Last Updated March 30, 2020
The following guidance is drawn primarily from the Centers for Disease Control and Prevention’s (CDC) resources for health care professionals on COVID-19. Additional information is provided based on resources from the American Medical Association, the Maryland Department of Health, and Montgomery County Health and Human Services. Every effort is being made by MCMS staff to keep this guidance up to date, but we recommend always referring to both MDH and CDC guidance for the most recent information. Please refer to the resource list at the bottom of this article for reference links.
Maryland Department of Health All-Physician COVID-19 Phone Calls
Coordinated by MedChi, The Maryland State Medical Society, these statewide, all-physician calls are hosted by Howard Haft, MD, of the Maryland Department of Health. Join for critical updates on the spread, treatment of, and resources for combatting COVID-19. The calls are held on Monday and Wednesdays at 5 pm, and Friday at 12 noon. For dial-in information, visit MedChi’s COVID-19 Resource Center, and click on their latest update email. Or, find it in your inbox. Not receiving the email? Contact us at 301.921.4300 or firstname.lastname@example.org.
What to Tell Patients
The Montgomery County Health Department has created a resource page that is a helpful guide on what to say to patients, and to refer patients to. The CDC has created a handout for medical practice to make available for concerned patients. Click here to download the pdf, or visit the CDC’s web page of printable handouts and posters.
Practice Protocols & Preparedness
Pre-Screening: When scheduling appointments, instruct patients and persons who accompany them to call ahead or inform staff upon arrival if they have symptoms of any respiratory infection (e.g., cough, runny nose, fever) and to take appropriate preventive actions (e.g., wear a surgical mask upon entry to contain cough, follow triage procedures).
Promote Respiratory Hygiene: Take steps to ensure all persons with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) adhere to respiratory hygiene and cough etiquette, hand hygiene, and triage procedures throughout the duration of the visit. Consider posting visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and health care personnel with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use surgical masks or tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
Provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS), tissues, no touch receptacles for disposal, and surgical masks at healthcare facility entrances, waiting rooms, patient check-ins, etc.
Limit Exposure: Ensure that patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough) are not allowed to wait among other patients seeking care. Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies. In some settings, medically-stable patients might opt to wait in a personal vehicle or outside the healthcare facility where they can be contacted by mobile phone when it is their turn to be evaluated.
Rapid Triage: Ensure rapid triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection (e.g., fever, cough):
- Identify patients at risk for having COVID-19 infection before or immediately upon arrival to the healthcare facility.
- Implement triage procedures to detect persons under investigation (PUI) for COVID-19 during or before patient triage or registration (e.g., at the time of patient check-in) and ensure that all patients are asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of SARS-CoV-2, the virus that causes COVID-19, or contact with possible COVID-19 patients.
- Implement respiratory hygiene and cough etiquette (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done) and isolate the PUI for COVID-19 in an Airborne Infection Isolation Room (AIIR), if available. See recommendations for “Patient Placement” below. Additional guidance for evaluating patients in U.S. for COVID-19 infection can be found on the CDC COVID-19 website.
- Inform infection prevention and control services, local and state public health authorities, and other healthcare facility staff as appropriate about the presence of a person under investigation for COVID-19.
The above is summary guidance for practices. Please visit the CDC’s protocol for full details; it is being updated on a rolling basis. MCMS encourages practices to utilize the CDC’s preparedness checklist for COVID-19 and the CDC’s interim guidance for community transmission preparation in various facility and practice modalities.
What to Look For
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. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing). Priorities for testing may include:
- 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, older 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.
There are epidemiologic factors that may also help guide decisions about COVID-19 testing. Documented COVID-19 infections in a jurisdiction and known community transmission may contribute to an epidemiologic risk assessment to inform testing decisions. 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 their healthcare provider by phone for guidance about clinical management. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.
At this time, the Maryland Department of Health asks that practices make every attempt to provide remote care for patients through telemedicine and/or telephonic communications. MDH has also emphasized in their letter to clinicians on March 13, 2020 that:
- Asymptomatic persons do not need to be tested.
- Mildly symptomatic patients who are otherwise healthy can self -quarantine, monitoring temperature, and symptoms and check in with the provider as needed. These patients do not need to be tested.
- Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness. In most situations, those patients will need to be evaluated in an emergency department.
How to Test
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. Testing of asymptomatic people is not advised. You do not need to call the state or local health department about these cases. It’s important to test for other respiratory pathogens at the time of the initial evaluation. Note that clinical laboratories should NOT attempt viral isolation from specimens collected from persons suspected to have COVID-19 unless this is performed in a BSL3 laboratory.
CDC now recommends that a nasopharyngeal (NP) swab alone is adequate. You do NOT need to collect both an NP and oropharyngeal/throat (OP) swab. Maintain proper infection control when collecting specimens.
Overall, since COVID-19 testing is available at commercial and some hospital labs, clinicians should send specimens to those laboratories for testing. These labs process but do not obtain specimens.
Clinicians do NOT need approval from the Maryland Department of Health or the local health department to order, collect, or submit specimens to commercial or hospital laboratories. You do NOT need to call the health department if you use a commercial or hospital lab for COVID-19 testing. You should check with these laboratories for specific information on specimen collection and packaging requirements. LabCorp and Quest Diagnostics have each posted web pages (1, 2) that they are updating on a rolling basis. For a list of designated testing sites, click here.
Secretary Neall issued a Directive and Order Regarding Various Healthcare Matters stating that health care providers shall prioritize COVID-19 test orders to the following groups. The Maryland Department of Health is continuing to conduct COVID-19 testing and will accept specimens for patients in these prioritized groups (A-D). MDH cannot accept lower priority specimens for testing at this time
- A. Hospitalized patients, who should be tested by the most expeditious means available (either a hospital lab, private lab, or the State Laboratory);
- B. Symptomatic Emergency Medical Service Personnel, healthcare workers, and law enforcement personnel;
- C. Symptomatic patients in nursing homes, long-term care facilities, or in congregate living facilities housing individuals who are medically fragile; OR
- D. Symptomatic high-risk unstable patients whose care would be altered by a diagnosis of COVID-19.
Health department approval is no longer required for COVID-19 testing performed at MDH. Clinicians do not need to notify the local or state health department of the decision to test or the decision to submit the specimen to MDH for testing.
Clinicians may only submit specimens to MDH for patients in these prioritized groups. However, clinicians are NOT required to use MDH for COVID-19 testing of these groups. Clinicians should use their own swabs and viral transport media for specimens submitted to MDH for testing. An MDH Laboratories Administration test order form must be completed and accompany the specimen, AND must indicate the specimen’s priority group (A, B, C or D). Continue to follow MDH Laboratory Administration guidelines related to specimen collection, shipping guidance, and the required test request form. The Maryland Department of Health also has a web page on specimen collection and shipping.
The following is contact information for clinicians to use for local health departments, as necessary:
- Montgomery County Department of Health and Human Services: M-F Business Hours – 240.777.1755 After Hours & Weekends – 240.777.4000
- District of Columbia Department of Health: 202.727.3616 or report cases using this web portal.
- List of Contact Information for All Maryland Local Health Departments
*Each organization was contacted by MCMS staff to request the correct contact information for reporting. This listing will be updated on a rolling basis. Question? Call MCMS at 301.921.4300.
What Precautions to Take
Health care personnel should use standard precaution, contact precautions, airborne precautions and eye protection such as goggles or a face shield before entering the room. Please note that, in situations where fit-tested NIOSH-approved N95 or higher level respirator for healthcare personnel are in a shortage, surgical masks may be used. Eye protection, gown, and gloves continue to be recommended, but if there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP.
Section 2 of this CDC web page emphasizes important PPE compliance for COVID-19. For full precaution guidance, refer to the CDC’s isolation precautions guideline.
- On-Demand Webinar: Rapid Implementation of Telehealth
- On-Demand Webinar: Rapid Implementation of Remote Patient Monitoring
- Telemedicine Vendor Options
- Medicare Telehealth Coding/Billing Guidelines – March 26, 2020
- Telemedicine FAQ’s – Updated March 18, 2020
From the American Medical Association (AMA)
- AMA Quick Guide to Telehealth Implementation & COVID-19
- March 17, 2020 – AMA applauds Medicare telemedicine policy change during pandemic
From the Centers for Medicare & Medicaid Services (CMS)
- General Provider Telehealth and Telemedicine Tool Kit
- FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency
- Medicaid Telehealth Guidance
- Medicaid State Plan Fee-for-Service Payments for Services Delivered Via Telehealth
From Private Payors
- An overview of How to Get Paid for Telehealth and their Telemedicine 101 Overview
- MCMS Webinar with SimpleVisit on Rapid Implementation of Telehealth
- Backline Overview: Telehealth Care Coordination in Real-Time
- In response the COVID-19 crisis, DrFirst, a Maryland-based company is offering their Backline Telehealth platform to Maryland providers free of charge for 30 days. To register for this service, please click here. Please contact Colleen George with questions.
From the Maryland Department of Health (MDH)
- March 26, 2020: Telehealth – Maryland State of Emergency – COVID-19 Frequently Asked Questions
- Notice: RE: COVID-19 #1: Temporary Expansion of Medicaid Regulations to Permit Delivery of Telehealth Services to the Home to Mitigate Possible Spread of Novel Coronavirus (“COVID-19”)
From the Maryland Healthcare Commission (MHCC)
From the U.S. Department of Health and Human Services (HHS)
Employment Law Resources
The legal framework surrounding employment law as it relates to COVID-19 continues to evolve. MCMS held a Q&A session with Paley Rothman, a local law firm, last week. It is available to stream online: COVID-19 Employment Law Q&A. For frequently asked questions, please refer to the end of this slide deck. Additional resources will be posted here on a rolling basis, but please contact MCMS staff if your questions are not answered by these materials.
Emergency Loans, Grants, & Tax Relief*
Relief Programs for Your Practice
- Maryland Small Business COVID-19 Emergency Relief Grant Fund – This grant fund offers working capital to assist Maryland small businesses and nonprofits with disrupted operations due to COVID-19. Grant assistance is intended to provide interim relief complementing actions with its bank, business interruption insurance, and financial partners. Learn more.
- Maryland Small Business COVID-19 Emergency Relief Loan Fund – Loans up to $50,000 (not to exceed three months of cash operating expenses) open to Maryland businesses impacted by the COVID-19 with fewer than 50 employees. Learn more.
- Small Business Administration’s Economic Injury Disaster Loan Program – The SBA’s Economic Injury Disaster Loan Program provides loans to qualified entities that are impacted by the Coronavirus (COVID-19). The estimated time for completing this entire application is two hours and ten minutes, although you may not need to complete all parts. Learn more.
HR748: “Coronavirus Aid, Relief, and Economic Security Act” (CARES Act)
The CARES Act was passed and signed into law on Friday, March 27. The following are key highlights for physicians and practices, but MCMS recommends reading the AMA’s full summary of the bill.
Provisions that will benefit physicians and physician practices:
- Provides $100 billion through the Public Health and Social Services Emergency Fund to provide immediate financial relief for health care entities by covering non-reimbursable expenses attributable to COVID-19.
- Authorizes $10 billion for an “emergency” Economic Injury Disaster Loan (EIDL) to eligible entities with not more than 500 employees. Allows an eligible entity that has applied for an EIDL loan to request an advance on that loan, of not more than $10,000, which the SBA must distribute within 3 days.
- For health care professionals who answer the call to serve, the language makes clear that physicians who provide volunteer medical services during the public health emergency related to COVID-19 have liability protections.
- Temporary waiver of requirement for face-to-face visits between home dialysis patients and physicians.
- Requires Medicare Prescription Drug Plans and MA-PD Plans to allowduring the COVID- 19 emergency period for fills and refills of covered Part D drugs for up to a 3-Month supply.
- Creates exemptions in high deductible plans to allow telehealth visits for free without recategorization of the plan and gives the HHS Secretary further leeway to expand telehealth services for Medicare during the emergency.
- Group health plans or health insurance issuers are required to reimburse the provider of a diagnostic test either at the negotiated rate in effect before the COVID-19 public health emergency was in effect or, if there is no negotiated rate, the cash price as publicly listed by the physician.
- Read more…
Maryland business and individual income taxpayers will be given a 90-day extension for tax payments. No interest or penalty for late payments will be imposed if 2019 tax payments are made by July 15, 2020. See 90-day extension for tax payments for more information. The federal tax filing deadline has been moved to July 15. Learn more.
Comptroller Franchot also extended business-related tax filing deadlines to June 1. Get additional information regarding business tax returns – including sales and use tax, alcohol tax, etc. – and income tax extensions. Businesses who paid their Maryland Sales & Use Taxes for March early may request a refund of their payment by emailing email@example.com or by calling 410-260-4020.
*Each practice should consult on an individual basis with their tax attorney and/or accountant.
The Maryland Responds Medical Reserve Corps are seeking volunteers to staff clinics and field hospitals. To register for Maryland Responds, please visit the Medical Reserve Corps here.
For the A-Z resource guide, and additional information on how to help – including Red Cross blood donations, Meals on Wheels, and other ways – visit Maryland Unites.
Montgomery County is also looking for volunteers – both clinical and non-clinical. If you are interested in assisting the community, please visit their website here. Bethesda Transit has also provided information on essential transportation updates and how to help local businesses here.
Resources for Physicians
OCR 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. Learn more.
On Saturday, March 14, 2020, MedChi, The Maryland State Medical Society, hosted a Q&A session with Howard Haft, M.D. from the Maryland Department of Health. Click here to stream or download the audio.
Information on Maryland’s emergency COVID-19 regulations, including requirements to waive copayments and deductibles. Maryland Medicaid has expanded coverage of telemedicine services, as has Medicare. CPT has released new billing codes for COVID-19 related care.
From the Centers for Disease Control and Prevention
- Resource Center for Health Care Professionals
- Situation Summary
- Latest HAN Update Summary
- Factsheets, Handouts, and Posters
From the World Health Organization (WHO): WHO Coronavirus Home which is updated on a rolling basis with technical guidelines on a rolling basis.
From the Journal of the American Medical Association (JAMA): Guidance for diagnosis and treatment, updated on a rolling basis.
Local Maryland/Montgomery County Resources
- MDH Coronavirus Clinician Letter — 3.26.20
- COVID-19 – Surgical Procedures Guidelines
- MDH Directive Regarding Availability of Testing — 3.20.20
- Emergency COVID-19 Regulations
- Maryland Department of Health’s (MDH) web page for the latest updates on the virus
- MDH Coronavirus Clinician Letter — 3.13.20
- MDH Coronavirus Clinician Letter — 2.28.2020
- Montgomery County’s Health Department’s general information page for the public
- MedChi, The Maryland State Medical Society’s resource page
In the News
- The Washington Post‘s live updates page
- AMA’s COVID-19 Resource Center
- From the AMA Wire, “When global health emergencies strike, how should doctors respond?”
- MedChi, The Maryland State Medical Society’s press release on nCoV
For an up-to-date incidence map, see the Johns Hopkins School of Public Health GIS map.
Rockpointe Webcourse CME: Understanding and Addressing the Global Spread of the COVID-19 Infection: A Clinician’s Guide – This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Potomac Center for Medical Education and Rockpointe. The Potomac Center for Medical Education is accredited by the ACCME to provide continuing medical education for physicians. The Potomac Center for Medical Education designates this enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.