How to do telemedicine in the time of COVID-19

The novel coronavirus disease (COVID-19) pandemic has led CMS and most private insurers to dramatically change their requirements for remote physician visits. As a result of these changes—along with social distancing and other measures to avoid exposure to the virus—physician use of telemedicine has exploded.

On March 17, President Donald Trump announced that CMS would expand its coverage for telehealth visits, Michael Brown, DO, explained in a March 25 AOA/AOIA webinar on telemedicine.

How reimbursement has changed

“Telehealth services are [now] paid under the Physician Fee Schedule at the same amount as in-person services,” the CMS announcement read.

This means that telemedicine services are now reimbursed by Medicare and Medicaid at the same rates as in-person services—a change Dr. Brown has been advocating for for a decade.

Before the pandemic, telemedicine hadn’t been widely adopted by physicians, in part because reimbursement for a telehealth visit was typically two to three times lower than it was for an in-person visit, notes Dr. Brown, a former health system director of telemedicine who currently practices family medicine for a Missouri health system that fully blends live patient visits with telemedicine visits.

In addition, the technology required to do telehealth—in order for visits to be HIPAA-compliant—was expensive and often difficult to set up, and figuring out billing and coding for telemedicine visits was also complicated.

All these things have rapidly changed since March 17, Dr. Brown said.

“With all the pandemic stuff that’s going on right now, to me this has been a little bit of a silver lining for our patients,” he says. “We now have a greater ability to give them care through telemedicine.”

To assist physicians who are new to telemedicine, Dr. Brown provided a summary of recent regulatory changes as well as technical tips and videoconferencing advice.

Other very recent changes to telemedicine:

• Ability to see a first-time patient via telemedicine: The Department of Health and Human Services (HHS) has said that it is currently not auditing visits to ensure a prior relationship between a physician and a patient, Dr. Brown said. This effectively means that HHS is waiving this requirement.
• Ability to conduct appointments via FaceTime, Skype, Facebook Messenger and other popular videoconferencing services: Physicians previously needed to use an end-to-end encrypted videoconferencing service and obtain a signed agreement from the software provider prior to conducting visits. FaceTime and Skype are end-to-end encrypted, but physicians don’t have the ability to obtain a signed agreement for their use for telemedicine. Currently, HHS is waiving penalties for HIPAA violations for physicians serving patients in good faith via Skype, Facetime and other videoconferencing services. However, physicians cannot conduct visits using services that stream video to the public such as Facebook Live.
• Many states have enacted emergency changes to support CMS’ changes. A list of state-by-state COVID-19 resources and related regulatory changes is available here.
• Many private insurers have also made adjustments in reaction to COVID-19 to favor telemedicine. A list compiled by America’s Health Insurance Plans is available here. For instance, Blue Cross Blue Shield of Kansas City is now waiving fees for urgent and sick virtual care visits, Dr. Brown said.

Tips for using FaceTime, Skype and other videoconferencing services to conduct telehealth visits

• To bill with in-person codes, the visit must be conducted using audio and video. Physicians can only bill using lower-paying codes for audio-only visits.
• Physicians with iPhones can easily set up their phone to have their work email listed in the caller ID for FaceTime calls so patients don’t get their personal phone number. To do this, they can:
  -Associate their work email with their Apple ID, and then:
  -Change their caller ID in FaceTime settings.

Encouraging patients to try telemedicine

Dr. Brown created a workflow chart to help reception staff understand when to suggest telemedicine to patients when making appointments. He also sits down every morning and reviews all of his appointments for the day. For those that look like they could be done remotely but are scheduled as in-person visits, he has a staff member call the patient and suggest telemedicine.

Other technical/telemedicine tips from Dr. Brown

• Assign a tech-savvy staffer to be your telemedicine check-in person. This person can handle the check-in process with your remote patients via video and ensure that the technology is working on your end and theirs.
• Make sure you have the patient’s contact information so you can call them if you need to. For instance, sometimes video will work but audio won’t. If this happens, you can run the video while having a simultaneous phone call.
• Always keep a headset that contains a microphone in your bag in case you need better audio; iPhone earbuds work great.
• Do not proceed with the visit until you are sure the patient can hear you OK.
• You may find using a workflow chart to guide the visit to be helpful. Here’s what Dr. Brown uses.
• Be mindful of your background: Avoid white boards or screens that might display confidential patient information.
• Try to avoid distractions such as ringing phones, shiny jewelry and clothes in loud patterns.
• Keep your workspace neat and clean.
• Help focus the visit. Ask patients, ‘What are you most concerned about?’ Be sure to address that concern before the end of the visit.
• Be sure to summarize what the patient says to show you are listening.
• Avoid complicated medical terminology.
• Use what Dr. Brown calls the “E-visit Rule of Law:” What would you do at 11 p.m. on a Friday night? “Most physicians have been practicing telemedicine for a very long time—with their telephones,” he says. “When someone calls you at 11 p.m. on Friday, think of what you’d normally do in that scenario.” This can help answer a lot of questions. For instance, what if a patient needs a prescription? (Probably call it in or wait a few days.) What if a patient needs a higher level of care? (Send them to a higher level of care.)
• Get started now. “Telemedicine is keeping patients from being exposed to a potentially lethal virus,” Dr. Brown said. “We need to do everything we can to avoid exposing patients to this virus while still being able to give them high-quality care.”

Q&A

Following his webinar, Dr. Brown took questions. Following are the highlights.

Do you document at the time of the visit, or do you go back and do it later?

I will do a little bit of documentation during the visit. I’ll put my computer right next to my other computer so I can do both at the same time. But for the most part, I just talk to the patient, then do my documentation right after. Typically these are not going to be long visits, so documentation is usually pretty quick and easy.

How do you handle vital signs and do a physical exam with telemedicine?

Ask yourself if you need the vital signs. If you do, the patient should probably be in your office. If you don’t need the vital signs, then proceed how you would without the vital signs.

There’s a lot we can tell without taking vital signs. For instance, if a patient is breathing and talking to you, then you know that they don’t have a serious respiratory problem.

What’s the average duration of the typical telemedicine visit?

It depends on what a patient is being seen for. It’s no more than my inpatient visit. It’s probably less. You might do less chit-chatting during a video encounter. The average diagnosis/history/exam is taking the same amount of time.