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Chapter 1

Bonus Short - Telemedicine in the Time of COVID-19

Edward Kaftarian, MD and Neda Frayha, MD
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Has your clinical practice shifted to telemedicine yet? In the era of COVID-19, clinicians everywhere are being thrown into telemedicine, often without any experience or background knowledge. To help us all get up to speed with this patient care technology, Hippo Education’s Dr. Neda Frayha sits down with Dr. Edward Kaftarian, the Vice Chair of Mental Health at the American Telemedicine Association and CEO of Orbit Health Telepsychiatry. Together they explore the benefits and potential pitfalls of telemedicine, the equipment required, billing and coding considerations, appropriate etiquette, and much more.

Definition

  • Providing evaluations, therapy, patient education and medication management remotely, most often by using videoconferencing

 

Categories of Telemedicine

  • Live two way video conferencing - most common; interactive, synchronous appointments

  • Store-and-forward - record information (interview, photo of a rash), store it, forward it to the clinician for later review

  • Remote monitoring - tracking telemetry, vital signs

  • Mobile health - wearable devices like Fitbits that relay information to the clinician

 

Benefits

  • Matches resources to patients

  • Can be used in many settings such as correctional facilities, courts, hospitals, emergency departments, community health centers

  • Meets patients where they are, allows them greater convenience & comfort

  • Spans geography: you can work at one clinic in the morning and another in the afternoon

  • Leverages time zones

 

Challenges

  • Technology less and less of an issue

  • Insurance carriers sometimes are confused by telemedicine

  • Physical examinations should be guided

  • Limited to what you see on camera unless you get collateral information

  • HIPAA rules

  • Emergency plans must be coordinated ahead of time

  • Policy landscape can vary from state to state 

 

Policy Landscape, Billing and Coding

  • Fewer barriers and greater flexibility now than before

  • CMS: Medicare has three types of telehealth visits

1. Medicare Telehealth visit: interactive, synchronous communication over video

  • Codes start with 99201 and go through 99205

  • Previously needed to be in a rural area or an area with a shortage of health professionals, but now with COVID-19, this restriction has been lifted

2. E-Visit: a digital visit initiated by the patient through smart phone or portal, used to determine if a fuller office visit is needed. 

  • For established patients

  • Codes 99421, 99422, 99423

3. Virtual Check-In: can be done via telephone or other telecom device 

  • Codes G2012 and G2010

  • Need verbal consent from patient

  • We can’t see the patient within 24 hours of this visit or in the previous 7 days in order to bill

 

Source: CMS Medicare Telemedicine Health Care Provider Fact Sheet (https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet)

 

  • Private insurance starting to drop their reimbursement restrictions here as well

  • Other areas of increased flexibility: the site of origination can now be any health care office or facility as well as the home, and services provided don’t have to be limited to covid-19 related diagnoses or symptoms 

  • Potential loosening of penalties around HIPAA

  • State licensure requirements also evolving

  • In general, always consult with your own institution, state board, malpractice attorney before embarking on your new telemedicine practice

 

Technology Considerations

  • Bandwidth minimum requirement is 1.5 MB/sec, but recommend at least 3 MB/sec if you are running other programs simultaneously

  • Preferred download speeds of at least 30 but up to 100 Mbps

  • Preferred upload speed of 10 Mbps

  • Hardwired preferred, but WiFi can work

  • Fancy equipment not necessary

  • Need a good quality camera, 720p or above

  • Appropriate diffuse lighting

  • Noise canceling microphone/speaker (USB plug and play)

  • HIPAA-secure telemedicine platform

    • Many options exist, from formal software programs to Zoom to Skype for Business

    • Try to stay away from public domain sites such as Facebook, TikTok, YouTube

    • Have a HIPAA Business Associate Agreement with whichever platform you use

  • Need an EMR or HIPAA-compliant way of transmitting paper records and writing orders

  • Need a contingency plan if you lose power or internet

 

Etiquette

  • Private, quiet space to protect patient confidentiality

  • Position camera for virtual eye contact

  • Position camera at the right distance

  • A quiet keyboard helps

  • Minimize personal items in background

  • Don’t shuffle papers around 

  • No distractions in the background (kids, pets, electronics)

  • Be punctual

  • Dress appropriately

  • Never forget that this is a real clinical appointment

 

Telemedicine Resources for Listeners

 

References 

  1. COVID-19 Telehealth Coding and Billing Practice Management Tips. American College of Physicians. https://www.acponline.org/practice-resources/business-resources/covid-19-telehealth-coding-and-billing-practice-management-tips (Accessed 23 March 2020)

  2. AMA Quick Guide to Telemedicine in Practice. American Medical Association. https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice (Accessed 23 March 2020)

  3. Medicare Telemedicine Health Care Provider Fact Sheet. Centers for Medicare and Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet (Accessed 23 March 2020)

  4. Telehealth and Telemedicine. American Academy of Family Physicians. https://www.aafp.org/about/policies/all/telemedicine.html (Accessed 23 March 2020)

  5. Moore K. Coronavirus (COVID-19): new telehealth rules and procedure codes for testing. Getting Paid: A Blog from FPM Journal. March 10, 2020. https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/coronavirus_testing_telehealth.html (Accessed 23 March 2020)

  6. Liebson E. Telepsychiatry: Thirty-Five Years’ Experience. 1997. www.medscape.com/viewarticle/431064_1. Accessed January 17, 2019.

  7. Arndt RZ. Turning to telemedicine for prisoners’ mental health treatment. January 6, 2018. www.modernhealthcare.com/article/20180106/NEWS/180109957. Accessed January 17, 2019. 

  8. Center for Connected Health Policy. www.cchpca.org/

  9. Hubley, et al.  Review of Key Telepsychiatry Outcomes. World J Psychiatry. 2016 Jun 22; 6(2): 269–282.

  10. Campbell, et al. Reactions of Psychiatric Patients to Telepsychiatry. Ment Illn. 2015 Sep 30; 7(2): 6101.

  11. Brodey et al, 2000. Satisfaction of forensic psychiatry patients with remote telepsychiatric evaluation. Psych Services: Oct 51(10): 1305-7.

  12. Ermer D.J., 1999. Child and adolescent telepsychiatry clinics. Psych Services Jul 29(7): 409-14

  13. Sharp, IR, et al: The use of videoconferencing with patients with psychosis: a review of the literature. Annals of Gen Psychiatry 2011 10:14

  14. Ruskin PE, Silver-Aylaian M, Kling MA, Reed SA, Bradham DD, Hebel JR, et al. Treatment outcomes in depression: comparison of remote treatment through telepsychiatry to in-person treatment. The American journal of psychiatry. 2004;161(8):1471-6.

  15. Rabinowitz T, Murphy KM, Amour JL, Ricci MA, Caputo MP, Newhouse PA. Benefits of a telepsychiatry consultation service for rural nursing home residents. Telemedicine journal and e-health. 2010;16(1):34-40. 

  16. State Telemedicine Gaps Analysis, February 2017. American Telemedicine Association. www.americantelemed.org/home

  17. Interstate Medical Licensure Compact. https://imlcc.org. Accessed January 17, 2019. 

  18. American Telemedicine Association. www.americantelemed.org/home

  19. Rheuban K, Shanahan S, Wilson K. Telemedicine: innovation has outpaced policy. AMA Journal of Ethics, December 2014. https://journalofethics.ama-assn.org/article/telemedicine-innovation-has-outpaced-policy/2014-12 (Accessed 23 March 2020). 

  20. Breen GM, Matusitz J. An evolutionary examination of telemedicine: a health and computer-mediated communication perspective. Soc Work Public Health. 2010;25(1):59–71. doi:10.1080/19371910902911206

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