Telemedicine  an easy introduction

Telehealth intro  — video calls, Virtual check in calls , Telephone-Only E/M, eVisits, Inter-professional consultations, Remote patient monitoring

Categorized as Operations Tagged

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.

  • 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

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

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. 

Telehealth is often used for lower intensity urgent care 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

You can bill for Outpatient Evaluation and Management Visits.

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

Meanwhile, non-facility rates are higher. These 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-ins. The code is G2012 and is for MEDICARE ONLY.

Telephone-Only E/M

You can use this 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.

eVisits / Online digital E/M

For this, you need to use a HIPAA compliant patient portal or secure messaging system. 

Refer to my 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).

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 consults only. 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.

You need to include a verbal and written report to get paid.

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

You get reimbursed for the same services as above.

If you only provide a written report, you get paid $37.53 for code 99451.

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.

  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.

One of a few things will then occur.

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.

This frees 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 or SIM cards, 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

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).

Here’s a 2019 consolidated report.

There were restrictions around each modality. These were temporary limited due to the COVID 19 outbreak. The modalities included 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.

  1. Qualifying rural area and facilities no longer have restrictions. Therefore, this enables providers throughout the USA to deliver telehealth services to their patients.
  2. Medicare allows you to reduce or waive all patient cost-sharing payments for telehealth visits.
  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 were relaxed. Therefore, you could use Skype, WhatsApp video calls.

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.