How to Create A Successful Orthopedic Telehealth Program For COVID-19 And Beyond
Perspectives from Orthopedic Surgeons
By Alfred Atanda Jr., MD; Reid L. Nichols, MD; Jeanne M. Franzone, MD
A few years ago, we demonstrated that there are several benefits to utilizing telemedicine such as increased patient satisfaction, shorter wait times, and decreased cost for the patient and orthopedic department.1
Now more than ever, is the time to embrace the idea of telemedicine and digital health technology as our ability to evaluate and interact with our patients in-person has been significantly limited during the COVID-19 crisis. However, once social distancing restrictions are lifted, it is very likely that patients will still want the ability to utilize telemedicine in certain situations. There are several key things that one must think about and consider prior to creating a long-term, telemedicine offering for their practice or hospital.
BILLING, LICENSING, AND CODING
There are a few definitions that Medicare uses to describe telemedicine services that one must be aware of.
Originating site – location of patient at the time the service is provided (provider must be licensed in this state)
Distant site – site where provider is located at the time of the service
Synchronous service – remote service performed using live, interactive, real-time communication
Asynchronous service – communication between provider and patient is typically via email or text, not in real-time
Medicare typically mandates that an eligible beneficiary must be seen at an approved originating site and by an approved provider. The visits must be real-time, there must be documented patient consent (written preferable, but verbal accepted), and the documentation must support the level of service.
With COVID-19 crisis, many of these rules and regulations have been lifted, but it’s hard to say at this point if they will be re-enforced once the epidemic is under control.
Depending on the state, coverage for telemedicine services may be none, limited, or broad.
Some states have parity laws that mandate that telemedicine services be reimbursed at similar rates compared to in-person visits. Other key questions to ask individual commercial payors include:
- Which specific services are covered and reimbursed?
- Are there cost-shifting protection measures that prevent payors from shifting excess cost to patients?
- What restrictions on acceptable originating sites exist?
- Is asynchronous telemedicine covered?
- Are there restrictions on patient type (i.e., can new and established patients be seen virtually?)
All 50 states and Washington, DC offer some sort of payment to physicians for synchronous telehealth visits. Currently, 14 states pay for asynchronous telehealth, 22 states pay for remote patient monitoring, and 23 states have restriction limits for where the originating site can be. Stay updated on your state’s Medicaid rules regarding telehealth at www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies#.
One of the basic tenets of telehealth is that the provider must be licensed in the state where the patient is located at the time the service is provided. The Interstate Medical Licensing Compact has been created as an expedited pathway to licensure for qualified physicians who wish to practice in multiple states if desired. The same exists for physical therapists. We recommend that you contact your individual state licensing board for further information and verify whether your state has enacted legislation related to the licensure compact at ptcompact.org/ptc-states.
In order to code telehealth services appropriately, standard current procedural terminology (CPT) codes should be used similar to in-person visits. A place of service code (POS) should be used to identify the location where health related services are provided or received. POS 02 is utilized to refer to a telehealth visit. Appropriate modifiers should be used to append the CPT code to indicate which type of telehealth service has been provided. Modifier “95” is used for synchronous telehealth and modifier “GQ” is used for asynchronous telehealth.
For the purpose of most practitioners, any device with a camera and a microphone will suffice. Mobile phones, tablets, laptops, and desktops are all reasonable options. With the initial telehealth offering, we recommend the utilization of devices that are already available to providers to minimize cost expenditure and administrative burden.
Most exiting telehealth platforms offer much more than what the average practitioner requires to complete telehealth visits, so try to keep things simple. Some other important features to look for include a virtual waiting room, text/email notification and scheduling, billing and payment collection capabilities, and the ability to screen share to facilitate image review. It may be helpful, although not necessary, to invest in a platform that can easily integrate into your existing electronic medical record.
You want to make sure that the platform you are using is HIPAA-secure. What this means is that the covered entity (hospital or practice) and the software vendor (business associate) have signed a “Business Associate Agreement” (BAA). The BAA outlines the type of protected health information (PHI) that will be transmitted over the platform, the allowable uses and disclosures of the PHI, the measures taken to protect the PHI, and most importantly, the steps
that will be taken in case of a PHI breach. During the COVID-19 outbreak, non-HIPPA secure platforms such as Zoom, FaceTime, and Skype will be temporarily permissible, however, it is not recommended to rely on such platforms
as a long-term, telehealth solution.
Your administrative and clinical team will most likely be responsible for explaining to your patients what telehealth is, scheduling them for their appointments, and also ensuring that they can connect to the platform easily. Ideally, you would have real-time IT support to help with any audiovisual glitches that may arise during a telehealth visit, however, when you start with this service, you may be on your own when it comes to troubleshooting.
It’s helpful to start off doing these visits early in the morning, after hours, or during your administrative time. With more experience, you can then schedule them in conjunction with your traditional clinic visits. During the visit, you want to make sure that you have access to a mobile phone, a regular phone, and potentially a laptop or desktop. It’s helpful to have multiple ways to interact with the patient, both audibly and visually, should your primary hardware device stop working.
APPROPRIATE PATIENT SELECTION
We would recommend that you start with established patients that you have previously evaluated and examined, have a good rapport with, and have a relatively simple problem. In this situation, you will already be familiar with the patient’s primary complaint and limiting factors which will allow you to address their needs more easily.
Whether it’s to get through the COVID-19 pandemic or to create a long-term digital health solution, you have to do your homework before you implement telehealth into your existing practice. Make sure to review state and federal guidelines, policies, and resources to ensure that you are billing appropriately and are in compliance with the legal and licensing regulations in your state/region. As with any new endeavor, you to have remain patient and flexible, as successful implementation and integration will not happen immediately. We do think telehealth is a great way to keep our patients, staff, and providers safe during social distancing. More importantly though, we think offering telehealth is a great way to stay relevant within the evolving healthcare landscape, to provide convenient, high-quality care, and to re-imagine how we deliver care to orthopedic patients.
1Atanda A, Pelton M, Fabricant PD, Tucker A, Shah SA, Slamon N. Telemedicine in a Pediatric Sports Medicine Practice: Decreased Cost and Wait Times and Increased Satisfaction. JISAKOS. 2018;0:1–4. doi:10.1136/jisakos-2017-000176.
Reid L. Nichols, MD, FAAOS, is a pediatric orthopedic surgeon that specializes in clubfoot, arthrogryposis, and limb deformity and practices in Wilmington, Delaware. Jeanne M. Franzone, MD, is a pediatric orthopedic surgeon that specializes in limb deformity and brittle bone disease and practices in Wilmington, Delaware.