D.15 Tele-Eye Care Supplement.pdf

D.15 Tele-Eye Care Supplement 36C24621R0068

TeleEye Care Supplement

February 2020 vaww.telehealth.va.gov

TeleEye Care Supplement – February 2020 Page i

Table of Contents

1. TeleEye Care Overview

2. Program Planning & Development

3. Types of TeleEye Care

3.1 TeleEye Screening for Eye Disorders/Diseases

3.2 TECS (Technology-based Eye Care Services)

3.3 Low Vision TeleRehabilitation

4. TeleEye Care Clinical Pathway: Consults, Scheduling and Workload

4.1 Telehealth Clinical Pathway

4.1.1 Common Resources

4.1.2 Clinical Resources

4.1.3 Business Resources

4.2 Asynchronous/SFT Clinical Pathway

4.2.1 Asynchronous TeleConsultation Pathway

4.2.2 Asynchronous TeleConsultation Workflow

4.2.3 Standardized TeleEye Imaging Pathway

4.3 TeleMedicine Consults and Workflow

4.3.1 Asynchronous TeleMedicine Pathway

4.3.2 The TECS Eye Screening TeleMedicine Workflow Process

4.4 Synchronous/CVT Clinical Pathway

4.4.1 Types of TeleEyeCare Low Vision Rehabilitation Services

4.4.2 Vision TeleRehabilitation Therapy for Traumatic Brain Injury (TBI)

5. TeleEye Care Visit and Examination

6. Risk Management

7. Infection Control Considerations

8. Quality Management

8.1 Conditions of Participation

8.2 Asynchronous Store and Forward Telehealth Benchmarks

8.2.1 Timeliness of Reads

8.2.2 Image Quality

9. TeleEye Care Additional Resources

10. Appendix A: Standardized TeleEye Imaging Pathway...............................................................................A-1

11. Appendix B: Synchronous/Clinical Video Telehealth Clinical Applications .................................... B-1

12. Appendix C: Low Vision Recommended Devices (per CBOC site) for Demonstration of

Magnification Only and Audio Devices...................................................................................................................... C-1

13. Appendix D: Chief Consultants and Directors Endorsement of TeleEye Care Eye Care

Supplement ...........................................................................................................................................................................D-1

TeleEye Care Supplement – February 2020 Page ii

List of Tables

Table 1: Summary of Care Provided through TeleEye Care

Table 2: Diabetic Retinopathy Risk Factors

Table 3: Macular Degeneration Risk Factors

Table 4: Glaucoma Risk Factors

Table 5: Technology-based Eye Care Services Patient Criteria

Table 6: Patient Candidate Criteria for Low Vision TeleRehabilitation Program

Table 7: Primary Stop Codes

Table 8 Secondary Credit Stop Codes

Table 9 TeleEye Care Program Credit Stop Codes and CPT Codes Summary

Table 10 Asynchronous/SFT Guidance

Table 12: Synchronous/CVT Guidance by Diagnostic Conditions

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Acknowledgment

The development and maintenance of this document is the responsibility of the Veterans Health Administration (VHA), Office of Health Informatics: Connected Care/Telehealth. Proposed changes to this document should be submitted to VHA_10P8_TH_DIQ@va.gov.

NAME

OFFICE

Gerald J Selvin, OD Chief, Optometry, VA Boston Healthcare System National TRI Optometry Lead

Leonard Goldschmidt, MD, Ph.D.

TeleRetinal Lead VHA, Palo Alto VAMC National TRI Ophthalmology Lead

April Maa, MD Ophthalmologist, Clinical Director of Technology-based Eye Care Services (TECS), VISN 7 Regional Telehealth Services

Timothy Elcyzyn, OD Optometrist, TeleRetinal Director of VISN 20 Resource Hub Boise VAMC

Carolyn Ihrig, OD Optometrist, Chief, Low Vision Rehabilitation VA WNYHS, Buffalo

Rhonda Johnston, PhD, BC-FNP, BC-ANP

Director | OCC Quality and Training VHA Office of Connected Care (10A7D) | Office Health Informatics

Matthew Squires, MBA SFT Training Specialist, Store-and-Forward Telehealth Master Preceptor, Telehealth Training and Quality, VHA Office of Connected Care (10A7D)

Sara DeRycke-Brawdy, MHCA Asynchronous Telehealth Lead VHA Office of Connected Care (10A7D) | Office Health Informatics

Leonie Heyworth, MD, MPH Synchronous Telehealth Lead VHA Office of Connected Care (10A7D) | Office Health Informatics

Bruce L Jones Interim, Deputy Director Senior Supervisory Technology Program Analyst VHA Office of Connected Care (10A7D) | Office Health Informatics mailto:VHA_10P8_TH_DIQ@va.gov

TeleEye Care Supplement – February 2020 Page iv

Document Version History

Responsible Office

The development and maintenance of this document is the responsibility of the Veterans Health

Administration (VHA), Office of Connected Care (10A7D) | Office Health Informatics Proposed changes to this document should be submitted to contact.

DOCUMENT

REVISION

EFFECTIVE DATE PAGE DESCRIPTION

3 November 2019 Reformatted to new TeleEye Care Format;

Revised process flow maps Updated tables Combined all changes into final document

2 August 2019 Reformatted to new TeleEye Care Format;

updated contents to cover Asynchronous/Store-and-Forward Telehealth and Synchronous/Clinical Video Telehealth modalities

1 September 2016 Supplement provides standard clinical guidance to implement and monitor the quality of TeleEyeCare care delivered to

Veterans via Telehealth technology.

TeleEyeCare Supplement – February 2020 Page 1

1. TeleEye Care Overview

The purpose of the TeleEye Care Supplement is to provide standard clinical guidance to implement and monitor quality delivery of eye care to Veterans via Telehealth technology. The

Supplement applies to the changes in operational and clinical practices that allow for integration of Telehealth services into Eye Care services and identifies the resources needed to support safe, quality TeleEye Care services. This guidance provides detail for readers to gain the understanding required for the development and management of TeleEye Care programs.

In order to establish a TeleEye Care clinic, use the TeleEye Care Supplement along with the following Veterans Health Administration (VHA) Telehealth Services Manuals and Supplements:

• Connected Care/Telehealth Operations Manual (Telehealth Manual)

• Telehealth Management Platform Supplement

• VA Video Connect Supplement

VA Health Care Systems considering new Telehealth Eye Care programs should contact the following for assistance putting together the planning team: Eye Care contact as appropriate, Veteran Integrated Service Network (VISN) Telehealth Manager or Lead and/or the Facility

Telehealth Coordinator (FTC). TeleEye Care services can be part of an interdisciplinary care team and sites should consider including other disciplines that may be involved in the programs (e.g., Diabetes, Wound Management, or Prosthetics Clinics). Using shared resources and experiences from other disciplines builds on the success for any Telehealth program.

TeleEye Care may be offered to different locations and under different modalities. Possible locations include Veteran Affairs Medical Centers (VAMCs), Community Based Outpatient Clinics

(CBOCs), Non-VA institutions, and the Veteran’s home. To enhance access to TeleEye Care services, VHA employs the use of Telehealth modalities, which may include Clinical Video

Telehealth (CVT), VA Video Connect (VVC), Store-and-Forward Telehealth (SFT), Home Telehealth

(HT), and mobile software applications (APPs).

For TeleEye Screening, sites will be at varying degrees of transition from established Diabetic

TeleRetinal Imaging model to expanded TeleEye Screening program.

The purpose of the TeleEyeCare Supplement is to provide specific guidance in the delivery of outpatient eye care through the following telehealth modalities:

• Asynchronous/SFT eye disease screening utilizing Teleconsultation and/or TeleMedicine provider services

• Synchronous/CVT to provide Low Vision rehabilitation to Veterans.

https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-spp.pdf

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Asynchronous/SFT is used for the collection of data, images, sounds, and/or videos to be viewed later by the specialist. Synchronous/CVT is used to perform direct face-to-face, yet remote, appointments. The use of TeleEyeCare is expanding to meet the needs of the Veteran population.

2. Program Planning & Development

This section addresses topics a team should consider during the telehealth planning process.

Guidance includes Service Line Approval, Team Selection, Oversight Committees, Telehealth

Service Agreements (TSAs), Memorandums of Understanding (MOUs) and scheduling processes.

Common Telehealth Services’ policies and practices are provided in the documentation listed above (CVT and SFT Operations Manuals are currently under development) and will not be repeated in the TeleEye Care Supplement. This supplement contains additional links to training, tools and resources necessary to successfully implement and manage TeleEye Care programs.

The Connected Care/Telehealth Manual contains the requirements to implement and maintain a Telehealth Program. This includes but is not limited to:

• Quality Management and the Conditions of Participation;

• Policies covering the Telehealth Program;

• Documentation required for implementation;

• Requirements for Credentialing and Privileging;

• Types and characteristics of services;

• Risk Management; and,

• Training.

3. Types of TeleEye Care

This section describes care available through TeleEye Care. TeleEye Care may be offered to different locations and under different modalities. Telehealth visits can provide two types of services: TeleConsultation and TeleMedicine. During TeleConsultation the Teleprovider does not assume responsibility for patient care. They do not write orders or prescribe medication. The consult is completed by providing guidance and advice to the referring provider on subsequent care. It is the referring provider’s decision to implement or not the recommended plan of care.

During a TeleMedicine appointment, the Teleprovider is responsible for writing orders, prescribing medicine and/or prescriptive devices as necessary, as well as directing other aspects of care. The referring provider may or may not assume responsibility for ongoing treatment of the condition. In either case, the level of participation with the patient by the specialist should be well-documented in the medical record.

Table 1 lists services or diagnostic groups that may be offered under TeleEye Care. This table also lists the available modalities for each service. See the Clinical Video Telehealth (CVT) Operations https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf

TeleEyeCare Supplement – February 2020 Page 3

Manual, Store-and-Forward Operations Manual, and VA Video Connect (VVC) Supplement for further information on telehealth modalities.

Note: Telehealth encounters can be within a facility or health care system (intrafacility), between facilities or health care systems (interfacility), or the Veteran patient may be located at a non-VA clinical setting.

Table 1: Summary of Care Provided through TeleEye Care

Type of Visit/Service Modality Description of Visit/Service

TeleEye Screening Asynchronous/

SFT

TeleConsultation

VHA Certified Imager captures retinal images and intraocular pressure of ‘at-risk’ population, provides required patient education (per the tenets of the Imager Training) at patient site and sends to remote Reader (optometrist or ophthalmologist) for review and recommendation of care. *

Technology-based Eye Care Services (TECS)

Asynchronous/

SFT

TeleMedicine

TECS certified ophthalmic technician collects select eye health data (screening) and determines refractive status of ‘low-risk’ population at patient site and sends to remote Reader (optometrist or ophthalmologist) for review and recommended timeline for patient to receive a comprehensive in-person eye examination by an eye care provider (optometrist or ophthalmologist).*

Low Vision Services Synchronous/

CVT

Various disciplines use CVT to provide training on vision-enhancing devices, education, and rehabilitation services to low vision patients. May include prevention, assessment, intervention, advocacy, consultation, education, research and administration.

* This screening exam does not replace an in-person comprehensive eye examination performed by an eye care provider (optometrist or ophthalmologist).

3.1 TeleEye Screening for Eye Disorders/Diseases

TeleEye Screening involves the systematic assessment of “at-risk” populations to detect specific sight-threatening eye disease. This assessment involves the capturing of retinal images from the targeted population and transmitting them via a secure and reliable telecommunications network for reading. The stored image and the associated report must then be available for the patient’s clinician(s) to assist in the care of the patient.

Populations identified to be at risk for the following eye diseases should be considered for screening using TeleEye pathways: diabetic retinopathy, age-related macular degeneration, and glaucoma (future extended applications may be included as necessary). The goal of the program is to detect these sight-threatening eye diseases in early stages so that education, prevention, and treatment can be provided in a timely manner to reduce the risk of vision loss and potential blindness. Patient status is best assessed using the pertinent Clinical Reminders embedded in

VA’s Computerized Patient Record System (CPRS). The concerted effort to reach at-risk patients is https://vaww.infoshare.va.gov/sites/telehealth/docs/vvc-spp.pdf

TeleEyeCare Supplement – February 2020 Page 4 a joint effort of the Optometry/Ophthalmology Clinic(s), Primary Care and other health care providers.

Table 2: Diabetic Retinopathy Risk Factors Diagnostic Group At Risk for Diabetic Retinopathy

At Risk: Those patients with Diabetes Mellitus enrolled with Primary Care with no evidence of eye care within last 2 years, who meet the following criteria:

1 Patients not having an eye exam within the past year.

Patients who failed to keep their VA eye clinic appointment or who fail to provide documentation of an eye exam by a non-VA eye professional.

3 Those patients with poorly controlled blood glucose on insulin or a hemoglobin A1c (HbA1c) greater than 8% after one year of treatment.

4 Poorly controlled blood pressure, exceeding a systolic measurement of 140 mm Hg and a diastolic measurement of 90mm Hg.

5 Vision impairment not associated with elevated blood glucose.

Pregnancy in a diabetic, with follow-up in each trimester.

Table 3: Macular Degeneration Risk Factors

Diagnostic Group At Risk for Age-Related Macular Degeneration

At Risk: Those patients 60 years and older enrolled with Primary Care with no evidence of eye care within last 2 years, who meet the following criteria:

1 Patients with family history of macular degeneration and/or other eye disorder with vision loss.

Patients with history of smoking or tobacco/nicotine use.

3 Patients with history of abnormal body mass index (BMI).

4 Patients with history of coronary artery disease (CAD).

5 Patients with history of drusen of macula/posterior pole.

Patients with history of previously diagnosed age-related macular degeneration, any type or stage. *

*Inclusion of group per national/local determination

Table 4: Glaucoma Risk Factors

Diagnostic Group At Risk for Glaucoma

At Risk: Those patients 60 years and older (African Americans 40 years and older) enrolled with Primary Care with no evidence of eye care within last 2 years, who meet the following criteria:

1 Patients with family history of glaucoma.

2 Patients with history of ocular hypertension.

3 Patients with long term (current) use of corticosteroids.

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Diagnostic Group At Risk for Glaucoma

At Risk: Those patients 60 years and older (African Americans 40 years and older) enrolled with Primary Care with no evidence of eye care within last 2 years, who meet the following criteria:

4 Patients with history of glaucoma suspect/borderline glaucoma.

5 Patients with history of previously diagnosed glaucoma, any type or stage. *

*Inclusion of group per national/local determination

Note: Evidence of eye care is determined by query of primary stop codes 407, 408, and 718:

diagnostic group identification is by query of relevant diagnostic codes (ICD-9-CM and ICD-10-CM).

These queries are performed using the relevant clinical reminders embedded in CPRS.

Tables 2,3 & 4 show endorsed conditions for screening. Future conditions may be included upon endorsement by VHA Eye Care Telehealth Council as meeting efficiency, economy and quality of care standards for approved condition.

3.2 TECS (Technology-based Eye Care Services)

The TECS program is a Veteran-centric eye care delivery model designed to screen ‘low-risk’

Veterans who are medically underserved and/or socioeconomically disadvantaged (rural/highly rural; homeless) for cataract, macular degeneration (AMD), glaucoma, and diabetic retinopathy (if the patient is diabetic) at their primary medical care home. TECS performs select eye tests such as measurement of visual acuity, refraction, intra-ocular pressure (IOP), central corneal thickness

(CCT), and fundus photography. The TECS program also aims to improve quality of life by providing spectacles to Veterans using standard refraction measurement techniques – including auto-refraction technology refined by manifest refraction. The health data captured by the ophthalmic technician is sent to a remote Reader for review, authorization of the spectacle prescription, and a recommended timeline for the patient to receive a comprehensive in-person eye examination by an eye care provider (optometrist or ophthalmologist). Any patient with high risk conditions and/or risk factors (excluding those risk factors recognized for candidacy within the TeleEye Screening Program) without a documented eye exam in the timeframe recommended by appropriate clinical practice guidelines/preferred practice patterns (endorsed by the American

Optometric Association, the American Academy of Ophthalmology, and the American Diabetes

Association) should be followed by direct in-person comprehensive eye examinations by an eye care provider (optometrist or ophthalmologist).

Table 5: Technology-based Eye Care Services Patient Criteria Patient Criteria for TECS Program

Inclusion Criteria Low-risk patients who cannot access VA specialty eye care services within driving or wait times as designated by VA Mission Act. Patients must meet VA eligibility requirements.

Exclusion Criteria Patients who do not meet VA eligibility requirements.

Patients with known history of ocular disease (such as optic nerve disorders, macular disorders, retinal disorders, and corneal/anterior segment disorders) as

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Patient Criteria for TECS Program these conditions are best followed by direct in-person comprehensive examinations by an eye care provider. *

Patients who present with an acute eye care issue.

Patients who failed to keep their VA eye clinic appointment (or fail to provide documentation of an eye examination by a non-VA eye care provider) since their prior TeleEyeCare encounter.

Patients who desire in-person comprehensive eye care services.

*Unless otherwise endorsed by VHA Eye Care Telehealth Council as meeting efficiency, economy and quality of care standards for approved condition

TECS efforts are best directed towards Veterans who meet VA Mission Act criteria (e.g. cannot access VA specialty eye care services within average driving time of 60 minutes or wait times of 28 days from request date) but wish to have access to VA eye care screening and spectacle services at their primary medical care home. TECS efforts are not meant to circumvent or duplicate available comprehensive eye care services or to discourage Veteran utilization of community care as designated by VA Mission Act.

3.3 Low Vision TeleRehabilitation

Low Vision TeleEye Rehabilitation is the use of Synchronous/CVT to provide a low vision evaluation, vision-enhancing devices, training, education, and rehabilitation services to low vision patients. Low Vision TeleEye Rehabilitation is patient-centered, data-driven, continuously-improving, team-based, accessible, timely, comprehensive, coordinated, and provides continuity of care over time. TeleProvider and TCT use Synchronous/CVT to provide a low vision evaluation, vision-enhancing devices, strategies, education, and rehabilitation services to low vision patients.

Under the direction of the TeleProvider, TCTs demonstrate the use of Low Vision tools to the patients.

Table 6: Patient Candidate Criteria for Low Vision TeleRehabilitation Program

Patient Criteria for Low Vision TeleRehabilitation Program

Inclusion Criteria Patients with ocular pathology resulting in decrease in best-corrected central visual acuity (typically 20/70 or worse in the better seeing eye) that results in a decrease of daily activities.

Patients with significant central and/or peripheral visual field loss that reduces function with daily activities.

Before a Low Vision TeleEye Rehabilitation evaluation can be scheduled, a referral and report are needed that includes the patient’s most recent comprehensive eye examination with a local (VA or Non-VA) optometrist &/or ophthalmologist. The report must include corrected distance visual acuity, lensometry, refraction, visual field, diagnosis & treatment.

Patients with traumatic brain injury (TBI) and/or functional vision loss that impacts patient safety or impairs or restricts one or more activities of daily living. Polytrauma optometrist completes a face-to-face visit to evaluate Veteran’s vision and needs. A referral is then created for vision therapy delivered in person or via Telehealth modalities.

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Patient Criteria for Low Vision TeleRehabilitation Program

Exclusion Criteria Patients who qualify but desire a direct in-person low vision eye examination with a low vision specialist.

Patients requesting comprehensive eye examination including refraction.

Patients requiring orientation and mobility training with long cane or another modality.

4. TeleEye Care Clinical Pathway: Consults, Scheduling and

Workload

Veterans’ entrance into optometry and/or ophthalmology care is usually either by self-identification to a particular eye clinic or by a consult/referral process. Scheduling of TeleEye

Care visits is more complicated than scheduling of traditional in-person medical visits. However, at a minimum, the scheduling system for visits should not differ from the system already in place for in-person visits, in terms of telephone access number, personnel, etc.

Asynchronous/SFT encounters involve the acquisition and storage of clinical information (e.g., data, image, sound and/or video). Once the information is stored, it is then forwarded to and retrieved by a provider or reader at a different time for clinical evaluation. The

Asynchronous/SFT model of care uses a recognized or nationally approved clinical pathway utilizing VistA Imaging or other approved vendor data collection or imaging interface. Detailed scheduling information and guidance, can be found in the Scheduling sections of the Connected

Care/Telehealth Operations Manual and Telehealth Management Platform (TMP) Supplement.

The following recommendations are required for TeleEye Care consults:

• TeleEye Care provider determines if the use of Telehealth is appropriate.

• Identify whether TeleConsultation or TeleMedicine is the requested service.

• Is the Telehealth encounter for a preventative screening, comprehensive assessment or a focused visit?

• Acute care of unstable patients is not appropriate. These patients are to be referred to the local emergency setting.

• Some Eye Care Specialists may prefer to perform new patient evaluations in person.

When scheduling for TeleEye Care, in addition to the routine telehealth workflows, be sure that you include:

• Required pre-appointment laboratory, imaging, radiographs, and diagnostic studies.

• TeleSpecialist determines the level of expertise of the originating site (patient site)

TelePresenter: Telehealth Clinical Technician (TCT), Registered Nurse (RN), or

TeleProvider.

https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/tmp-spp.pdf

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In order to capture the workload for TeleEye Care, be sure to use the primary and secondary stop codes specific to this Eye Care as found in in the Connected Care/Telehealth Operations Manual and the MCAO Intranet page.

TeleEye Care current procedural international Current Procedural Terminology and Internal

Classification of Disease codes will follow face to face coding processes and policies for

Synchronous Clinical Video Telehealth visits. Some Current Procedural Terminology codes are listed for Store and Forward only and are current as of publication date of this supplement.

All new telehealth programs must contact their local Health Information Management System, /coding office to ensure all stop codes, Internal Classification of Disease, and Current Procedure

Terminology codes are the most current.

Table 7: Primary Stop Codes Primary Credit

Stop Code Description

Ophthalmology

Records patient visit for consultation, evaluation, follow-up, and/or treatment provided by a provider trained in diseases and surgical procedures of the eye. Includes provider and support services.

Optometry

Records patient visit for the examination, diagnosis and/or treatment of the eyes for ocular and vision defects by a provider trained in disease of the eyes.

Includes provider and support services.

Eye Telehealth

Screening

Retinal screening for Veterans with one or more of the following: diabetic retinopathy, macular degeneration, and/or glaucoma.

VISOR & Advanced

Blind Rehab

Records services provided in a Visual Impairment Services Outpatient Rehabilitation (VISOR) Program or Advanced Blind Rehabilitation Program with an intensive Blind Rehabilitation Clinic that provides skills training, orientation and mobility and low vision therapy. Clinic is staffed by interdisciplinary or multidisciplinary members such as social workers, Blind Rehabilitation Specialists, Blind Rehabilitation Outpatient Specialist (BROS), Visual Impairment Service Team Coordinators (VIST) which could be either social workers or Certified Low Vision specialists, and an Eye Care Practitioner (optometrist or ophthalmologist). Usage of a secondary Stop Code to identify the discipline of the provider is encouraged.

VICTORS & Advanced Low Vision

Records services provided in a Visual Impairment Center to Optimize Remaining Sight (VICTORS) Program or Advanced Low Vision Clinic that provides definitive medical diagnosis, functional vision evaluation, prescribing and training in the use of low vision devices, low vision therapy, and counseling and follow-up. These clinics are part of a comprehensive low vision rehabilitation program. Staffing for these clinics includes optometrists, ophthalmologists, low vision therapists, social workers, blind rehabilitation specialists, Blind Rehabilitation Outpatient Specialist (BROS), occupational therapists, counselors and/or psychologists in an interdisciplinary or multidisciplinary team. Usage of a secondary Stop Code to identify the discipline of the provider is encouraged.

Intermediate Low

Vision Care

Records services provided in an Intermediate Low Vision (LV) Clinic which provides low vision training, limited activities of daily living/communication, orientation and mobility, and adjustment. Staffing for these clinics is composed of a multidisciplinary or interdisciplinary team that may include http://vaww.dss.med.va.gov/programdocs/pd_oident.asp

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Primary Credit Stop Code

Description an eye care practitioner (optometrist or ophthalmologist), low vision therapist, social worker, psychologist, blind rehabilitation specialist, Blind Rehabilitation Outpatient Specialist (BROS), occupational therapist, etc.

Usage of a secondary Stop Code to identify the discipline of the provider is encouraged.

Low Vision Care

Records services provided in a Low Vision Clinic within an Eye Clinic which provides evaluation and prescription of low vision devices and low vision training. Staffing for these clinics is composed of an eye care practitioner (optometrist or ophthalmologist) with occasional support from other disciplines such as a vision rehabilitation specialist, social worker, psychologist, occupational therapist, etc. to support adjustment to loss of sight and the ability to maintain activities of daily living. Usage of a secondary Stop Code to identify the discipline of the provider is encouraged.

Table 8 Secondary Credit Stop Codes

Secondary Credit

Stop Codes

Description

179 Real Time Clinical Video Telehealth to Home- Provider Site

Records workload at the provider site (distant site) using real-time clinical video telehealth as a means to replicate aspects of face-to-face assessment and care provided to Veteran patients in their home (e.g., private residence, vacation home, daughter’s home, etc.) or at a non-VA location/home (e.g., homeless shelter, university dormitory room, transitional housing, assisted living center, etc.) when the Veteran patient independently coordinates and conducts the Clinical Video Telehealth (CVT) encounter with their VA provider, without assistance from a non-VA site or 3rd party organization’s staff or resources to coordinate, support or assist with the successful completion of the CVT encounter. Assessment and care may include:

health/social evaluations, wound management, exercise plans, patient appearance, monitoring patient self-care, medication management, monitoring vital signs, including pain, etc. These CVT encounters must be electronically documented in CPRS fully meeting criteria for a provider encounter. Use provider work-unit as the primary Stop Code, i.e. 171179 HBPC Nurse, 323179 Home Tele-Primary Care, 502179 Home TeleMental Health.

Real Time Clinical Video Telehealth –

Patient Site -assisted encounter to Non-VA

Center

Records workload at the provider site (distant site) using real-time clinical video telehealth as a means to replicate aspects of face-to-face assessment and care provided to Veteran patients in a non-VA location (e.g., Vet Center, university student health clinic, Indian Health Service clinic, Department of Defense medical treatment facility, State Veterans Home, etc.) when the non- VA patient site staff have actively participated in the coordination and support of the Clinical Video Telehealth (CVT) encounter. This non-VA site coordination and support activity may include but is not limited to: providing assistance with scheduling; providing a suitable CVT space; management of VA CVT device and/or related equipment (either owned by the non-VA site or the VA); or accompanying the Veteran patient to or during the CVT encounter. Typically, this coordination and support is documented in a

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Stop Codes

Description formal written document (e.g., memorandum of understanding (MOU) and/or Telehealth Service Agreement (TSA) between the non-VA site and the VA provider site, however, the 648 CVT encounter could be ‘ad hoc’ without such written agreement. Telehealth is the use of electronic communications and information technology to provide and support health care when distance separates the participants. Both the patient and provider must be present during the real-time video session.

Real Time Clinical Video Telehealth-

Patient Site

Records at the patient’s site (originating site), real time clinical video telehealth care provided to patients. Telehealth is the use of electronic communications and information technology to provide and support health care when distance separates the participants. Both the patient and provider must be present during the real time video session. This secondary code can be attached to any primary Stop Code related to the workgroup that provides telehealth consultations (e.g., teledermatology for wound care management, telemental health for medication management, etc.).

Real Time Clinical Video Telehealth-

Provider Site (Same Division/Station)

Records at the provider site, Real Time Clinical Video Telehealth care provided to patients where the site of the patient and the site of the provider share the same division or the STA3 (Station Number/Company Code) such as in the case of a Community-Based Outpatient Clinic (CBOC) and its parent station. Examples include CVT conducted when the patient and provider are both located/assigned to the same division/campus but in separate physical locations, when a provider is teleworking from the division where the patient is located and recording workload at the same division where the patient is located or between a VAMC and a CBOC belonging to that VAMC. Example-patient is seen at the Denver VA and the provider is also assigned to the Denver VA but is working from an off-campus location such as their home in another state. Telehealth is the use of electronic communications and information technology to provide and support health care when distance separates the participants. Both the patient and provider must be present during the real time video session.

Real Time Clinical Video Telehealth - Provider Site (Not

Same Station)

Records at the provider site, real time clinical video telehealth care provided to patients where the site of the provider and the site of the patient have a different STA3 (Company Code). For example, VA medical center to VA medical center or CBOC of VA medical center #1 and VA medical center #2.

Telehealth is the use of electronic communications and information technology to provide and support health care when distance separates the participants. Both the patient and provider must be present during the real time video session.

Store & Forward

Telehealth- Patient Site

Records at the patient site (originating site), the capturing of data used in a Store-and-Forward telehealth procedure that enables provision of care to a patient. This secondary code may be attached to any primary Stop Code related to the workgroup providing the telehealth session (e.g., Store & Forward imaging for teleretinal screening or teledermatology). Store and Forward Telehealth is the use of electronic communications and information technology to provide and support health care when time and distance separates the participants. The patient’s site (usually a technologist)

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Stop Codes

Description captures, stores, and forwards images for later review by an interpreting provider. During Store & Forward telehealth visits, there is an asynchronous transmission of clinical data from one location to another. The interpretation of data by the provider does not happen simultaneously with the patient's encounter. (For telehealth occurring real-time/live such as telemental health video teleconferencing, use Stop Code 690 for the patient site.)

Store & Forward

Telehealth- Provider Site (Same

Division/Station)

Records at the provider site (distant site), Store & Forward telehealth care provided for patients where the site of the patient and the site of the provider share the same division or STA3 (Station Number/Company Code) such as in the case of a Community Based Outpatient Clinic (CBOC) and its parent station. This secondary code may be attached to any primary Stop Code related to the workgroup providing the telehealth session (e.g., review of Store & Forward images for teleretinal screening or teledermatology). Store & Forward Telehealth is the use of electronic communications and information technology to provide and support health care when time and distance separates the participants. Images are captured, stored and forwarded by the patient’s site for later review/interpretation by a provider).

During this type of telehealth visit, there is an asynchronous transmission of clinical data from one location to another. The interpretation of data by the provider does not happen simultaneously with the patient's encounter.

Store & Forward

Telehealth- Provider Site (Not Same

Station)

Records at the provider site (distant site), Store & Forward telehealth care provided for patients where the site of the patient and the site of the provider have different company codes (a.k.a. Station Numbers, a.k.a. STA-3). This secondary code may be attached to any primary Stop Code related to the workgroup providing the telehealth session (e.g., review of Store & Forward images for teleretinal screening or teledermatology). Store & Forward Telehealth is the use of electronic communications and information technology to provide and support health care when time and distance separates the participants. Images are captured, stored and forwarded by the patient’s site for later review/interpretation by a provider. During this type of telehealth visit, there is an asynchronous transmission of clinical data from one location to another. The interpretation of data by the provider does not happen simultaneously with the patient's encounter. (For telehealth occurring real-time/live such as telemental health video teleconferencing, different station uses Stop Code 693 for the provider site).

Table 9 TeleEye Care Program Credit Stop Codes and CPT Codes Summary

Type of Service Primary Stop Code

Secondary Stop Code

CPT & ICD Codes

TeleEye Screening (TeleConsultation) Asynchronous/SFT

718 694

Patient Side:

Primary ICD: Z13.5 – Encounter for screening for eye and ear disorders

TeleEyeCare Supplement – February 2020 Page 12

Stop Code

Secondary Stop Code

CPT & ICD Codes

CPT Codes:

92227 – Patient side: Remote imaging for detection of retinal disease

Provider Side:

Primary ICD: Z13.5 – Encounter for screening for eye and ear disorders

CPT Codes :

99451 – Provider side:

Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time.

Technology-based Eye Care Services (TECS) (TeleMedicine) Asynchronous/SFT

Patient Side:

Primary ICD: Z01.00 – encounter for examination of eyes and vision without abnormal findings (or) Z01.01 – Examination of eyes and vision with abnormal findings (Note primary ICDs do not have to match on patient and provider side for SFT)

CPT Codes:

92015– Determination of refractive state is necessary for obtaining glasses and includes specification of lens type (monofocal, bifocal, other), lens power, axis, prism, absorptive factor, impact resistance and other factors

92227 – Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral

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Code

Secondary Stop Code

CPT & ICD Codes

(or) 92228 – Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral.

92341 – Fitting of spectacles, except for aphakia (to be coded at time of dispensing/fitting (or) 92342 – Dispensing/fitting of eyeglasses, monofocal

Provider Side:

Primary ICD: Z01.00 or Z01.01 – examination of eyes and vision

*Secondary ICD codes will be determined by diagnostic findings (e.g. cataract, AMD, etc.)

99451 – Provider side:

Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time.

Or

CPT 99091 describes collection and interpretation of physiologic data.

Low Vision Rehabilitation VISOR & Advanced Blind Rehabilitation Synchronous/CVT

220 179

For Clinical Video Telehealth use the same CPT codes as used for face to face visits

Low Vision Rehabilitation VICTOR & Advanced Low Vision Clinic Synchronous/CVT

437 179

For Clinical Video Telehealth use the same CPT codes as used for face to face visits

TeleEyeCare Supplement – February 2020 Page 14

Code

Secondary Stop Code

CPT & ICD Codes

Intermediate Low Vision Optometry Clinic Synchronous/CVT

438 179

For Clinical Video Telehealth use the same CPT codes as used for face to face visits

Low Vision Care Optometry Clinic Synchronous/CVT

439 179

For Clinical Video Telehealth use the same CPT codes as used for face to face visits

A CPT code that may apply for the referring provider for any of the available TeleEyeCare Clinics is 99452-Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional; 30 minutes

*note that "other health care professional" is defined in this case as those that can perform E/M services.

** Do not report [92227, 92228] in conjunction with 92002-92014, 92133, 92134, 92250 or with the evaluation and management of the single system organ system, the eye, 99201-99350.

Note: The Imager closes the encounter and places themselves as the primary provider on the encounter form. This has been approved by the National Health Information Management System as this is a non-billable/no-copay patient side clinic set up with relative value units (RVUs) of the imager staff type. This is also imperative for Image Quality reports and the health factor tying to the

Imager being the primary provider on the patient side encounter.

Note: Coding staff validates all billable encounters and will append modifiers as appropriate (GQ and

95).

See the Telehealth Manual and the MCAO Intranet page for more detailed information on stop codes.

4.1 Telehealth Clinical Pathway

The structure of the TeleEye Care visit will vary depending on the Type of Visit/Service or

Diagnostic Group provided.

4.1.1 Common Resources

TeleEye Care common resources are required and need documentation in the TSA. Common resources include but are not limited to:

• Technologies

• Rooms http://vaww.dss.med.va.gov/programdocs/pd_oident.asp

TeleEyeCare Supplement – February 2020 Page 15

• Sites

• Clinics

• Consults

Technology includes equipment that is required to conduct the visit. For example, many visits require the presence of a clinical cart.

A Blanket Purchase Agreement (BPA) provides VISNs/Facilities access to approved Telehealth

Technology. Prior to deployment in the field, all Telehealth Technology is required to be evaluated and then placed onto the BPA. The Office of Connected Care Telehealth Services has a process in place, as well as Subject Matter Experts available for completing the technology evaluation.

Please visit the technology approval website at https://vaww.telehealth.va.gov/technology/approval.asp for information regarding the approval status for telehealth equipment, and information regarding the approval process. If equipment currently used in your program has not been approved by Office of Telehealth Services, please contact the National Telehealth Technology Manager with any questions.

Rooms/Sites/Clinics: The room, site, and clinic are used to ensure that a space is reserved for the visit and that workload is captured properly. Established space planning criteria for coordinated primary and specialty healthcare service should be observed. Note that the establishment of any form of TeleEye Care Services does not preclude a VA hospital from pursuing other eye care delivery methods.

• For TeleEye screening, patient (acquisition) sites must provide the space necessary to accommodate the imaging device, workstation and supporting furniture. Rooms require darkening and, should be in a windowless location or use complete blackout filters over windows.

• For Technology based Eye Care (TECS) the room needs to have some portion of two walls in parallel at least six feet apart in order to accurately mount the vision testing screen.

4.1.2 Clinical Resources

Clinical resources directly support the provider. These include but are not limited to:

• TelePresenter (can be a TCT/TeleImager, a certified ophthalmic technician for TECS, or a therapist supporting Low Vision Care)

• Pre-visit labs, radiographs/imaging or diagnostic results

• Provider preferences are another example of Clinical Resources

Some visits are easily performed by a Telehealth Clinical Technician (TCT) while other visits require a certified ophthalmic technician, or even potentially a Licensed Practical Nurse

(LPN)/Registered Nurse (RN) or a provider.

https://vaww.telehealth.va.gov/technology/approval.asp

TeleEyeCare Supplement – February 2020 Page 16

The TeleImager completes both courses and in-person training and evaluation of competencies to ensure mastery of processes required in TeleRetinal Imaging. TeleRetinal SFT Preceptors are the primary resource for coordinating and delivering initial SFT Imager training, as well as an excellent resource for providing additional competency and training needs for existing TeleRetinal

Imaging / Tele Eye Screening Imagers.

Ophthalmic technicians participating in TECS receive training by the local eye clinic and have competencies assessed by national TECS preceptors. Ophthalmic technicians in TECS should be certified by the Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO) as a

Certified Ophthalmic Assistant (COA) or higher level (Certified Ophthalmic Technician/COT, Certified Ophthalmic Medical Technician/COMT). VA Office of Personnel Management does allow for uncertified ophthalmic technicians to be hired if they can demonstrate adequate competency in the critical skills required for the TECS protocol but they must obtain their COA within 2 years of appointment.

Refer to the Connected Care/Telehealth Operations Manual for the standard role descriptions and competencies. Some visits are easily performed by a Telehealth Clinical Technician (TCT) while other visits require a Licensed Practical Nurse (LPN)/Registered Nurse (RN) or a provider.

4.1.3 Business Resources

Include but are not limited to:

• Additional information, details, further requirements or actions that do not neatly fall into the other categories.

• Clinic templates/schedules

• Scheduling support, for initial and follow-up appointments

• Consult management

Refer to the Connected Care/Telehealth Operations Manual for detailed information regarding business requirements. TeleEye Care consult management will follow VHA Directive 1232, Consult Processes and Procedures. For clinic set up refer to the Clinic Set Up Guidance

4.2 Asynchronous/SFT Clinical Pathway

Table 11 describes the various types of diagnostic groups/services/appointments that are provided by TeleEye Care using the SFT modality.

Table 10 Asynchronous/SFT Guidance Type of Visit Common

Resources

Clinical

Resources

Business

Resources

Additional

Information

TeleEye Screening (TeleConsultation) Asynchronous/SFT

Tonometer, non-mydriatic fundus camera

TCT/Imager competent in acquiring retinal

Schedule

Template;

Consult

VA-certified

TeleEye Care

Imager; Imager https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf https://vaww.infoshare.va.gov/sites/telehealth/docs/th-mnl.pdf https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3230 https://vaww.infoshare.va.gov/sites/telehealth/docs/clnc-stp.docx

TeleEyeCare Supplement – February 2020 Page 17

Type of Visit Common

Resources

Clinical

Resources

Business

Resources

Additional

Information images and Management; is required to tonometer usage, clinical complete a administration of reminders minimum 24 eye drops for patient imaging dilation if required visits each year by specific site; to maintain software to upload competency. * images to

Electronic Medical

Record (EMR);

Reader

(optometrist or ophthalmologist)

TECS/Asynchronous/SFT

Telemedicine

Auto-refractor, lensometer, tonometer, pachymeter, non-mydriatic fundus camera, vision screen, phoropter, eyeglasses, pupillometer

Ophthalmic

Technician/Imager competent in refraction, tonometer usage, pachymetry usage, administration of eye drops for dilation; Reader

Schedule

Template;

Consult

Management;

Follow-up visit scheduling

Technicians should be certified at the

Joint

Commission of

Allied Health

Professionals in

Ophthalmology

Certified (optometrist or Ophthalmic ophthalmologist) Assistant (COA) level**

*Imagers that do not meet the minimum competency requirements should have their skills and knowledge assessed by a Preceptor. The Preceptor should evaluate their knowledge and skills according to the SFT Core Competencies (virtually, over the phone, and/or with reviewing their most recent imaging). Based on the Preceptor’s assessment, the Preceptor will identify what, if any, specific training is needed along with recommendations on how it can be addressed. It is recommended that the Preceptor summarize their efforts in what was provided and reviewed with the Imager in a written summary to the Imager’s supervisor.

**Uncertified Ophthalmic Technicians with appropriate competencies to obtain certification within 2 years of starting to work in the program.

4.2.1 Asynchronous TeleConsultation Pathway

1. Requires 2 CPRS consults

2. First consult, for the technical component of the procedure, goes to the individual (TRI

Imager/TCT) performing the technical component (e.g., acquisition of the retinal photos)

3. Second consult is directed to the remote provider performing the interpretation

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• For Interfacility Programs

1. Imagers should review the results of the reader and complete the follow up note

(in a non-count clinic) to update the clinical reminders.

2. Alternatively, Imagers can complete a reminder dialog instead of the follow up note to reset the reminder in the patient side CPRS

Standard consult templates and pathways have been developed by the Eye Care Work Group and monitored at Conditions of Participation (CoP) reviews of each VISN. See section 4.2.3 SFT

TeleEye Care Clinical Workflow below.

4.2.2 Asynchronous TeleConsultation Workflow

A Computerized…