Reasons could include feeling disconnected from the therapist with the computer screen between them, discomfort with the technology, lack of access to the technology, lack of private or safe space in their home, etc.
  • We can appreciate that for some clients this platform feels comfortable and works well. Might this impact what format they want to continue receiving therapy with after the national emergency is over?

Feelings some therapists might have about providing videoconferencing

  • Do we want to, or are we comfortable with using this format to provide psychotherapy? It can be important to notice: do we feel less engaged, or have more difficulty with “screen silence” than we would with silence in a room both you and your client are present in?

Distractions

  • Are we, or our clients, distracted by things the other person cannot see, such as email, texts, etc? How easy is it for any of us to lose our focus in this environment?

Contribution of the electronic platform to our therapeutic work

  • What nuances in the clinical encounter might we be missing, i.e.: the shift in affect that you feel when you are sitting with someone? The electronic platform, with delays and pauses, lack of synchronicity with visual and audio signals, presents general challenges of the medium.
  • Does the medium impact client response; ie: might time delays impact your client’s reactions by them becoming more passive, for example?
  • Does the screen permit some clients to express themselves more freely than in-person work does? What dynamics are at work that we can help the client look at to increase their understanding of the difference?
  • What impact does the medium have on us? How does the screen impact our sense of engagement? Increased tiredness due to constantly having someone “in your face” hour after hour?

Technological problems

  • When the technology for videoconferencing breaks down, patients may experience anxiety about the abrupt interruptions and this should be anticipated in discussion at the beginning of telemental health therapy. A plan for reconnecting with the patient should be agreed upon in advance, should the connection be lost.

Diagnostic criteria

  • What risks might there be to seeing people with specific diagnoses via telemental health therapy? Some diagnostic criteria can make videoconferencing or telephone sessions problematic or potentially dangerous. We need to assess the level of suicidal or homicidal thoughts a client has and whether we can manage them successfully without being in the same room with them. Having clear boundaries in the informed consent about when the client may be referred to a different level of care is a prudent part of videoconferencing.

Uncertainty

  • The questions around how long the pandemic and physical distancing will last creates anxiety for clients and therapists alike. In particular, we all feel uneasy about the length of time we will be unable to meet in person with our clients. Exploring this topic with patients, and understanding for ourselves how difficult we find this, can be helpful.

Support

  • The GWSCSW list serve has provided both an exhaustive and exhausting series of announcements, updates, and helpful commentary from our members.  Some members are offering webinars and/or discussion groups, some paid, some free.  We are our own wonderful resource!
  • CSWA is offering CE webinars on telemedicine, ethics, and more, free to members (and free for newly joining members), as well as “Get Together” sessions to provide support and connection.
  • This is a time to reach out to one another, explore feelings, renew or develop new collegial friendships as we navigate this new world together…. 

ADDITIONAL RESOURCES

More helpful information from CSWA

Mental health resource

  • This looks like a wonderful resource, which we learned of through CSWA’s collaboration with the Mental Health Liason Group. Scroll about a quarter of the way down the page and click on Mental Health Providers.  https://psychhub.com/covid-19/

Many thanks to Margot Aronson, Laura Groshong and Melissa Grady for their assistance in the development and editing of this document.
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