Telehealth in the Time of COVID19 pt.2

Implementing Telemedicine in Response to the 2020 COVID-19 Pandemic.

Gadzinski AJ, Ellimoottil C, Odisho AY, Watts KL, Gore JL.

Disclaimer: This is a summary of the highlights of this article, I do not own any or endorse any of the findings within this article. This is for educational purposes only and a full link for further review is included.

Bite Sized Take-Away:

The authors of this article have summarized the implementation of telemedicine during the COVID19 through their recommendations on equipment, navigation of legislative concerns, coding, and logistical concerns. They express suggestions on how to include telemedicine in urology practice in the midst of the COVID19 pandemic and how to maintain post-pandemic.

Key Points:

Background

• Secretary of Health and Human Services, Alex Azar, has waived restrictions on telemedicine services for Medicare Part B beneficiaries retroactive to March 1, 2020.

  • Allows Medicare patients to engage in video visits from anywhere (including their homes).

• The authors have provided an overview of pre-existing regulations and changes specific to the COVID19 pandemic, platform resources for urologists, and offer pragmatic solutions to common telemedicine implementation.

• Most urology practices should convert almost all urology clinic visits to telemedicine visits or postpone the appointment.

  • Most postoperative video visits can replicate the in-person visits.

  • Most outpatient visits aren’t urgent.

  • Maintenance of care can ameliorate patient concerns that health problems are being deferred and can help decrease the surge of patients requiring care after the resolution of the COVID19 crisis.

  • Reduction of financial strain on urology practices.

Telemedicine Implementation: Equipment

• Pre-pandemic: strict HIPAA compliant technical specifications

• Pandemic: emergency provisions allow for non-HIPAA compliant platforms like FaceTime

• Suggestion: urologic practices should prioritize secure and reliable platforms. Some of these platforms are embedded within EMR and others are standalone softwares separate from the EMR. All of the below platforms meet the strict HIPAA compliance specifications.

  • Zoom for Healthcare

  • Skype for Business

  • Doxy.me

  • Updox

  • VSee

  • Google G Suite Hangouts Meet

• The applications mentioned above can be used with desktop, laptop, tablet computer, and/or smartphone.

  • Allow for multiple guest participants so that providers can invite family members or language interpreters to join the encounter.

• 2 important reasons to prioritize HIPAA-compliant platforms:

  • Changes to the federal law are superseded by state-specific policies

    • Some states still need HIPAA compliant platforms for telemedicine

    • Wise to prepare for some of the emergent changes to telemedicine policy to persist after the crisis abates

      • Appropriate implementation could make sure that rapidly scaled programs are sustained later on.

Telemedicine Implementation: Legislative Considerations

• The Center for Connected Health Policy

  • Resource for state-specific policies and laws around telemedicine

  • Includes details emergency legislation during COVID19 crisis

• Need to familiarize oneself with their state’s policies surrounding video visits (including licensure requirements, need for consent documentation to conduct a video visit, prescription regulations)

• 1135 Waiver: Centers of Medicare and Medicaid Services (CMS) is allowing for interstate telemedicine for providers with an active non-restricted medical license in another state

  • Many states still mandate that providers submit an emergency application for credentialing.

Telemedicine Implementation: Coding

• 15 min in-person established patient visit and 15-minute telehealth established patient visit are both billed with the Common Procedural Terminology (CPT) code 99213.

• Important differences in documentation for telemedicine vs. in-person visit.

  • Healthcare provider needs to document patient consent to conduct a live face-to-face video conference visit

    • Need to include the location of the treating provider and the patient location

    • Provider location is the distant site and the patient location is the originating site.

  • Claims derived from the video visit must include a Place of Service = 02 or modifier code (ie. GT or 95)

    • Codes mean that the telemedicine encounter occurred and this is usually required of private payers.

    • Medicare doesn’t need a modifier but a Place of Service = 02 is needed.

  • Most providers use time-based billing for telemedicine encounters

• Reimbursement varies by payer

  • Medicaid doesn’t specific the originating site location 29 states and this is being expanded to address patient and provider safety during the COVID19 pandemic

  • As per the 1135 Waiver, Medicare allows the patient’s home to be the originating site for both new and established patients during COVID19

Telemedicine Implementation: Logistical Concerns

• Recommend a mock visit to that the providers can familiarize themselves with chosen video conferencing platform.

  • Allow people to test the various capabilities of the software

  • The distant site should be a secure, private location like a closed office

• Office staff is suggested to contact the patient at the time of appointment to help deliver instruction on how to download any needed software and is supplemented by tip-sheets.

• Telephone Visits

  • Not all patients have the necessary device for a video visit so a phone call may be necessary

  • Telephone visits are billable visits –> CPT does 99441-3 cover phone visits and must be accompanied by a G2012 code

  • Some states allow for emergency legislation that reimburses Medicaid telephone visits on par with telemedicine visits during the pandemic