Telemedicine – The Emerging Face of Healthcare Amidst COVID-19
The COVID-19 crisis has opened up a new flexible version of telemedicine that allows providers to continue providing care, information and education to patients digitally through telecommunication technologies.
Bookmark this page to keep yourself updated on telemedicine including the new guidelines, tools, best practices, case studies and key updates relevant to accelerate your telemedicine- readiness.
Understanding the Basics
► Telemedicine
Telemedicine is the practice of providing remote clinical care to patients when the provider and patient are not physically present with each other using electronic information and telecommunication.
► Telemedicine vs. Telehealth
Telehealth has broader scope than telemedicine. It involves providing clinical and non-clinical services using electronic information and telecommunication. For example: surveillance, access to medical knowledge, training, monitoring patients remotely etc.
► Commonly used terms
◘ Synchronous – Synchronous telemedicine refers to the delivery of health care in real-time. This involves the use of audio-video or audio to have a live communication between patient and healthcare professional to deliver medical care.
◘ Asynchronous – Asynchronous telemedicine captures clinically important digital samples (for example still images, video, audio, text files) and relevant data in one location and subsequently transmits these files for interpretation by health professionals at remote site without requiring the simultaneous presence of the patient involved.
◘ Store and Forward – This is a technique used in telemedicine where information like patient data, images, lab reports, videos are stored in a location and are later forwarded to healthcare provider at distant site for interpretation.
◘ Real time encounter – Patient and doctor can see and hear each other using a video conferencing software.
◘ Audio conferencing – Patient and doctor can hear each other using a video conferencing software using only audio feature.
◘ Originating site – Refers to the site where the patient is present while taking telemedicine services.
◘ Distant site – Refers to the site where the physician is present while giving telemedicine services.
► Telemedicine: The COVID-19 Version
Telemedicine is constantly evolving. Although there are many advantages of adopting this method, there have been roadblocks implementation challenges. Strict reimbursement rules, originating site and distant site guidelines made it difficult for healthcare professionals to align and seamlessly implement telemedicine. On March 17,2020 CMS published a fact sheet which was followed by interim final rule on March 30, 2020 to provide additional flexibility to physicians during the COVID-19 pandemic.
Below are few key takeaways –
◘ Flexibility in the originating site rules – Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.
◘ A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients
◘ During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services. Everyday communication technologies such as FaceTime or Skype are allowed during this crisis.
◘ Providers can bill for telehealth visits at the same rate as in-person visits (POS 02 is not mandatory. The services can be billed with place of service as applicable with Modifier 95)
◘ Telehealth visits, virtual check-ins and e-visits can be billed for both new and established patients.
◘ Providers also can evaluate beneficiaries who have audio phones only (telephonic codes 99441-99443 and 98966-98968 can be billed).
◘ CMS will now allow for more than 80 additional services to be furnished via telehealth.
◘ CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice and home health.
◘ Telehealth visits include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth.
◘ CMS is making it clear that clinicians can provide remote patient monitoring services to patients with acute and chronic conditions, and can be provided for patients with only one disease.
◘ CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.
◘ A subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233).
◘ A subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days (CPT codes 99307-99310).
◘ Critical care consult codes may be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation (CPT codes G0508-G0509).
◘ For Medicare patients with End Stage Renal Disease (ESRD), clinicians no longer must have one “hands on” visit per month for the current required clinical examination of the vascular access site.
◘ For Medicare patients with ESRD, exercising enforcement discretion on the following requirement so that clinicians can provide this service via telehealth: individuals must receive a face-to-face visit, without the use of telehealth, at least monthly in the case of the initial three months of home dialysis and at least once every 3 consecutive months after the initial three months.
◘ Beneficiary consent should not interfere with the provision of telehealth services. Annual consent may be obtained at the same time, and not necessarily before, the time that services are furnished.
◘ Physician visits: CMS is waiving the requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.
◘ Office/outpatient E/M level selection for these services when furnished via telehealth can be based on MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record.
► Telemedicine Services
Telehealth visits: Interactive real time evaluation of patient’s health.
Mode: Audio only, Audio-Video
Type: Synchronous
◘ Common Telehealth visits include office or other outpatient visits, telehealth consultations for emergency department or initial inpatient, follow up inpatient telehealth consultation in small nursing facilities.
◘ Telehealth visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
◘ Applicable for new and established patients in all types of settings across the country, including homes.
◘ No audits will be conducted to check if prior relationship existed for claims.
◘ Use modifier 95 and applicable place of service to bill these services
Virtual check-ins: Brief communications with providers, often initiated by patients.
Mode: Audio only, recorded video, images
Type: Synchronous and Asynchronous
◘ Applicable for established and new patients.
◘ HCPCS code G2012: Usually a brief 5-10-minute medical discussion.
◘ HCPCS code G2010: Remote evaluation of recorded video or image submitted by the patient for interpretation.
◘ Applicable across broad range of methods, unlike Telehealth visits that requires real-time audio/video.
◘ Use applicable place of service (no modifier required) to bill these services.
E-Visits: Online digital Evaluation and management service initiated by patient.
Mode: Online patient portal, other secure platform (audio or video but not telephone)
Type: Synchronous and Asynchronous
◘ Applicable for established and new patients. No geographic restrictions.
◘ Communication via patient portals.
◘ Medicare co-insurance and deductibles would apply.
◘ Cumulative time for 7 days is calculated for this service.
◘ Use applicable place of service (no modifier required) to bill these services
Telephonic visits: Evaluation and management services that occur via telephone between providers and patients.
Mode: Telephone
Type: Synchronous
◘ Applicable for established and new patients.
◘ Telephonic visit should not originate from E/M service within last 7 days and not lead to E/M service in next 24 hrs or earlier.
◘ Payments for these codes start March 1, 2020.
◘ Use applicable place of service (no modifier required) to bill these services.
Remote patient monitoring: Technology enabled monitoring of patients outside of conventional clinical settings.
Mode: Patient portal, email, secure text messaging, phone, audio/video
Type: Asynchronous
◘ Asynchronous transmission of healthcare information.
◘ Physiological parameters can be monitored.
◘ Physician, clinical staff or other health care professional ‘s time is calculated in a calendar month.
◘ Use applicable place of service (no modifier required) to bill these services.
BILLING AND CODING GUIDELINES:
Telehealth rules are continuously evolving to make Telehealth accessible to the masses.
> Click below to download the updated one-page Telemedicine Coding guide for quick reference.
> Learn More about Medicare and Commercial Insurances Telemedicine Billing Policies here
TOOLS:
HHS OCR announcement dated March 17th, 2020, allows the use popular apps that allow for video chats to provide Telehealth without risk of non-compliance under HIPAA.
Tools include:
Apple FaceTime, Facebook Messenger video chat, Google Hangouts video and Skype.
Note: Public facing video communication apps such as Facebook Live, Twitch, TikTok, and similar apps cannot be used to provide care virtually.
Healthcare providers may choose to use HIPAA compliant telehealth tools and will enter into HIPAA business associate agreements.
Examples of such tools include:
Skype for Business/Microsoft Teams, Updox, Zoom for Healthcare, Doxy.me, Google G Suite Hangouts Meet, Amazon Chime, etc.
► Tips to triage telemedicine appointments
◘ Identify patients with chronic conditions in the existing patient pool.
◘ Identify the last appointment completed with the practice.
◘ Prepare a list of patients which are due for follow-ups.
◘ Communicate and schedule a telemedicine appointment with these patients.
◘ Explain patients on advantage of following up for their existing symptoms/new symptoms through telemedicine.
◘ Explain the process in brief and assist them if any technical help is required.
► Implementation methodology
Telemedicine implementation requires thorough understanding of the practice patient pool, chronic conditions pertaining to the specialty of the physician, technical understanding of the methodology, compliance rules and regulations, cost involved in deploying the technology, ongoing maintenance and aligning the staff and patients to the new healthcare system.
> Click below to know the steps to incorporate best practices and standard templates while implementing telemedicine.
► How are the early adopters doing
Telemedicine came into spotlight during COVID-19 pandemic and several healthcare professionals started adapting to it. The regulatory barriers that had held back telemedicine all these years are now relaxed, and the healthcare systems are slowly embracing it.
Doctors are more focused to render continuity of care to their patients. They do face issues initially but for them patient care is always on priority. Here’s a case study of how a practice we closely work with have used telemedicine to positively impact care for patients.
> Learn how this practice used telemedicine to resume 35% of their regular patient volume amid total lockdown
► Pro-Bono Services:
◘ Email service – Mass emailing on behalf of the practice and educating patients on the availability of telemedicine.
◘ Tool selection and integration – Assisting the practice in selecting telemedicine tools based on workflow requirements.
◘ Triage and scheduling telemedicine appointments for the practice.
◘ Assist patients for telemedicine visits/training new patients to adapt to virtual appointments.
◘ Training the practice on telemedicine coding and related documentation.
◘ Reimbursement guidance for the practice (timely updates upon coordination with various stakeholders including insurance, CMS).
◘ Periodic telemedicine reimbursement analysis.
Adapting Telemedicine during COVID-19 is a learning for both doctors and patients and by the time the pandemic recedes telemedicine will become the new norm in healthcare.
> Need help with telemedicine implementation at your practice?
References:
General Provider Telehealth and Telemedicine Tool Kit (CMS)
AMA quick guide to telemedicine in practice
United Healthcare Telehealth services – Care provider coding guidance
Special coding advice during COVID-19 public health emergency
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