televisit-skilled-nursing-facility-start-call

Telemedicine benefits for your medical practice

Telemedicine technology helps you provide better patient care, lower no-shows, retain patients and also to generate additional reimbursement dollars. Here’s a primer on telehealth, the various options you have and the pros/cons of each. Hopefully this guide will help you decide whether your practice should invest in telehealth or not – especially as providers must now live both in a fee-for-service and fee-for-value world.

We have taken advantage of the latest technical advancements for teleretinal screenings, televisits for skilled nursing facilities, telvisits in ophthalmology, televisits in ergonomics – this primer has inputs from our direct experience as well.

Table of Contents

Quick guide on telemedicine

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.

There are 3 modalities to understand:

Evisits or televisits

Remote patient monitoring

Store and forward

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.

CodeShort descriptorStatus
77427Radiation tx management X5Temporary Addition for the PHE for the COVID-19 Pandemic
90785Psytx complex interactive
90791Psych diagnostic evaluation
90792Psych diag eval w/med srvcs
90832Psytx pt&/family 30 minutes
90833Psytx pt&/fam w/e&m 30 min
90834Psytx pt&/family 45 minutes
90836Psytx pt&/fam w/e&m 45 min
90837Psytx pt&/family 60 minutes
90838Psytx pt&/fam w/e&m 60 min
90839Psytx crisis initial 60 min
90840Psytx crisis ea addl 30 min
90845Psychoanalysis
90846Family psytx w/o patient
90847Family psytx w/patient
90853Group psychotherapyTemporary Addition for the PHE for the COVID-19 Pandemic
90951Esrd serv 4 visits p mo <2yr
90952Esrd serv 2-3 vsts p mo <2yr
90953Esrd serv 1 visit p mo <2yrTemporary Addition for the PHE for the COVID-19 Pandemic
90954Esrd serv 4 vsts p mo 2-11
90955Esrd srv 2-3 vsts p mo 2-11
90957Esrd srv 4 vsts p mo 12-19
90958Esrd srv 2-3 vsts p mo 12-19
90959Esrd serv 1 vst p mo 12-19Temporary Addition for the PHE for the COVID-19 Pandemic
90960Esrd srv 4 visits p mo 20+
90961Esrd srv 2-3 vsts p mo 20+
90962Esrd serv 1 visit p mo 20+Temporary Addition for the PHE for the COVID-19 Pandemic
90963Esrd home pt serv p mo <2yrs
90964Esrd home pt serv p mo 2-11
90965Esrd home pt serv p mo 12-19
90966Esrd home pt serv p mo 20+
90967Esrd home pt serv p day <2
90968Esrd home pt serv p day 2-11
90969Esrd home pt serv p day 12-19
90970Esrd home pt serv p day 20+
92507Speech/hearing therapyTemporary Addition for the PHE for the COVID-19 Pandemic
92521Evaluation of speech fluencTemporary Addition for the PHE for the COVID-19 Pandemic
92522Evaluation speech productionTemporary Addition for the PHE for the COVID-19 Pandemic
92523Speech sound lang comprehenTemporary Addition for the PHE for the COVID-19 Pandemic
92524Behavral qualit analys voicTemporary Addition for the PHE for the COVID-19 Pandemic
96116Neurobehavioral status exam
96130Psycl tst eval phys/qhp 1stTemporary Addition for the PHE for the COVID-19 Pandemic
96131Psycl tst eval phys/qhp eaTemporary Addition for the PHE for the COVID-19 Pandemic
96132Nrpsyc tst eval phys/qhp 1stTemporary Addition for the PHE for the COVID-19 Pandemic
96133Nrpsyc tst eval phys/qhp eaTemporary Addition for the PHE for the COVID-19 Pandemic
96136Psycl/nrpsyc tst phy/qhp 1sTemporary Addition for the PHE for the COVID-19 Pandemic
96137Psycl/nrpsyc tst phy/qhp eaTemporary Addition for the PHE for the COVID-19 Pandemic
96138Psycl/nrpsyc tech 1stTemporary Addition for the PHE for the COVID-19 Pandemic
96139Psycl/nrpsyc tst tech eaTemporary Addition for the PHE for the COVID-19 Pandemic
96156Hlth bhv assmt/reassessment
96168Hlth bhv ivntj indiv 1st 30
96159Hlth bhv ivntj indiv ea addl
96164Hlth bhv ivntj grp 1st 30
96165Hlth bhv ivntj grp ea addl
96167Hlth bhv ivntj fam 1st 30
96168Hlth bhv ivntj fam ea addl
96160Pt-focused hlth risk assmt
96161Caregiver health risk assmt
97110Therapeutic exercisesTemporary Addition for the PHE for the COVID-19 Pandemic
97112Neuromusulcar reeducationTemporary Addition for the PHE for the COVID-19 Pandemic
97116Gait training therapyTemporary Addition for the PHE for the COVID-19 Pandemic
97161PT Eval low complex 20 minTemporary Addition for the PHE for the COVID-19 Pandemic
97162PT Eval mod complex 30 minTemporary Addition for the PHE for the COVID-19 Pandemic
97163PT Eval high complex 45 minTemporary Addition for the PHE for the COVID-19 Pandemic
97164PT re-eval est plan careTemporary Addition for the PHE for the COVID-19 Pandemic
97165OT eval low complex 30 minTemporary Addition for the PHE for the COVID-19 Pandemic
97166OT eval mod complen 45 minTemporary Addition for the PHE for the COVID-19 Pandemic
97167OT eval high complex 60 minTemporary Addition for the PHE for the COVID-19 Pandemic
97168OT re-eval est plan careTemporary Addition for the PHE for the COVID-19 Pandemic
97535Self care mngment trainingTemporary Addition for the PHE for the COVID-19 Pandemic
97750Physical Performance TestTemporary Addition for the PHE for the COVID-19 Pandemic
97755Assistive Technology AssessTemporary Addition for the PHE for the COVID-19 Pandemic
97760Orthotic mgmt&traing 1st enTemporary Addition for the PHE for the COVID-19 Pandemic
97761Prosthetic traing 1st encTemporary Addition for the PHE for the COVID-19 Pandemic
97802Medical nutrition indiv in
97803Med nutrition indiv subseq
97804Medical nutrition group
99201Office/outpatient visit new
99202Office/outpatient visit new
99203Office/outpatient visit new
99204Office/outpatient visit new
99205Office/outpatient visit new
99211Office/outpatient visit est
99212Office/outpatient visit est
99213Office/outpatient visit est
99214Office/outpatient visit est
99215Office/outpatient visit est
99217Observation care dischargeTemporary Addition for the PHE for the COVID-19 Pandemic
99218Initial observation careTemporary Addition for the PHE for the COVID-19 Pandemic
99219Initial observation careTemporary Addition for the PHE for the COVID-19 Pandemic
99220Initial observation careTemporary Addition for the PHE for the COVID-19 Pandemic
99221Initial hospital careTemporary Addition for the PHE for the COVID-19 Pandemic
99222Initial hospital careTemporary Addition for the PHE for the COVID-19 Pandemic
99223Initial hospital careTemporary Addition for the PHE for the COVID-19 Pandemic
99224Subsequent observation care
99225Subsequent observation care
99226Subsequent observation care
99231Subsequent hospital care
99232Subsequent hospital care
99233Subsequent hospital care
99234Obser/hosp same dateTemporary Addition for the PHE for the COVID-19 Pandemic
99235Obser/hosp same dateTemporary Addition for the PHE for the COVID-19 Pandemic
99236Obser/hosp same dateTemporary Addition for the PHE for the COVID-19 Pandemic
99238Hospital discharge dayTemporary Addition for the PHE for the COVID-19 Pandemic
99239Hospital discharge dayTemporary Addition for the PHE for the COVID-19 Pandemic
99281Emergency dept visitTemporary Addition for the PHE for the COVID-19 Pandemic
99282Emergency dept visitTemporary Addition for the PHE for the COVID-19 Pandemic
99283Emergency dept visitTemporary Addition for the PHE for the COVID-19 Pandemic
99284Emergency dept visitTemporary Addition for the PHE for the COVID-19 Pandemic
99285Emergency dept visitTemporary Addition for the PHE for the COVID-19 Pandemic
99291Critical care first hourTemporary Addition for the PHE for the COVID-19 Pandemic
99292Critical care addl 30 minTemporary Addition for the PHE for the COVID-19 Pandemic
99304Nursing facility care initTemporary Addition for the PHE for the COVID-19 Pandemic
99305Nursing facility care initTemporary Addition for the PHE for the COVID-19 Pandemic
99306Nursing facility care initTemporary Addition for the PHE for the COVID-19 Pandemic
99307Nursing fac care subseq
99308Nursing fac care subseq
99309Nursing fac care subseq
99310Nursing fac care subseq
99315Nursing fac discharge dayTemporary Addition for the PHE for the COVID-19 Pandemic
99316Nursing fac discharge dayTemporary Addition for the PHE for the COVID-19 Pandemic
99327Domicil/r-home visit new paTemporary Addition for the PHE for the COVID-19 Pandemic
99328Domicil/r-home visit new paTemporary Addition for the PHE for the COVID-19 Pandemic
99334Domicil/r-home visit est paTemporary Addition for the PHE for the COVID-19 Pandemic
99335Domicil/r-home visit est paTemporary Addition for the PHE for the COVID-19 Pandemic
99336Domicil/r-home visit est paTemporary Addition for the PHE for the COVID-19 Pandemic
99337Domicil/r-home visit est paTemporary Addition for the PHE for the COVID-19 Pandemic
99341Home visit new patientTemporary Addition for the PHE for the COVID-19 Pandemic
99342Home visit new patientTemporary Addition for the PHE for the COVID-19 Pandemic
99343Home visit new patientTemporary Addition for the PHE for the COVID-19 Pandemic
99344Home visit new patientTemporary Addition for the PHE for the COVID-19 Pandemic
99345Home visit new patientTemporary Addition for the PHE for the COVID-19 Pandemic
99347Home visit est patientTemporary Addition for the PHE for the COVID-19 Pandemic
99348Home visit est patientTemporary Addition for the PHE for the COVID-19 Pandemic
99349Home visit est patientTemporary Addition for the PHE for the COVID-19 Pandemic
99350Home visit est patientTemporary Addition for the PHE for the COVID-19 Pandemic
99354Prolonged service office
99355Prolonged service office
99356Prolonged service inpatient
99357Prolonged service inpatient
99406Behav chng smoking 3-10 min
99407Behav chng smoking > 10 min
99468Neonate crit care initailTemporary Addition for the PHE for the COVID-19 Pandemic
99469Neonate crit care subsqTemporary Addition for the PHE for the COVID-19 Pandemic
99471Ped critical care initialTemporary Addition for the PHE for the COVID-19 Pandemic
99472Ped critical care subsqTemporary Addition for the PHE for the COVID-19 Pandemic
99473Self-meas bp pt educaj/traiTemporary Addition for the PHE for the COVID-19 Pandemic
99475Ped crit care age 2-5 initTemporary Addition for the PHE for the COVID-19 Pandemic
99476Ped crit care age 2-5 subsqTemporary Addition for the PHE for the COVID-19 Pandemic
99477Init day hosp neonate careTemporary Addition for the PHE for the COVID-19 Pandemic
99478Ic lbw inf < 1500 gm subsqTemporary Addition for the PHE for the COVID-19 Pandemic
99479Ic lbw inf 1500-2500 g subsTemporary Addition for the PHE for the COVID-19 Pandemic
99480Ic inf pbw 2501-5000 g subsTemporary Addition for the PHE for the COVID-19 Pandemic
99483Assmt & care pln cog impTemporary Addition for the PHE for the COVID-19 Pandemic
99495Trans care mgmt 14 day disch
99496Trans care mgmt 7 day disch
99497Advncd care plan 30 min
99498Advncd are plan addl 30 min
G0108Diab manage trn per indiv
G0109Diab manage trn ind/group
G0270Mnt subs tx for change dx
G0296Visit to determ ldct elig
G0396Alcohol/subs interv 15-30mn
G0397Alcohol/subs interv >30 min
G0406Inpt/tele follow up 15
G0407Inpt/tele follow up 25
G0408Inpt/tele follow up 35
G0420Ed svc ckd ind per session
G0421Ed svc ckd grp per session
G0425Inpt/ed teleconsult30
G0426Inpt/ed teleconsult50
G0427Inpt/ed teleconsult70
G0436Tobacco-use counsel 3-10 min
G0437Tobacco-use counsel>10min
G0438Ppps, initial visit
G0439Ppps, subseq visit
G0442Annual alcohol screen 15 min
G0443Brief alcohol misuse counsel
G0444Depression screen annual
G0445High inten beh couns std 30m
G0446Intens behave ther cardio dx
G0447Behavior counsel obesity 15m
G0459Telehealth inpt pharm mgmt
G0506Comp asses care plan ccm svc
G0508Crit care telehea consult 60
G0509Crit care telehea consult 50
G0513Prolong prev svcs, first 30m
G0514Prolong prev svcs, addl 30m
G2086Off base opioid tx first m
G2087Off  base opioid tx, sub m
G2088Off opioid tx month add 30

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.

E-Visits or televisits using telemedicine technology

When most people think of telemedicine, whether they know it or not, they are imagining e-visits. Simply put, e-visits – which are sometimes referred to as televisits – 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, e-visits are used for lower intensity urgent care visits.

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.

Billing

You can use G2010 and G2012 as virtual Check-In Codes. These virtual checks can be done synchronously and asynchronously. You can use the telephone. Keep in mind that virtual checks in reimbursements are low and are to be used for quick checkins only. Make sure these quick check ins do not last for more than a few minutes and that these are used only for established patients. You cannot use these codes for patient initiated checkins and you cannot use these to result from or lead to an E/M service.

Meanwhile true eVisits for online digital evaluation should be billed as G2061-2063 and online medical evaluations should use codes from 99421-99423

Remote Patient Monitoring

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 as shown here for CHF and here 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.

Benefit 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.

Benefit 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.

Benefit 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.\

Benefit 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.

Billing

Remote patient monitoring services are a bit more complicated and aren’t necessarily considered as true “telehealth”.e.g. Chronic Care Management, Complex Chronic Care Management, Transitional Care Management, Remote Physiologic Monitoring, Principle Care Management treatments are to be billed with very specific codes. 

Store-and-Forward in telemedicine technology

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.

  • The receiving provider will furnish a recommended course of treatment to the patient if the transmission occurred directly from the consumer.
  • 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
  • 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.

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.

EConsults help reduce these long wait times for patients at specialty care offices. 

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 econsults with their referring partner, care coordination has been proven to trend higher.

Billing

Store and forward econsults are treated as inter-professional consultations. These can be delivered via the phone/web or even via the consulting providers’ EMRs. These should be billed as 99446, 99447, 99448, 99449, 99451 and 99452. The good thing is that it pays both the providers – however, there has to be specific time periods that the consultation needs to last, for it to be billable.

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.

Nothing is ever going to beat face to face patient consults.

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.

Should you take advantage of telemedicine or telehealth services?

Deciding to take the take the leap and implement one or more variants of telemedicine in a practice is a big 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 satisfactions, patients are apt to look elsewhere for their care.

The best advice is to look at the practice’s strategic goals for the next few years to see what telemedicine modality will make the most sense. Are you in primary care practice looking to fully embrace PCMH?

Perhaps then extending hours through e-visits might be a good test case. A dermatology practice may look at store-and-forward.

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 – where do they stand?

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.

How to deploy 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 teleheatlh
  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

telemedicine-dermatology-nisos-health

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.

Telemedicine Technology needed for offering telehealth services

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.

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.
  4. 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. 

#1 Example store and forward telehealth solution – occupational therapy

Here’s how we helped an Ergonomist and Occupational Therapist working in the field of injury prevention for hi-tech, insurance and healthcare enterprises.

Much like any service based business, our client understood that the only way to grow revenues was to add more staff / increase headcount. The more headcount they added, the more the overheads – in other words, profit margins kept getting smaller. Increased headcount also led to higher revenue & cash flow requirements… all the problems that you know very well.

The basic idea was to do the following:

  • Acquire – Generate more patient leads with a “foot in the door” offer, at a low cost of acquisition
  • Convert – Provide tangible value to these new patients with this low priced offer. This is serviced with minimal effort from our client’s side.
  • Nurture – Be in regular contact with these new patients, provide tangible value and aim for the larger business – being introduced to the companies these customers work for.
  • Up-sell – Present these initial customers with a slightly higher priced service offering that isn’t a big ask from these new leads. For this, only two pictures were required from the customer. Again, this was also serviced with minimal effort from our client’s team.

How it was executed

Our customer launched a simple mobile app that allows their providers to achieve all of the above (telehealth doesn’t necessarily need to be a mobile app).

The mobile app presents 4 paths to help someone with aches/pains (patient)

televisit app for occupational therapy
  • Self assessment – the patient is asked a series of questions to help them with their aches and pains
  • Solutions for body discomfort – wherein the patient can click on various body parts to identify self care and ergonomic tips.
  • Help videos – helps the patient make immediate changes to their posture with self help videos
  • Ergonomic equipment recommendation – helps the patient choose from various products to ease their aches and pains.

Acquire patients

Facebook was a perfect venue for advertising the app. Considering the segment that the app was going to help, this would have been a very large audience.

The app was advertised on Facebook with a small ad spend of $5/day (of course, proper audience creation, segmentation etc was done to identify the right kind of audience and show the app to only these users).

In fact, the audience was limited to California as well since it provided more than enough ROI.

Mobile app downloads were achieved at a very low cost per acquisition.

Convert patients

The “foot in the door” offer was for patients to immediately see value in an ergonomic consultation. Here are the observations from our experience:

  • Approximately 80% of people that downloaded the app used both the self assessment.
  • Approximately 20% of these users also used the various solutions the app provides for body discomfort.
  • About 35% of these users that downloaded the app also signed up to hear more directly from the practice
  • About 20% of the users that answered various assessment questions, also signed up as a lead to hear more from the practice
  • To service this “foot in the door” offer, the practice owner and their team didn’t have to spend a single minute. These assessment questions and the solutions for various body discomfort were all canned responses.

In other words, the initial “foot in the door” offer was a raging success !

Nurture – Be in regular contact with these new patients.

All leads that were signing up to hear more from the practice are constantly nurtured via various methods.

Push notifications – there are several ways that the practice is staying in touch with their patients. Push notifications is one of them.

As an example, when a patient is seen using the app within the past hour (i.e. they are actually active), a push notification is sent to remind the patient to take a 2 min break and stretch every 30 mins of sitting at their desk. This has a dual purpose. First, for people that are really using the app, it keeps them engaged and helps them achieve their goals. On the other hand, if someone hasn’t opened the app in the last hour, it doesn’t bother them at all.

Does that mean that the practice is not going after these “inactive” patients? Nope !

Campaigns are set up and regular push notifications are sent to patients that have downloaded the app but are not using it actively. The practice also monitors the conversion rates of these mobile users.

For patients that have already provided their email address or phone number, they are nurtured via email/ SMS providing various occupational hazards and tips on how to avoid them.

Up-sell to existing patients

The idea was to present these initial customers with a slightly higher priced service offering that isn’t a big “ask” from these new patients.

Once we saw that people were interacting with the app and using the various self help and self assessment areas of the app, it was now time to up-sell these customers to a personalized recommendation. We called this “Ask an expert”.

Of course, for their regular practice, this would require an in-person visit from the patient or if this was being done at a contracted enterprise, the team would have to make in person visits to their offices.

Instead, this up-sell, again, required minimal inputs from both the patient and the practice team.

The patient was asked for a single picture from the side of them sitting at their desk (capturing the computer, keyboard and their feet). This allowed the practitioner to “virtually” see the patient and immediately recommend posture changes, recommend any changes to various equipment in use in addition to recommending any alternate desk/chair options.

This was a very easy up-sell as the patient had just undergone self diagnosis, already obtained a lot of tangible value from the get-go.

#2 Example store and forward telehealth solution – ophthalmology

As is well known, diabetic retinopathy is the leading cause of blindness in the USA (mostly for adults 20-74 yrs of age). About 30 million Americans and 414 million people worldwide have diabetic retinopathy. With early detection, vision loss is preventable in up to 95% of the cases.

AAO, NCA and NQF recommend annual retinal exams for diabetic patients – however, only 20-50% really comply. These are assumed to be due to various reasons including, but not limited to:

  1. Lack of patient awareness and education
  2. Lack of access to healthcare and even more so, specialists.
  3. Patient logistics are usually the biggest factor.

Even though retinal exams are to be included in NCQA HEDIS and CMS STAR ratings (and even for CMS ACO diabetes management), despite the fact that DRE compliance increases incentives under HEDIS/STAR ratings, compliance has been poor.

Fort Drum Regional Health planning organization had started a telemedicine based diabetic retinopathy screening program where 95 % of the target population live in a health profession shortage area (HPSA) across various sites (see here). In less than a year after launch, they reported pretty promising results here.

As reported numerous times, the main challenges of patient logistics are due to the current workflow (as below)

  1. A patient visits their PCP for a check up (not necessarily related to diabetic retinopathy)
  2. The PCP office knows that they are supposed to do yearly retinal exams (well, many PCP offices are not equipped with this clinical decision support system either).
  3. The PCP office refers the patient to a specialist office (ophthalmologist). They typically do so by handing the patient a note or a referral pad referral.
  4. The patient leaves the office – there’s no further follow up.
  5. A minority of those patients call the ophthalmologist offices (specialty – hence, they are already backed up)
  6. The patient faces barriers in setting up an appointment with the specialist office
  7. Finally, and when the patient does get an appointment with the specialist office, they may or may not show up.
  8. Even when the patient does actually show up for the visit, the encounter/visit notes may or may not be sent back to the PCP office.. Therefore leaving an open care loop. 

The options already out in the market include the likes of retinalscreenings, Welch allyn RetinaVue network etc.

An ophthalmology group in NYC that deals with a large diabetic population wanted to offer teleretinal screening services to their referring partners.

This not only assisted in medical marketing for them but at the same time extended patient compliance in addition to assisting the primary care providers to meet their yearly CDC screening goals.

How it was executed:

Acquire patients

In this particular case, the PCP office was responsible for patient acquisition, identification for retinal screening cases and therefore the ophthalmology group depended on the PCP offices.

The PCP office would create the patient as a new screening case to be diagnosed. They would then upload their images (right and left eye) to the web portal. This would send the alert to the retinal specialists on staff at our ophthalmology group and the specialists would immediately diagnose the images.

More often than not, while the patient was still at the PCP office, the PCP would get a report back. The system would generate a report with all information and notes necessary for billing purposes as well. 

Convert patients

For patients that were diagnosed with NPDR, the PCP office could immediately send an electronic referral to the ophthalmology group so the patient compliance was already expected to be higher.

While WelchAllyn and retinalscreenings offer a slew of retina specialists that grade images, this does not help individual ophthalmology practices generate new patient business. Using those existing services is like listing themselves on ZocDoc – you cannot predict the amount of business you can generate, because every retina specialist is already on those networks.

Since the patient referral was generated immediately and the patient got an appointment before leaving the PCP office, the problem of patients forgetting to follow up with the specialist office was entirely eradicated.

That was it – the ophthalmology group was able to serve their referring partners above and beyond what they expected, many more diabetic retinopathy cases were determined as well.

#3 Example audio visual /econsult telehealth solution – skilled nursing facility

Skilled nursing facilities face a severe shortage of workers. As it is there is a documented shortage of primary care physicians and the gap keeps getting wider.

On top of it, SNFs have been known to have a shortage of direct care workers. Add to this, the primary care shortage – makes matters even worse.

The fact that a majority of baby boomers are above 65 and will soon be entering into the purview of skilled nursing facilities, this acute shortage needs to be addressed.

One way to deal with this is to provide primary care providers on call. This is exactly what one telemedicine company wanted to do – they had a roster of USA licensed physicians that were ready to provide on-call services.

This is not a new business model per se, as primary care providers have been provided on an on-call basis for a while. However, in this particular case, the telemedicine company wanted to provide video and voice calling facilities to the skilled nursing facilities.

The basic idea was that when the SNFs would face a volume of patients without having enough primary care providers on site, they would immediately book an appointment with these on-call doctors. Each provider would have VPN access to the EMR of the skilled nursing facility hence would have the ability to look at patient records as well as update with diagnosis and treatment/care plans.

How it was executed

The idea was executed quite simply – the nurse would create appointments on available providers’ calendar. The provider being on call, would always have their calendar up to date. At the time of the call, the provider would read the nurse’s note for the upcoming patient video call, login to the SNF’s EMR, read the patient chart and thereafter, start the video call. While on a video call with the patient, the provider would take as many notes as needed and as part of the after-call-work (ACW), they would update the patient’s record on the SNF EMR to reflect these notes.

At all times, these recordings needed to be available for audit and security reasons, stored on a HIPAA secure infrastructure.

That’s about as simple as it is.

There are several ways you can take advantage of telehealth – whether it is store and forward, e-visit or remote patient monitoring.. that’s truly a business decision for you to make.