Quick guide to telemedicine

Learn how to increase patient access, service patients AND profit with/from telemedicine. In telemedicine, these are the modalities to understand
1. Telehealth – video calls
2. Virtual check in calls
3. Telephone-Only E/M
4. eVisits
5. Remote patient monitoring

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    Table of contents

    Telemedicine – an easy introduction

    Looking for a telemedicine guide? Telemedicine itself is a complex and varied field – there are technologies such as e-visits which are encounters between a provider and a patient, remote patient monitoring, store-and-forward or asynchronous telemedicine which is an encounter that doesn’t take place in real-time but involves the review of electronic documentation followed by a recommendation for follow-up care.

    The multitude of different means for care delivery creates the opportunity to customize solutions to meet a patients’ needs. In addition to meeting the patient’s needs, there is potential for telemedicine in all its variants to improve a provider’s satisfaction with their vocation.

    As providers look at more fully transitioning to a value-based payment paradigm and begin examining different network models – be it joining a health system as a contracted or employed provider, forming a supergroup, affiliating with a multi-specialty group, or joining a looser group of connected providers in a physician-led clinically integrated network or independent practice association (IPA) – telemedicine provides an avenue to better profit from such a transition and to improve the patient’s care experience at the same time.

    These are the modalities to understand (a lot more details on CMS website):

    • Telehealth – video calls
    • Virtual check in calls
    • Telephone-Only E/M
    • eVisits
    • Inter-professional consultations (store and forward, calls)
    • Remote patient monitoring – device based, many a time patient wearable devices

    Telehealth – synchronous audio-visual

    When most people think of telemedicine, whether they know it or not, they are imagining telehealth. Simply put, televisits / telehealth – are usually audiovisual encounters that occur in real-time between a provider and patient that are both at separate locations.

    There are a lot of platforms out there for such services and, indeed, many health plans and employers have partnered with specific vendors and contract physicians to provide e-visit services. Often, telehealth are used for lower intensity urgent care visits.

    You can bill for Outpatient Evaluation and Management Visits

    • 99201 – 99205 E/M new patient. Office rates vary from $46 – $211 based on time spent. Facility rates vary from $27 – $172 based on time spent.
    • 99212 – 99215 E/M established patient. Office rates vary from $23 – $148 based on time spent. Facility rates vary from $9 – $113 based on time spent.
    • AWV G codes

    Facility rates are lower and are to be billed as place of service (POS) = 2 with no modifiers.

    Whereas, non-facility rates are higher and are to be billed as place of service (POS) = 11 with modifier = 95

    Virtual check ins

    This service can be provided by a physician to a new or established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

    This can include patient initiated phone calls OR image/video sent by patient and reviewed asynchronously by the provider

    You can get paid for Virtual Check in (G2012 – MEDICARE ONLY).

    Communication MethodCodeEstimated Reimbursement*
    Phone call (audio only)G2012$14.80
    Image or video submitted by patient reviewed G2010$12.27

    Telephone-Only E/M

    This is to be used solely for phone calls. Telephone evaluation and management service by a physician provided to a new or established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

    ProviderCodeEstimated Reimbursement*
    Qualified nonphysician98966-98968$14.80
    Physician99441-99443$12.27

    eVisits / Online digital E/M

    For this, you need to use a HIPAA compliant patient portal or secure messaging system. Refer to our other articles about using a patient management app – you could very well use the same for this as well (if it is HIPAA secure/compliant, which most of them are).

    ProviderCodeEstimated Reimbursement*
    Qualified nonphysicianG2061-G2063Office rates vary from $12 – $33 based on time spent. Facility rates vary from $13 – $43 based on time spent.
    Physician99421-99423Office rates vary from $15 – $50 based on time spent. Facility rates vary from $13 – $43 based on time spent.

    Inter-professional consultations (store and forward, calls)

    You can consult for other providers to help their patients – either via phone calls or via reading images and videos sent over (store and forward) by the other provider (provider’s office). This is reserved for provider to provider. It involves telephone or internet based “assessment and management” service provided by a consulting physician to the patient’s treating/requesting physician or other qualified health care professional.

    To get paid, you need to include a verbal and written report.

    The reimbursements range from $18-$74 based on the time spent and the codes to use are 99456-99449.

    You can also get reimbursed for the same services as above and get paid for code 99451 at $37.53 if you only provide a written report.

    Finally, if you are the treating provider, requesting the consult, you can get paid for code 99452 at $37.53 as well.

    Store-and-Forward or asynchronous telemedicine is probably the most technologically straightforward; however, it is also the one least discussed.

    It lacks the flashiness of real-time e-visits or the technological sophistication of remote patient monitoring.

    The process for store-and-forward involves sending data – usually text, pictures, and x-ray/radiology images – to a provider for their review.

    One of a few things will then occur.

    1. The receiving provider will furnish a recommended course of treatment to the patient if the transmission occurred directly from the consumer.
    2. If it was another provider that submitted the information, the receiving provider will amend or concur with the treatment plan or diagnostic thinking of the submitting provider or
    3. The receiving provider will state that the complexity is such that a visit is required.

    Studies have found that with some specialties, store-and-forward technology has led to a decrease in wait times and eliminated the need to see specialists in person; thus, freeing up visits for those who have a medical need that cannot be resolved remotely.

    It has also been demonstrated to be successful in remote pediatric populations.

    While there are certainly challenges around its use – notably, it is hardly ever paid for by health plans, providers that are responsible for the entirety of a patient’s healthcare cost and utilization can, in a responsible way, reduce both under the right circumstances.

    Specialties such as radiology, pathology, dermatology, and ophthalmology are some of the most straightforward to implement via store-and-forward.

    Remote patient monitoring

    Most providers have barely dipped their toes into telemedicine. There’s a LOT more that each provider can do after launching a telemedicine line of service.

    Remote monitoring is a completely different area of telemedicine that has had significant potential and, already, great results.

    Remote monitoring or telemonitoring involves using technology such as tablets and specialized versions of blood pressure cuffs, spO2 monitors, glucometers, thermometers, and scales.

    Typically, using Bluetooth, the devices are connected to the tablet and the patient’s data is relayed from the tablet to a monitoring tool or application used by physicians, nurses, or care managers.

    Reminders from the care providers can be sent to the tablet, and the patient can report their medication adherence. If metrics deviate from expected norms, care providers can intervene earlier in the process and, hopefully, keep the patient in their home rather than have it exacerbate and lead to additional complications and hospital/ER utilization.

    While, initially, the patient may seem inconvenienced by having to use these devices and interact with the tablet, once the habit is formed, the patient’s day-to-day life will be more convenient as they will likely experience fewer flare ups of their chronic condition, and they will, hopefully, spend less time in the hospital or at a doctor’s office.

    For providers, as they are being pushed – willingly or not – into value-based arrangements or even population-based payments, additional tools are needed to manage the cost and increase the patient satisfaction for populations with costly and life-limiting disease such as CHF of COPD.

    In elderly populations, cost and utilization linked to these two diseases is often significant. Remote patient monitoring, if implemented well, can provide higher quality care and lower costs (e.g. for CHF and for COPD) although, to be fair, some studies have found little to no benefit, so it appears that there will still be a debate on the use of the technology.

    Providers, especially those in value-based arrangements such as one of the Medicare ACO models (notably the NextGen ACO or the traditional Medicare Shared Savings Plan) can work with their partners to see where, for their population, remote patient monitoring can provide a benefit.

    Unlike e-visits which can be implemented more-or-less population wide, remote patient monitoring will likely need to occur in a much more targeted manner to be effective.

    From a billing POV, digitally Stored Data Services/Remote Physiologic Monitoring can use billing codes 99453,99454,99091, 99473,99474 and get reimbursed anywhere between $11-$62 for in office and anywhere between $9-$62 for facilities.

    Understand these basics first and then you can delve deeper into how to use these in your patient access and medical marketing initiatives.

    Let’s take a quick look at COVID-19 updates on telemedicine

    COVID-19 updates on telemedicine

    Even though telemedicine adoption had increased from 5% to 22% between 2015 and 2018, barriers still existed. Most providers were not clear on the reimbursement rates and there were several restrictions from Medicare/Medicaid as well. One must consult numerous restrictions around Medicaid reimbursement, private payer law and professional regulation/health & safety laws (statewide and national). A 2019 consolidated report can be found here

    There were (temporarily limited due to COVID 19 outbreak) restrictions around each modality (: Live Video, Store-and-Forward, Remote Patient Monitoring). 

    Traditionally, video calling was the easiest to get reimbursements for. Store and forward had numerous restrictions around what constitutes as an originating site, provider facility location (rural vs urban), whether radiology, dermatology, ophthalmology fit into the realm of “store and forward” or not etc. 

    However, in light of COVID 19, CMS has relaxed quite a few of those restrictions due to this public health challenge facing us all. A few salient points to note – so you can construct your telehealth strategy specifically around COVID-19.

    1. The qualifying rural area and facility requirements restrictions have been lifted. This enables providers throughout the USA to deliver telehealth services to their patients. 
    2. You, the healthcare provider, are now allowed to reduce or waive all patient cost-sharing payments for telehealth visits paid by Medicare.
    3. In addition to Medicare, state Medicaid programs and commercial payers also have updated telehealth policies. 
    4. HIPAA requirements around using telephone only or free video stand-alone applications have been relaxed – so you can use Skype, Whatsapp video calls.

    Latest reimbursement guidelines from CMS for practices leveraging telemedicine technology

    CMS updated their telehealth services guidelines recently. The document can be found here.

    The crux of it is that while initial guidelines were to use place of service for billing as 02 in your EMR. Now, that has been changed to 11 – that’s the same as “face to face” or in person billing place of service. So, you do not really have to do anything extra other than to add a visit type in your EMR of “TELEVISIT”.

    CMS was going to make some E/M codes effective from 2021 – this included usage of E/M codes and billing them as Medical Decision Making (MDM) or Time. Now, CMS is allowing you to choose E/M levels based on MDM or Time.

    More importantly – you do NOT need to document history and / or physical exam in the medical record if you are going to use a synchronous audio-visual telehealth visit (i.e. a video call).

    Typically, you needed to record a place of service as the provider’s home or “originating site” – but due to COVID-19, CMS is no longer requiring you to do so. You can just use the practice address and CMS, for this Public Health Emergency (PHE) is going to disregard all discrepancies.

    For COVID-19 purposes, CMS is also covering Telephone E/Ms (CPT 99441-99443) – this is both for new and established patients.

    Store and Forward (G2010) and Virtual Check-in (G2012) – now you can use it for BOTH new and established patients. Before this, you could only use it for established patients.

    Updated list of covered services

    The list has been updated here.

    Updated list of eligible providers

    While the list of providers that are eligible to deliver telehealth services has been updated, note that FQHCs and RHCs are added only during the emergency period. The current list of eligible providers include Physicians, Nurse practitioners, Physician assistants, Nurse-midwives. Clinical nurse specialists, Certified registered nurse anesthetists, Clinical psychologists (CP), Clinical social workers (CSWs), Registered dietitians or nutrition professionals. 

    Please note that CPs and CSWs cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.

    Where can you deliver telehealth services?

    Before COVID outbreak, you needed to have a valid license in the state where you the patients resided (ie. you could not cross state borders). However, just for the time being (for COVID), this particular restriction has been removed. You can provide telehealth services in the state where an emergency is happening (e.g. NYS as of writing). However, an interesting point to note is that the state requirements will still apply.

    Hopefully this allows you to create your own practice’s telehealth strategy. Let’s look at some pros and cons of telemedicine.

    Pros and cons of telemedicine

    While this is not an exhaustive list for prons and cons of telemedicine, it is good to be aware of some of these before you get started.

    Benefit of televisits – Reduced emergency utilization

    Such visits can be used – when appropriate – to reduce Emergency Department utilization. Additionally, they provide patients with a way of receiving some care without having to leave their home and at an affordable cost.

    Benefit of televisits – Address specialist shortages

    If one is uninsured or has a high-deductible, the cost for an e-visit is often around $45-55. There are also specialties providing these services. For example, telepsychiatry has grown and is continuing to grow and other specialties such as rheumatology have been experimenting with ways to leverage telemedicine to address their specialty’s shortage.

    Benefit of televisits – Improved efficiencies for uncompensated encounters

    Medical practices, specifically, can use e-visits in a few unique ways. If the practice is, for example, a surgical group where there are numerous uncompensated encounters post-op, if it is medically responsible, it may be more efficient for both the provider and the patient to receive some or all the post-op appointments via e-visits.

    Such virtual visits can also be used by specialist providers to monitor new or changed medication regimens.

    Both uses can allow a provider to more quickly see patients and, possibly, save a patient from having to drive or have a caregiver drive them into a practice that may -especially in rural areas – be a significant distance from their home and involve missing work.

    Such a process will save the front desk staff check-in time and save the patient waiting room time; moreover, the provider will be able to see more patients since the logistics of having patients check-in and meeting with a medical assistant or nurse is removed.

    Benefit of televisits – Reducing no-shows and improving office workflow

    Primary care practices can also benefit from e-visits.

    Providers have had success with using telemedicine for routine follow-up visits such as those for depression or ADHD medications. Some have also used them for hypertension follow-up to assess how a patient uses their home blood pressure cuff.

    Visits that might lead to a loss of revenue because the patient is diverted to an urgent care after hours can be captured by the primary care practice which might provide uncompensated on-call care prior to diverting to an urgent care.

    If a practice has a relatively high cancellation rate, e-visits can be used to augment a practice’s income as well. Pediatric practices, likewise, can increase patient satisfaction and encourage a stronger continuity of care by providing telemedicine.

    For example, pediatric groups could provider e-visits early in the morning – the provider can even be at home – to assess children for parents who are concerned that they may be too sick for school.

    Also, as with adult primary care, there already exists significant uncompensated care or care that is diverted to Emergency Rooms or Urgent Cares that can be converted back into income for the pediatric practice.

    Benefits of RPM – Reimbursements

    CMS has already announced reimbursement policies and associated reimbursement codes for remote patient monitoring. According to mhealthintelligence,

    “The final rule for the 2020 Physician Fee Schedule gives hospitals and health systems more opportunities to use remote patient monitoring and paves the way for new telehealth and mHealth programs.” 

    The Centers for Medicare & Medicaid Services (CMS) updated their CPT codes and now, CPT code 99453 pays $19 on average, CPT code 99454 pays about $64, CPT code 99457 pays around $51 for non-facility and $32 for facility and CPT code 99091 pays about $58.

    There is much more clarity on RPM reimbursements, CPT codes and a clear path to additional revenues in exchange for taking on this additional burden.

    Benefits of RPM – Higher patient engagement

    There are several studies like this one done by NIH that speaks volumes about the increased patient engagement due to remote patient monitoring. There’s another brilliant article written by becker’s hospital review here, that is based on the “nudge theory”. This is the same theory that we use in our patient contact center / medical call center as well. Nudging patients / reminding patients seems to keep them engaged to our customers.

    Benefits of RPM – Higher patient care adherence, easier value based care

    As we move towards value based care and value based payments, care adherence becomes even more important when it comes to achieving the triple aim. Care adherence and preventive care allow providers to be better equipped to reduce acute/episodic care and demonstrate higher value based care.

    Simply put, higher care adherence = higher patient engagement = lower acute episodes = demonstration of higher value based care.

    Benefits of RPM – Higher patient satisfaction and reviews

    This should have been expected but never was that guiding principle for adoption of remote patient monitoring. In general, it has been documented (see here) that 25% of survey respondents stated remote patient monitoring increased patient satisfaction.. Which inevitably leads to better patient reviews.

    Benefit of econsults / store and forward – Easier access to specialists

    Patient no shows rates are notoriously high – national average is around 30%. After spending years managing practices that deal with a certain patient population, we can easily attribute no-show rates to the patient’s social determinants of health.

    Patients like the convenience of being able to get in and out of meeting with a provider within 30 mins. In metropolitan areas, having long waits at a specialist office almost always guarantees increasing no-show rates.

    Benefit of econsults – reduced unnecessary referrals

    Studies have shown that “About 52% of PCPs reported making unnecessary referrals” (read this). Being able to conduct econsults with specialty providers within your referral network allows referring providers to determine the medical necessity of such referrals. As an example – a PCP office could very easily send retinal scans of their diabetic patients to an ophthalmologist in their referral network to determine diabetic retinopathy and whether the patient should be sent to the specialist as a referral or not.

    Benefit of econsult – lesser scheduling friction

    Most administrative personnel will gladly tell you that coordinating “live” televisits between a patient at the PCP office and the specialist at a referring partner of choice can be a real nightmare. Conflicts arise with specialist availability. Electronic consults alleviate this friction due to the fact that the specialist can review a patient’s econsult request at a time that’s more convenient for them. This leads to higher fulfillment rates that is simply not possible with video / evisits.

    Benefit of econsult – better care coordination

    An additional benefit is that store-and-forward telemedicine strengthens the patient’s relationship with their primary care provider by keeping patients within their practice. It is a well known fact that closing a referral loop has never been a forte for most specialist offices that are already overburdened with treating cases of their own. 40% of patients that are referred out to a specialist office do not even make an appointment with the specialist provider. Coordination of care breaks down in such cases. When a PCP office has the ability to request e-consults with their referring partner, care coordination has been proven to trend higher.

    Issues with telemedicine

    It’s not all that rosy a picture. There are (were) several barriers to telemedicine. Some of them have been relaxed due to COVID, however, challenges still remain.

    Reimbursements

    State laws are complex and reimbursements are varied across payers. Make sure that you understand your reimbursements well enough before you get started.

    At a minimum, you need to understand the parity laws for that state, the limitations of locations in your state, the types of telemedicine allowed in that state, the covered services, who the eligible providers are (whether your specialty can even use / offer these services), whether you can e-prescribe or not, whether you need patient consent or not (there are specific rules around patient consent).

    Still not a complete exam

    Doctors in specific specialties still will not feel 100% comfortable with telemedicine or televisits. Take ophthalmology as an example – tele refractions have been around for a while now, but still do not have a great deal of traction; primarily because of questionable reliability.

    While it can solve problems, it is used essentially as some form of triaging. E.g. a patient might complain of bilateral itching and can be sent antihistamine drops. However, this also depends on whether the patient and provider state allows e-prescribing for these scenarios or not.

    Meanwhile, if a patient presents with flashes, floaters, vision loss – this may need immediate in person evaluation.

    In ophthalmology, as an example, most anterior segment conditions can have some amount of telemedicine evaluation.

    This is not a problem with telemedicine as a concept in general. It’s a problem with perception – telemedicine cannot be thought of as a replacement to a full, comprehensive exam. In many provider groups, there will certainly be cases that cannot be diagnosed via telemedicine. In such cases, triaging is important and that in itself contributes to the success story of telemedicine.

    Hopefully this gives you a general idea of the pros & cons involved with telemedicine. Let’s look at whether you should offer telemedicine services or not.

    Should you offer telemedicine services

    Even during COVID, we noticed that many practices are not offering telemedicine services. Our position has remained that it is unacceptable to not offer telemedicine services to your patients. Before COVID, there were confusions around reimbursements and hence most patient access strategies did not include telemedicine services. However, with CMS opening up the floodgates around telemedicine during COVID, there’s simply no reason not to see patients through telemedicine.

    Deciding to take the leap and implement one or more variants of telemedicine in a practice is a big decision to make. We understand that. However, it is not a very complicated decision to make.

    There are costs incurred, training that must be undertaken, and there is likely also the concern that patients won’t respond well to it.

    These are all valid and good concerns for a practice to have; their business is to provide high quality, efficiently delivered care to patients, and if it isn’t done to a certain degree of satisfaction, patients are apt to look elsewhere for their care.

    How to make a decision?

    Take a look at the pros and cons of telemedicine. Look at the various ways you can serve your patients, other providers AND at the same time get reimbursed for your services.

    Even if you create a simple spreadsheet with the average reimbursements per telmedicine modality, you can very easily see how much you can get reimbursed per provider.

    The best part? You do not need to invest in an expensive office space for the same nor purchase any office equipment for it. All you need is a computer and a good internet connection. That’s it. You can reserve your office space usage to in office procedures or higher paying patient visits.

    Take a look at your practice’s strategic goals for the next few years to see what telemedicine modality will make the most sense.

    e.g. Are you in primary care practice looking to fully embrace PCMH? Perhaps then extending hours through e-visits might be a good test case.

    e.g. A dermatology practice may look at store-and-forward.

    e.g.A cardiology practice that is part of an ACO may look at partnering with the ACO on a remote monitoring initiative.

    As with any project – and especially an IT project – there will be hurdles and frustrations; nevertheless, telemedicine has thus shown promise to increase efficiency and lower some costs in healthcare, and its consideration ought to be part of any practice’s strategic planning discussions.

    FQHCs and RHCs – can they offer telehealth services?

    CARES act (link here) is actually allowing FQHCs and RHCs a lot more flexibility than before. If you are an FQHC/RHC, you can be both the originating site or the distant site. This means that your patients can be at your location, receiving treatment from another provider facility. Vice versa, your providers can provide telehealth services to patients at another facility.

    Before this act, you were limited about the location / origin. Now you are not.

    Do keep in mind that you will not be paid the PPS rate – you will get reimbursed on an FFS rate instead. You are now allowed to use virtual checks and CCM tools. 

    However, point to note is that you are not allowed to use eConsults. Let’s get into how to deploy a telehealth strategy for your practice.

    How to deploy a telehealth strategy for your practice

    There are a few moving parts that you or your practice administrator would need to consider.

    1. Services you are going to offer via telehealth
    2. Telehealth technology platform of choice
    3. Reimbursement for services rendered
    4. Clinical workflow (re)configurations

    Telemedicine services you can offer

    Depending on your organization’s maturity and preparedness in addition to availability of providers, you can offer some or all of the following telehealth services.

    Colon and Rectal Diseases

    You can evaluate pre and postoperative patients using televisits (econsults). This allows you to offer surgical management of colorectal cancer, diverticular disease, inflammatory bowel disease as well as management of specific types of benign colorectal diseases. If medical necessity of surgery is deemed necessary, you can even offer video consults up until the day before of the actual surgery.

    Dermatology

    You can utilize store and forward telemedicine technology to offer remote medical care for complicated dermatology cases to others that do not have dermatology coverage. Using the right technology, images and clinical information can be transmitted to your facility for your readers to interpret and evaluate the images. The reader (your clinician) can then interpret and send their diagnosis back, with full documentation.

    Mt Sinai hospitals has had success using the same with furthering education of fellows and residents as well.

    Emergency Care and Trauma

    Real-time video evaluation allows your trauma specialists to render timely and effective treatment for patients if they are in remote or rural areas (definition by HRSA). Your trauma specialists can offer this service as an assistance with triage and transfer decisions

    Intensive Care

    If your providers have the clinical workflows set up well, you can provide team-based solutions for ICU shortages at neighboring hospitals. This helps reduce ICU complication rates and therefore the length of stay as well by teaming up with bedside physicians. This service typically uses Video Conferencing equipment and technology (econsults).

    Maternal-Fetal Medicine

    Your providers can be made to collaborate with obstetricians and primary care physicians of at-risk, high-risk, or complicated obstetrical patients with known medical problems in pregnancy, such as seizure disorders, clotting disorders, Thyroid disease, chronic hypertension, Gestational diabetes etc. These consultations can be provided before and during pregnancy, offering collaborative approaches towards patient management recommendations. Using store and forward telemedicine platforms, you can receive patient records for review upfront and thereby triage patients to telemedicine consultation, if appropriate, based on their condition. The referring provider, local to the patient, can continue providing care to the patient while collaborating with you and your providers.

    Ophthalmology

    You can use two modalities for these services and therefore, offer ophthalmic consultations, testing and interpretation services, retinal screenings for diabetic retinopathy. Real time audio/visual (evisit) consultations allow you to offer your services to providers without ophthalmology coverage. Meanwhile, using a store and forward platform allows your board certified ophthalmologists / retinal specialists to offer screenings for diabetic retina disease in PCP offices.

    Pathology

    Whole slide imaging consults can be offered by using store and forward technologies. In this mode, the requesting physician takes whole slide digital images, uploads these images to your telemedicine portal for your physicians to interpret and revert back with the pathology report. 

    Pediatrics

    Pediatric physicians are not that easy to employ. If you do happen to have some on staff, you can offer televisit services for urgent, emergent, and scheduled outpatient needs of young patients. This helps tremendously with missed work and school days (the biggest reasons for no-shows)

    Psychiatry

    These are one of the easiest ones to administer as you can use econsults with just audio as well. Simply by using an appropriate telemedicine platform, your mental health professionals can offer telemedicine services to facilities without in-house psychiatrists

    Radiology

    Teleradiology has been around for a while. Typically store and forward technologies are used to offer coverage from board certified radiologists to facilities without specific radiologist coverage. This service becomes even more critical when subspecialist radiologist coverage is needed.

    Remote Monitoring

    This usually involves higher levels of investment in telehealth enabled devices. However, once an investment is made in such equipment, you can offer remote monitoring and care for at-home patients, for chronic care management. Usage of telehealth equipment helps to promote proactive patient self-care. These devices also help with monitoring patients’ key measures, and enabling physicians to follow their patients’ health.

    Rheumatology

    If you have rheumatologists on staff, you can easily utilize econsults for patients with Rheumatoid Arthritis, Psoriatic Arthritis, Osteoarthritis, Lupus, Sjogren syndrome, Vasculitis, Scleroderma, Myositis. More importantly, this also allows you to engage and manage chronic rheumatologic diseases and provide the needed follow up care.

    Stroke

    For this, you need to use econsult technology. This allows you to perform assessments of stroke patients and provide consults in real time about using IV TPA. Using store and forward technology, your specialists can view CT scans and help ED physicians determine candidates for acute stroke therapy, including intravenous TPA.

    Surgery

    Using econsult (audio visual) technology you can provide telesurgery services that are pre and post operative consultations. You can offer pre anesthesia and preoperative clearance prior to surgery. You can also offer post operative follow up care for Bariatric Surgery, Cardiothoracic Surgery, Endocrine Surgery, Foot and Ankle Surgery, Neurosurgery etc. 

    Wound Care

    Wound care typically uses both modalities – store and forward plus audio/visual (econsults). Your specialists can provide remote consults for patients with poorly healing wounds and also assist with review of images to reduce patient transfer rates.

    Next, let’s look at the Telemedicine Technology needed for offering telehealth services

    Telemedicine Technology needed for offering telehealth

    Due to COVID 19,CARES has relaxed the rules for telemedicine. As of now, you can use publicly available audio/video and store/forward technologies to tend to these unusual circumstances. Noted exceptions are public facing audio/video platforms like Facebook live, Twitch etc. 

    Limitations and restrictions around HIPAA are also somewhat relaxed during these times. However, the following are general guidelines that can be followed even after we get back to the “normal”.

    The technologies you need would depend on the telehealth services you plan to launch and the type of care you intend to provide.

    Our recommendation has always been and still will be Amazon Chime.

    At a bare minimum, you are going to need:

    1. For eConsults – A HIPAA compliant video conferencing platform. The ability to call 1 or more people at the same time (for consulting physicians or triage reasons) – that includes at a minimum, you the provider and the patient. For video conferencing, you obviously need a secure high speed internet connection and you should be able to access the same from your desktop/laptop, tablets (ipad, android, whatever you choose) and /or a smartphone (iphone, android etc).
    2. For store and forward / Asynchronous telehealth services, you need a HIPAA-compliant software that allows you, the originating site, to be able to transfer patient’s images to the consulting physician. The consulting specialist should also have access to the same software so they can download/review the media you sent and can revert back with a diagnosis, interpretation and a care plan.
    3. If you are venturing into remote patient monitoring, you are going to need the same technologies as above in ADDITION to additional technologies (bluetooth enabled) that include (but are not limited to) Digital stethoscopes, otoscopes, ophthalmoscopes, digital scales and blood pressure cuffs etc. Your chosen HIPAA compliant technology needs to enable the patient and the clinician to be able see and hear each other during the consultation. In most cases, nurses or other medical staff would need access to the same platform as well because they will assist the physician in performing the exam (on the physician’s behalf), and would be using the digital instruments listed above.

    In all cases, your technology of choice should allow you to document your visits – even if that means that you are going to, later on, document the same (copy/paste) in the patient’s medical record. This is needed for you (or another clinician) to support continuity of care.

    Once the technology or platform is selected, the practice is faced with many decisions surrounding the specific guidelines that will govern the deployment of these visits.  A decision needs to be made whether telehealth visits are to be provided by all physicians or only a select team of physicians and whether advanced providers participate in the provision of these visits.  Is the practice going to make telehealth visits available to all patients or reserved for patients with certain diagnoses?  If only certain diagnoses are selected, the practice will need to determine how this triage will occur, and by whom. 

    It is helpful to determine if the practice or the health plan requires a certain length of time to be spent for each visit, and what specific documentation templates or billing codes they require.  It is extremely important to decide whether all schedule time slots are eligible for telemedicine visits or whether providers should assign dedicated blocks of time for these visits, allowing more predictable allocation of support staff who may not play as central a role in these type of visits, since patients do not need to be “roomed” in the traditional sense.

    It is necessary to plan for training staff, providers and patients on the use of the telehealth tools.  This is an area that is significantly impacted by choosing a highly usable, mature, purpose-built, EHR-integrated telehealth platform, as doing so will reduce the time and effort of implementation, training, and adoption of this new modality. 

    The following list is not exhaustive, but here are some options.

    For telehealth (video calls), a few options are:

    1. Skype for business
    2. doxy.me
    3. Vidyo
    4. Zoom
    5. Gotomeeting
    6. VSee

    Often, you are going to need peripheral devices. A few options are:

    1. Eko
    2. JedMed
    3. ThinkLab stethoscope.
    4. GlobalMed

    For remote patient monitoring, you can consider:

    1. AMC Health
    2. Raziel Health
    3. Carematix
    4. Honeywell

    Some of these vendors also sell mobile carts/kits as well. You’d be well advised to pursue an vendor that combines as many of these options together as possible (rather than having to integrate multiple systems).

    Let’s look at billing for telemedicine services.

    Billing for telemedicine services

    Hopefully you understand what you can bill for.

    It’s important to understand the telemedicine documentation requirements to avoid denials in the future. Make sure you instruct your providers accordingly as well.

    New patient 99202 – what you need to document

    Providers need to document for new patients

    This needs ALL 3 components: 

    • An expanded problem focused history
    • An expanded problem focused examination
    • Straightforward medical decision making

    Here’s a scenario for an ophthalmology practice

    1. Chief complaint
    2. 1-3 elements of HPI
      1. Location 
      2. Timing
      3. Context 
      4. Quality
      5. Modifying factor 
      6. Severity
      7. Duration 
      8. Associated signs and symptoms
    3. System in the HPI (history of present illness)
    4. If medically necessary (if you do document it, this helps your group’s MIPS reporting next year)
      1. Past history
      2. Family history
      3. Social history
    5. EXAM. Six to eight of the following 12 elements of the exam are performed
      1. Visual acuity – possible
      2. Ocular adnexa – possible
      3. Lens – not possible
      4. Confrontation visual fields  — possible. (Can be done with family member)
      5. Pupil and iris
      6. Intraocular pressure  — not possible.
      7. Extraocular motility — possible.
      8. Cornea – possible
      9. Optic nerve discs – not possible
      10. Conjunctiva – possible
      11. Anterior chamber — generally not possible
      12. Retina and vessels – not possible
    6. MDM (Medical decision making)
      1. Diagnosis
      2. ICD10 –  highest level of specificity please. Even if you have to add one each for OD OS, do it please.
      3. MUST HAVE ONE
        1. New problem to examiner: stable, improved or worsening
        2. Clinical lab test(s): ordered or reviewed
        3. Radiology tests: ordered or reviewed
        4. Other diagnostic tests: ordered or reviewed
        5. Review of old records and/or additional history from other than the patient. This generally means information gathered from sources other than the history and physical – lab tests, imaging, other diagnostic services, old records and history from sources other than the patient. Generally speaking, the guidelines ask that you record the decision to seek additional information and, if you have obtained the information, the results of your review of it.
    7. Must meet one of the two categories:
      1. Presenting Problem(s) – One self-limited or minor problem 
      2. Management Options Selected
        1. Observation
        2. Home care instructions, i.e. warm compresses, lid scrubs

    Established Patient 99212 – what you need to document

    Usually the presenting problems are of low severity. The same rules as above apply here as well.

    THIS NEEDS ALL 3 COMPONENTS – 

    • An expanded problem focused history
    • An expanded problem focused examination
    • Straightforward medical decision making

    Established Patient 99213 – what you need to document

    Usually the presenting problem(s) are of low to moderate severity

    For 99212 and 99213, you HAVE to have 2 out of these 3 components 

    • Problem focused history
    • A problem focused examination
    • Medical decision making (This has to be present)

    Providers need to document for ESTABLISHED patients

    1. The same points 1-7 as above 
    2. For point 7, 99213 criteria is different
      1. Presenting Problem(s)
        • Two or more self-limited or minor problems
        • One stable chronic illness
        • Acute uncomplicated illness or injury
      2. Management Options Selected
        1. Over-the-counter drugs or RX
        2. Minor surgery recommended with no identified risk factors

    Visit timings (how long should they be)

    So how long should the visits be? Follow this list below to understand what to code. Do keep in mind that all the time a physician spends during the telemedicine call, charting, reviewing patient data .. ALL of it counts.

    • 99201: 10 minutes
    • 99202: 20 minutes
    • 99203: 30 minutes
    • 99204: 45 minutes
    • 99205: 60 minutes
    • 99212: 10 minutes
    • 99213: 15 minutes
    • 99214: 25 minutes
    • 99215: 40 minutes

    Points to note for billing

    1. Code level selection is based on the same criteria for the base codes.
    2. Appending modifier -95 is optional during the public emergency.
    3. List place of service as 11 (same as an office location)

    How to decide what’s billable and what’s not?

    Just follow this decision tree.

    1. If it was a video call – you can bill right away as a telehealth visit (based on the guides above)
    2. If it was a phone call, find out if the patient’s insurance covers phone calls or not. If they cover it, you can bill right away (based on the guides above). If they do not cover it, next step is to find out if the telephone encounter was related to an E/M 7 days prior or resulted in an E/M encounter within 24 hrs after this call. If it did, then it is an un-billable visit. However, if it did NOT, then you need to ask whether this encounter included assessment and management of patient problem? If so – go ahead and bill this as a Telephone only E/M.
    3. For secure chat or secure email consults, first ask whether the patient initiated it or not. If the patient did not initiate it, then you cannot bill for it. But if the patient did initiate the consult via secure email/secure chat, you need to ask if this was related to an E/M 7 days prior. If it is, then you cannot bill for it. However, if it was not related to an E/M 7 days prior, ask yourself whether you are going to provide E/M service within the next 7 days or not. If not, then ask if you are going to provide E/M services in the next 24 hrs. If you are going to see the patient in the next 24 hrs AND you are going to include assessment and management of the patient problem, then you can go ahead and bill this as an eVisit.
    4. However, if you are going to provide services in the next 7 days, ask yourself whether the practice has seen this patient in the last 3 years or not (i.e. has this billing turned into a “new patient” visit or not). If the patient has not come in to see you in the past 3 years, then you cannot bill for it. However, if the patient has been seen in the last 3 years and you are going to provide services based on an image or a video that the patient sent, then go ahead and bill this as a “Virtual Checkin”.

    What you need to do for virtual checkins (HCPCS code G2012) documentation requirements

    1. Confirm patient identity (e.g., name, date of birth or other identifying information as needed, in particular if documenting independently from the patient’s electronic or paper record).
    2. Detail what occurred during the communication (e.g., patient problem(s), details of the encounter as warranted) to establish medical necessity.
    3. Document the total amount of time spent in communicating with the patient and only submit code G2012 if a minimum of five minutes of direct communication with the patient was achieved.
    4. Document that the nature of the call was not tied to a face-to-face office visit or procedure that occurred within the past seven days.
    5. Document that a subsequent office visit for the patient’s problems were not indicated within 24 hours or the next available appointment.
    6. Include that the patient provided consent for the service

    These should get you started. Overall, if you pick a telemedicine technology platform that already includes billing assistance, that’s of great help.

    Telemedicine is here to stay and our prediction is that it will be integrated into every willing practice’s clinical workflow to increase patient access to quality care. Let’s get into marketing telehealth services next.

    How to schedule and get paid for telemedicine

    There are some major differences between a televisit appointment and an appointment in office. Here are some tips on how to schedule telemedicine appointments and how to collect copays from patients (if any).

    One of the major differences that you will notice – you cannot quite overbook and it’s not that easy to have an overcrowded waiting room.

    Another difference is that when your provider sees a patient, a part of the visit time is spent around connectivity (no matter which technology you use). So, what usually takes 10 mins, will end up taking 15 mins. This means that it is hard to pack appointments back to back so your providers can see 30+ patients a day.

    You don’t have the grunt work done by a tech in this scenario as opposed to what you do in an office. Typically, in your office, your tech might spent the first 15-20 mins working up the patient and your provider sees the patient for 5 mins. However, the same is not true about a televisit appointment. There’s no tech available to “work up” a patient.

    Creating an appointment for an existing patient

    Important point to note before creating the appointment.. Ask the patient if they have internet access on their phone. We have encountered some patients that do NOT have internet access on their phones.

    If the patient doesn’t have internet access on their phone, ask them whether they have a computer at home AND if it has a webcam (most newer computers have it, but make sure that you confirm this with the patient). If the patient has a webcam enabled desktop, make sure you ask for their email address so that you can email them the confirmation instead of just sending an SMS (they won’t be able to copy the link from SMS to their computer browser).

    These minor things end up defining the success of your televisit appointment.

    Creating an appointment for a new patient

    You might have to create the patient from scratch first – this could be an inbound patient, referred patient, community outreach patient

    Important for all new patients – don’t try to gather ALL the required information right on the first call itself. You might be wasting your time. Get the basic information (including insurance coverage) and then get the rest of the patient intake information during your normal patient intake process of appointment reminders etc.

    Even more important – make sure that the patient gets their confirmation SMS while you are talking to them on the call.

    Patient confirmation SMS

    You need patients to confirm their appt using an SMS link because if they can go through that process, you have a confirmation that they are tech savvy enough to click on a link and actually be ready for a televisit.

    Sometimes the patients share their children’s cell phone number with the practice AND the child (son/daughter) is also a patient of the practice. ALWAYS let the patient know that you need THEIR cell phone number for a televisit.

    After you send the SMS to the patient, call the patient and find out if they could click on the link and everything works well. If this is the case, then will most likely show up for the appointment on time.

    The following script would depend on which telemedicine technology you use or whether you use a patient portal or not.

    “Hi Deanne, Please click on https://pa.nisoshealth.com to confirm your video call appointment with New York ophthalmology scheduled on 04/22/2020 at 02:45 PM. You can also call us at 1-888-212-1234. For Bengali, reply 1, Hindi, reply 2, Spanish 3.”

    ASK THE PATIENT – DID YOU GET MY TEXT? 

    1. If the patient says NO – then confirm the patient mobile number again and try to send the SMS again.
    2. If the patient says YES – “OK, cool, why don’t I stay on the call while you login to that website. If you have any problems or questions, I am here to help you.”

    Confirming televisit appts

    It is best if you use televisits in conjunction with a patient app as it makes life much easier. This allows you to have patients confirm their appointments via the patient app itself. Even if you use the patient portal to get the same accomplished, you are good to go.

    Calling patients that did not use the patient app

    If you have patients that did NOT confirm their televisit appt, call them 1-2 days beforehand and try to get them to confirm their appt on the phone AND to use the patient app to confirm their appt.

    Collecting payments for Televisit

    First, you need to find out whether your payer is waiving copays during COVID for televisits or not. If they are waiving copays, you CANNOT and should NOT collect copays. If they are not waiving copays for whatever reason, you can collect payments before or after you provide service (it is always preferable to collect payments before providing service).

    Decide on a charge for televisits. It is common to charge approximately $45 for self pay patients.

    For patients to pay, send them an SMS with a payment link to your patient bill pay portal. Hopefully you are using a bill pay portal – else, running after patients to collect copays ends up being a manual labor intensive and loss-leading process.

    “Hi Don, To pay for your video call with The Great Clinic please use this link https://billing.nhealth.com and pay $xx” (This $xx could be their copay or if they are a self pay patient, it could be $45).

    Appointment reminders

    Make sure that patients get reminders for their televisit appointments. We have noticed that patients tend to forget about televisit appointments quite a bit. Each patient should get an appointment reminder 30 mins before

    It’s a good habit to make sure that the patient gets an appointment reminder 15 mins before as well.

    The actual televisit appointment

    Be prepared for connectivity issues during televisit appointments. We have noticed that sometimes patients do not a strong enough data signal for the televisit appointment as well. It is best to let the patient know before hand to prepare accordingly. If your provider needs an assistant near the patient (e.g. to assist the patient with a visual acuity test), make sure that you let the patient know that they should have a family member with them during the televisit.

    Sometimes it does happen that the patient is running late and doesn’t inform your office that they are running late. To prepare for such cases, ask your provider to wait for a maximum of 5 mins on the call. There’s something you can do in such cases (since you have reserved at least 20 mins for this televisit). Look at your upcoming televisit appointments and send the patient an SMS to enquire whether they would be OK with preponing their appointment to now, We have noticed that in many cases, patients are willing to see the doctor earlier.

    You can use this same logic and move patients from appointments in future dates to fill up today’s schedule as well.

    Go ahead and do that.

    Connectivity issues

    There will be connectivity issues or patients might take a while to get used to televisits, much like providers are getting used to it. At any point in time providers can also send SMS to patients by logging into your telemedicine platform and sending the patient an SMS. So, if the patient is really having trouble connecting, for the time being providers can SMS back/forth with them here.

    This is also a billable encounter, hence our advice is not let go of this opportunity just based on connectivity issues.

    Hopefully this helps you manage your televisit workflows better. Next let’s look at how to Increase patient access and satisfaction with virtual checkins

    How to increase patient access with virtual checkins

    Most providers do not really know that they can also bill for virtual checkins.

    This service can be provided by a physician to a new or established patient, parent, or guardian. This cannot be originating from a related E/M service provided within the previous seven days. This cannot also be leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

    This can include patient initiated phone calls OR image/video sent by patient and reviewed asynchronously by the provider

    Barriers to offering virtual check-ins

    First of all, most practices shy away from telling patients that they can access their doctors via the patient portal or a patient app. The biggest reason for this being that providers are worried that patients will badger them at all hours of the day.

    That’s simply not true. Your patient portal or a patient app is a GREAT way to increase patient access. Increasing patient access has an undeniably high impact on patient satisfaction and getting more reviews. This has a direct effect on your medical marketing. It’s all inter-related.

    Steps to take towards offering virtual check-ins

    The first step to take is to let your providers know that they can bill for telecheckins / virtual checkins.

    The next step is to make sure that when patients call in to “speak to the doctor”, each patient is given an appointment that’s on the schedule/calendar for the provider. Some providers prefer to make all the patient calls at the end of the day or in a set block of time. That’s perfectly OK to do – go ahead and schedule those patient phone calls.

    The provider can call the patient from the office line (so that the patient doesn’t know the provider’s direct phone number), or can use *69 and dial the patient’s phone number (although, that leads to patients not picking up the call as it is an unidentified number) or they can use a messaging app. Regardless, the provider does not have to worry about patients finding out their direct phone number.

    Ideally, the provider calls the patient using a telemedicine solution. This ensures that the phone call durations are documented for audit purposes. It also helps the billing department gets the necessary billing information. Finally, the phone calls are scheduled and sync with the EMR, therefore helping your patient contact center.

    The right technology vendor solves it

    Try to find a vendor with an integrated solution for phone calls, telehealth, secure messaging (e.g. Werq Telemed). This truly helps as your patient can simply use the patient app (e.g. Werq Patients) and write to you, send images or videos of their issue or you can hop on a call with the patient as well.

    Your provider can also bill for the time spent in evaluating any image/video sent by patient and reviewed asynchronously by the provider. As long as it is patient initiated, you are good to go. Make the right telemedicine technology vendor choice and you can very well make telemedicine a profitable line of service.

    How to increase patient access with online digital E/M

    Online digital E/M is yet another way that you can extend care to patients beyond traditional office visits. As we have always mentioned, ensuring the highest patient access leads to higher patient satisfaction, thereby leading to higher patient reviews and ultimately, contributes to increased patient volumes.

    You can deliver online digital E/M synchronously and asynchronously and audio/video phone can be used. Please note that you cannot use a traditional phone. As with the other cases, this has to be patient initiated as well and the patient consent has to be recorded. Patient consent can be verbal and practices do not have to document this consent in any system.

    When can you use this?

    Consider this vignette – a patient calls in and initiates a virtual check-in. Now, your practice lets the patient know about their options. If the patient then calls back within 7 days, you can take that virtual check-in (lower, G2012) time and add it to the digital E/M code (99421-99423) . Thereafter, you bill ONLY the digital E/M code.

    You, of course, cannot use this for communication of test results, scheduling of appointments, or other communication that does not include E/M.

    This has to be an established patient, so please keep that in mind. The patient’s problem may be new to the clinician. However, you cannot use this for new patients.

    You can use this only once per 7-day period and unfortunately clinical staff time is not included in this.

    Documentation and the billing rules are the biggest headaches

    As you can see, documenting time and keeping track of all the rules are quite important in most of telehealth situations. While you and your biller can do this manually, it is always recommended to use a telemedicine technology solution that incorporates this rules engine within the software. Otherwise, you end up spending more time and resources in figuring out billing and recording time than the potential profits you could make.

    Typically, this is done via a secure patient portal that’s already included in your EMR (whichever EMR you use). However, traditionally, we have seen that adoption of patient portals is low when it is web based and clunky (which most EMR patient portals are). We have seen a much higher adoption and usage of patient mobile apps (like BHPS member management app) because these apps typically allow you to manage appointments, manage prescriptions, demographics, include provider finders etc.

    Our recommendation is to use patient mobile app/portals because patients seem to adopt it more than patient portals.

    Once you have your patients on the patient portal / mobile app, your practice should encourage patients to write to your providers. It is a HUGE differentiator from a marketing point of view and is something that should also be put up on the practice/hospital website as well.

    You can also advertise this VERY easily by simply sending an SMS to everyone that calls your front desk (e.g. if you leverage a VOIP solution like Amazon connect).

    Hopefully this gives you enough information to get started with marketing and billing for online digital E/M services.


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