COVID-19-Office Policy March 18, 2020

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It is of paramount importance to protect the health of our staff and provide a safe work environment. In order to ensure that, we will implement the following immediately:

a.  Messaging: on phone system, please include a message that patients with any fever and respiratory symptoms should NOT directly come to the office and await further instructions from the physician.

b.  If you answer the call, ask about travel, exposures, duration of symptoms, fever, cough, shortness of breath or distress. If you determine via telephone-triage that the patient requires urgent attention, please bring this to the attention of the physician and we will direct the pt. We will need to notify the receiving facility in advance so appropriate PPE can be used.

On March 8, 2020, the Centers for Disease Control and Prevention (CDC) revised its criteria and guidelines for healthcare professionals when assessing persons under investigation (PUI) as potential cases of COVID-19 due to the novel coronavirus SARS- CoV-2. The following FAQ is intended to answer the most common questions asked by healthcare staff:

Question: Who should we be testing for COVID-19?

Criteria to Guide Evaluation and Laboratory Testing for COVID-19 (by CDC)

Clinicians should work with their local and California state health departments to coordinate testing through public health laboratories. In addition, COVID-19 diagnostic testing, authorized by the FDA under an Emergency Use Authorization (EUA), is available in clinical laboratories, such as LabCorp and Quest as of Monday, March 9, 2020. It should be noted that neither LabCorp nor Quest will collect specimens on suspected COVID-19 cases. Instead, specimens are to be collected at healthcare facilities, such as hospitals and physician offices, and sent to Quest or LabCorp using standard procedures. LabCorp says test results will be made available in as little as 3 days. Local Public Health labs may offer a 24 hour turn- around time for results. Lab Corp and Quest each require their own viral media for testing, so should be contacted to order testing supplies.

Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Decisions on which patients receive testing should be based on the local epidemiology of COVID-19, as well as the clinical course of illness. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza.

Priorities for testing may include:

1
2
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Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control.
•Other symptomatic individuals, such as adults and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease).
•Any persons including healthcare personnel, who within 14 days of symptom onset had close contact with a suspect or laboratory- confirmed COVID-19 patient, or who have a history of travel from affected geographic areas within 14 days of their symptom onset.

Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g., influenza). Mildly ill patients should be encouraged to stay home and contact us by phone for guidance about clinical management and testing. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately but should call first so appropriate PPE can be used to meet the patient. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.

Q: What do I do if I have a patient who meets the criteria for COVID-19 testing (e.g., meets criteria for a person under investigation or PUI)?

Out-Patient/Office Setting:

Advise patients to call first so that you can perform telephone-triage of patient’s symptoms and need for medical attention versus testing alone. Most community settings do not have negative pressure isolation rooms where patients can await test results. Depending upon the number of requests in the community, you may wish to direct your patient to a hospital setting where there is adequate PPE and monitoring available. If the hospital system is overwhelmed, it is advised for you to have proper PPE for you and your staff members (N-95 mask, eye protection, disposable gowns and nitrile gloves) and a means for red-bag disposal. Some offices are meeting the patient at their car in order to minimize exposures and risks.

Q: What do I do about “concerned persons” who want testing but who do not meet COVID-19 testing criteria yet, who may be at moderate or greater risk?

Testing can be determined by the provider if the patient has some mild symptoms or is at risk from COVID-19 exposure and there is capacity to test (i.e enough supplies). Encourage asymptomatic persons at moderate or greater risk to self-isolate at home, avoid contact within six feet of others, and to call their health care provider if symptoms appear or their condition worsens. Advise these parties that they must call their health care provider prior to returning to any health care facility to obtain instructions on how and where to report to that facility for proper intake to avoid exposing others. Health care providers should make a record to follow up with all such patients every 2 to 3 days for at least two weeks.

Three additional items of note, particularly in context to family, friends and others in contact with a concerned person: First, young children appear to be relatively protected from COVID-19, with typically benign or mild courses of infection. Second, persons with co-morbidities, such as smokers, the elderly or those with chronic obstructive pulmonary disease, are more vulnerable and subject to worse outcomes. Third, individuals in contact with a concerned person who subsequently develop fever, cough or shortness of breath should be encouraged to contact their health care provider, and alert them to the untested status of the concerned person.

Q: How do I respond to persons who are “worried well,” who do not have any signs or any significant risk of COVID-19 but who would like to be tested?

Explain that CDC-sanctioned tests for COVID-19 are limited in availability and must be conserved for those who meet criteria or who require a confirmed diagnosis (such as hospitalized patients). Provide standard counseling measures and advice for addressing stress or anxiety. Remind them of best practices for prevention, such as frequent hand washing with soap and warm water, avoiding close contact with people who are sick, avoiding touching eyes, nose and mouth, staying home and informing us when sick and covering a cough or sneeze with a tissue, then throwing the tissue in the trash. A more expansive list of preventive measures can be found at:     https://www.cdc.gov/coronavirus/2019-ncov/ about/prevention-treatment.html.

Q: What specimens should be submitted for testing?

For initial diagnostic testing for COVID-19, CDC recommends collecting and testing upper respiratory tract specimens (nasopharyngeal swab) in viral media. CDC also recommends testing lower respiratory tract specimens, if available. For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended. Specimens should be collected as soon as possible once a person has been identified for testing, regardless of the time of symptom onset.

See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for COVID-19 (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical- specimens.html ) and Biosafety FAQs for handling and processing specimens from suspected cases and PUIs (https://www.cdc.gov/coronavirus/2019-ncov/lab/biosafety-faqs.html) .

Recommendations for Reporting
Since we will be using LabCorp or Quest for testing, reporting will be done via the lab if a case is positive and a PUI can be completed as with other reportable conditions.

from WHO:  • An emergency ICD-10 code of U07.1 is assigned to the disease diagnosis of COVID-19 (2019-nCoV acute respiratory disease) but won’t be adopted in the US until 10/1/20

From CDC and AAFP

For Testing:  • ICD Code: RO5-Cough, R50.9 (Fever)
For Known exposure to COVID-19:  • Z20.828
After diagnosis of COVID-19:  • (and ordering other tests like x-rays): J12.89 (other viral pneumonia) and B97.29 (other coronavirus)
For Follow-up of patient after negative COVID-19 test:  • Z03.811 (Encounter for observation for suspected exposure to biological agent ruled out)

Since 2018, Medicare pays for “virtual check-ins” for patients to connect with their doctors without going to the doctor’s office. These brief, virtual check-in services are for patients with an established relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to using virtual check-ins and the consent must be documented in the medical record prior to the patient using the service. The Medicare coinsurance and deductible would apply to these services. Doctors and certain practitioners may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).

Medicare also pays for patients to communicate with their doctors without going to the doctor’s office using online patient portals. The individual communications, like the virtual check ins, must be initiated by the patient; however, practitioners may educate beneficiaries on the availability of this kind of service prior to patient initiation. The communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would apply to these services.

Telemedicine:

On 3/17/20, CMS announced coverage of Telemedicine visits to be reimbursed at the level of Office visits. Use same E/M codes, but need #2 as place of service (instead of 11). The provider will need to include a statement such as:
"This visit was conducted with the use of an interactive audio and video telecommunication system that permits real-time communication between patient and provider. Patient consent for this visit was obtained before the visit."
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

Testing in Office (not available, but for providers linked to labs)

There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) can be used by laboratories and healthcare facilities to bill Medicare as well as by other health insurers

Q: How do I better triage and screen patients?

  1. It is very important to screen all respiratory patients after travel for 14 days prior to onset of symptoms and/or exposure to a known COVID-19 person.
  2. Travel screening has been updated to include an expanded list of countries for screening currently: South Korea, Japan, Italy, Iran, Europe, and China (except for Hong Kong, Macau and Taiwan).
  3. Ask for symptoms of cough, fever, shortness of breath or malaise and onset of symptoms.

Q: How does the physician protect himself/herself while collecting specimens?

We will try to meet patients at their car for testing and preferably at the end of the clinic day. The proper PPE for specimen collection includes: Gloves, disposable gowns, N-95 respirator or simple facemark with Eye protection- face shield. Red hazard bag and 60% alcohol for safety and disposal.

Donning (plan to triple glove so can peel off b/n pts.):

  1. Start w/hand washing
  2. Gown
  3. Respirator
  4. Face Shield
  5. Gloves
  6. Hand hygiene

Doffing:

  1. Hand hygiene-sanitizer
  2. Remove gloves
  3. Remove Face Shield
  4. Remove gown
  5. Respirator-outside of care area
  6. Finish with hand hygiene.....It is ok to change the gloves.

Q: What if we do not have enough N-95 respirators?

Limited re-use of N95 respirators when caring for patients with COVID-19 might become necessary. However, it is unknown what the potential contribution of contact transmission is for SARS-CoV-2 and caution should be used. Re-use should be implemented according to CDC guidance. Re-use has been recommended as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate- strategies.html

  • Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls;
  • Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
  • Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable; and
  • Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.
  • N95 Reuse may need to be assessed on a facility-to-facility basis in conjunction with local infection control authorities and resource availability. Extended use (versus reuse) is favored, given relatively lower risks of surface contamination. Irrespective, masks may need to be discarded after aerosol generating procedures (intubation, bronchoscopies), where source control is lacking by definition.

Q: What is a Surgical N95 respirator and who needs to wear it?

https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html

  • A surgical N95 (also referred as a medical respirator) is recommended only for use by healthcare personnel (HCP) who need protection from both airborne and fluid hazards (e.g., splashes, sprays). These respirators are not used or needed outside of healthcare settings. In times of shortage, only HCP who are working in a sterile field or who may be exposed to high velocity splashes, sprays, or splatters of blood or body fluids should wear these respirators, such as in operative or procedural settings. Most HCP caring for confirmed or suspected COVID-19 patients should not need to use surgical N95 respirators and can use standard N95 respirators.
  • If a surgical N95 is not available for use in operative or procedural settings, then an unvalved N95 respirator may be used with a faceshield to help block high velocity streams of blood and body fluids.

Q: If I am caring for a suspected or confirmed COVID-19 patient can I care for other patients?

Yes, at this time there is no guidance from the state or CDC that these patients need dedicated staff. If appropriate PPE was used, there is no reason staff cannot continue to work with other patients.

Q: Do I need to be in quarantined if I am caring for a COVID-19 case?

No. If the case is confirmed you will be given a list of symptoms to report if you should develop them within 14 days of last caring for an active confirmed case. Although there are now healthcare workers in the U.S. with confirmed COVID-19, these were linked to care prior to identifying the patient as a suspect case and therefore staff were not following the appropriate precautions. No reported cases in Western Europe, Australia, Canada or the U.S. have been among healthcare workers who were aware of the patient’s diagnosis and following precautions. You do not need to isolate yourself from loved ones, friends, family or pets unless told to do so.

Q: Outpatient Setting:

What if I or my staff are placed in quarantine status due to exposure? What are options for disability coverage?

The California Employee Development Department (EDD) is encouraging individuals who are unable to work due to exposure to COVID-19 to file a Disability Insurance claim.

EDD is also encouraging employers who are experiencing a slowdown in their businesses or services as a result of the Coronavirus impact on the economy to apply for an Unemployment Insurance work sharing program. This website has a form to download and criteria for qualification for the program. https:// www.edd.ca.gov/Unemployment/Work_Sharing_Program.htm Contact: 916-464-3343

Resources:

1. Dr. Maves’ talk at SCCM 2020 along with talks by Dr. Zhiyong Peng (CCM chief at Wuhan, senior author on the big JAMA case series) and Dr. Laura Evans (University of Washington). https://www.youtube.com/watch?v=Nz--4nrdMgI&t=1441s

2. The National Ebola Training and Education Center (NETEC) has a great video on the use of coronavirus PPE including proper donning and doffing. Entire video is 18 minutes long. Section on actual use of PPE starts at around 4 minutes. https://www.youtube.com/watch?v=bG6zISnenPg

3. California Health Alert Network: https://emergency.cdc.gov/han/2020/han00429.asp

4. Guidance for the identification and management of potentially exposed contacts of a confirmed case of COVID-19 can be found in Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposures: Geographic Risk and Contacts of Laboratory-confirmed Cases (https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html).

5. Separate guidance for the management of potentially exposed contacts of a COVID-19 case who are healthcare personnel is provided in Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk- assesment-hcp.html).

Information courtesy of:
Dr. Angela Wang, Scripps Clinic
Dr. Ryan Maves (Infectious Diseases Fellowship Director and Staff Intensivist, Naval Medical Center San Diego)
Dr. Francesca Torriani, Program Director, Infection Prevention/Clinical Epidemiology (IPCE) at University of California, San Diego

Reviewed and approved by CTS Clinical Practice Committee

Asha Devereaux, Sachin Gupta, Janine Vintch, Anna Breiberg, Abdullah Alismail, Cedric Rutland Date: 3/13/20

COVID-19 Concerns?

Due to risks to staff and others, it is advised you

contact us via telephone and we will discuss your clinical symptoms and advise you regarding testing.

At this time, we ask that patients refrain from ‘walking-in’ for your own personal safety.