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What is Telemedicine and How Does it Work in Practice?

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My recent blog about telehealth described it as the overarching term for healthcare services delivered using telecommunications technologies. Within telehealth, telemedicine is the term used to describe the delivery of clinical services and care, including evaluation, diagnosis, treatment plan, follow up care, and ongoing management of medications or chronic disease.

Given its convenience and 24/7 access, telemedicine is fast becoming a patient preferred way be treated for a wide variety of acute care needs and follow up issues. It’s convenient, often faster to schedule than an in-person visit, and saves patients from taking time away from work or childcare.

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Who Benefits?

Telemedicine is proving to be a great value to patients as well as providers. Let’s consider the patient first.

People with limited access, elderly populations, working parents, and patients who are less ambulatory during post-operative recovery all benefit from being seen by a clinician without having to travel to the doctor’s office.

For instance, people in rural areas can be treated and followed by a primary care provider or a specialist without driving great distances to a medical center. Elderly patients can visit with their doctor from their home or assisted living community. And as a pediatrician, I can tell you that a video visit with a working mom and her sick 5 year-old is infinitely better than mom taking time off work to bring her feverish, crying son to the doctor.

Are patients comfortable with telemedicine? Absolutely. One study found that 64% of patients would see a doctor by video. In another study of patients’ satisfaction with telehealth visits after receiving one, 94% - 99% reported being "very satisfied" with all telehealth attributes.

Providers also benefit. Colleagues tell me that video visits have lower no-show and cancellation rates than in-person visits, which is helpful for keeping the physician’s schedule on-time. And typically these visits take less time than seeing a patient in-person, which enhances efficiency and allows the physician to treat more patients.

One surgeon whose been conducting video visits for several years said the shorter visit length surprised him. Many in-person visits end up going beyond the scheduled time because once the patient is in front of the doctor, he or she may have more questions or issues than anticipated. But telemedicine visits are typically conducted with the patient at home, often while they are caring for children or making dinner. The result is that they are as efficient with the time as possible, often ending the visit before its scheduled end time, according to this colleague.

From my perspective, I think the biggest innovation of telemedicine over in-person visits is the opportunity for better patient follow up and improved health outcomes. In the old days, we recommended a treatment plan and/or prescribed medications, then hoped the patient followed our advice. But once they left the clinic, we had no efficient way of knowing whether patients followed the protocol or got better. Video visits and remote patient monitoring enable clinicians to reach out to the patient regularly to make sure they are healing or appropriately managing their condition. 

Which Conditions Can Be Treated?

Telemedicine visits can address a wide range of issues and conditions.

In primary care, patients are treated for minor acute conditions such as allergies, pink eye, rashes, back pain, otitis media, and poison ivy. Chronic conditions such as mental health issues, diabetes, or congestive heart failure can also managed by a combination of remote patient monitoring and video visits. And as long as a procedure isn't needed, nearly any kind of office visit follow up in primary care can be conducted using telemedicine.

On the specialty side, modern surgical groups are moving toward the delivery of post-op follow up visits using telemedicine. They can also deliver test review and consultations, and video visits are great for connecting specialists with rural hospitals and physicians to render opinions on their cases.

Telemedicine in Practice 

The two most common ways to deliver a telemedicine visit are: live video conferencing and remote patient monitoring. In this blog I've focused on live video visits, which are probably the most common images people have of telemedicine.

Live video visits involve a patient and a physician or non-physician provider having a HIPAA-compliant conversation via video conference software on a computer screen or mobile device. To get a flavor of how this works, watch this two and a half minute video from Johns Hopkins that shows how physician-patient video visits work in that organization, who is involved, and the value they bring for patients and physicians.

Organizations that offer video visits typically ask patients to sign a consent form prior to doing so, and schedule them in the same appointment schedule they do their in-person visits. For efficiency, most providers block time for video visits so they are not jumping from their laptop to the exam room. And specialists who use connected devices - such as a digital spirometer or otoscope to conduct virtual exams - often dedicate a room for their telemedicine visits, so the equipment stays in one place. A pediatric orthopedic colleague I know integrates his virtual visits within regular clinic hours or schedules them early in the morning or later in the evening, when children are home from school and parents are done working. This provides extra flexibility, unlike in-person visits that can only occur when the clinic is open and staff is available.

Telemedicine Technology

There are dozens of technology platforms that can be used to conduct video visits. Some offer health systems and physician practices the software only, for a subscription or license fee. Others offer the platform plus a service option - for example, if a primary care group wants 24/7 telemedicine visit coverage, it can contract with the telemedicine technology company’s clinical team, which is available to the practice’s patients after regular clinic hours.

Ideally, a telemedicine module is integrated with an organization’s electronic health record (EHR), but that’s not always the case. Regardless, the provider’s documentation must meet the same criteria as an in-person visit, and it must make its way back into the medical record.

The orthopedic department in a large multispecialty group offers video visits for post-op care, using the telehealth module in the group’s EHR. Physician assistants (PAs) see scheduled, post-op patient appointments using live video, freeing the physicians to see new patients or administer injections. Patients use their iPhone or iPad for the visit which is conducted using a HIPAA-compliant telehealth module in the group's electronic health record (EHR). At the point of surgery scheduling, staff offer the option of follow-up care in person or online.

Keep in mind, however, that not all telemedicine has to be delivered from within a physician office or health system. There are several telemedicine services available directly to the consumer. Anyone, regardless of their insurance plan or employer, can be seen 24/7. Patients simply download an app onto their mobile device, register, enter their insurance information and/or credit card number, and they can be connected with a physician or non-physician provider almost immediately.

Getting Paid for Telemedicine

Reimbursement for telehealth and telemedicine visits varies widely by state and by payor. Most payors do reimburse for it, but the rules are different for each one, so it’s essential that billing and practice teams know the details.

The best advice for any physician organization considering telemedicine visits is to get organized with billing and payor rules on the front end, before scheduling the first patient. Once you understand coverage rules, you’ll not only know how to bill the visits to payors, but also the portion you can appropriately collect from patients.

First, direct your team to collect the details about how your state defines telehealth and telemedicine, including rules about which types of providers can perform services, and which services can be delivered by telehealth. Determine too if your state is one of the more than 30 that have passed a telemedicine parity law. If it has, payors that cover in-person visits must reimburse telemedicine visits at the same rate. Obtain this information from your state medical society or your state board of medicine, and stay on top of legislation and policies.

Over the last few years, dozens of states have introduced hundreds of telemedicine bills. Even if your state does not have a parity law today, it may in the near future. Research your state’s Medicaid rules too. Although nearly all Medicaid programs reimburse for telehealth, what is covered varies state to state.

After determining state laws and policies, ask the billing team to contact payors and find out which codes and modifiers are needed for billing purposes, and the associated coverage rules. Medicare and most payors require providers to bill evaluation and management (E/M) codes (a type of CPT code) for telehealth services. However, to indicate it as a non in-person visit, you typically need to append the E/M code with a modifier, and those modifiers may vary by payor.

As one example, Medicare provides rules and guidance about which codes to bill, what is covered, and what isn’t. In a nutshell, to bill a telehealth visit to this payor:

  • Choose an E/M code that corresponds to the correct visit level. For example, the covered codes for Medicare include: 9920x, 9921x, 9923x.
  • Append the E/M code with the proper modifier. For Medicare, modifier GT is used to indicate that the service was performed by synchronous (live) method. Modifier GQ appended to a service indicates that the service was performed by asynchronous (store and forward) method.
  • Submit the claim as you normally would.

Other payors may have different requirements for submitting claims. Research the specific guidelines for your contracted plans. Organized billing teams gather the codes and coverage rules for the top twenty payors to be compliant and keep the details straight.

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