The Complete Guide to Telemedicine [COVID-19]

The Coronavirus has catapulted the world into a global pandemic, but this was predicted in 2015 by one of the brightest minds of our times – Bill Gates. In a TED presentation titled, ‘The Next Outbreak? We’re Not Ready,’ Gates chillingly refers to the biggest threat to humanity – a virus that could travel the world in a matter of weeks and kill millions. If you wanted proof that people can predict the future, then this is it. 

The coronavirus in less than six months infected nearly 600,000 people globally, with more than 27,600 deaths ( as of March 28, 2020). The United States, which is the most affected country, has over 100,000 confirmed coronavirus cases with more than 1700 deaths.

The virus spreads from human-to-human contact. Droplets from sneezing and coughing by an infected person can survive on copper and steel surfaces for a couple of hours and other surfaces such as cardboard and plastic for much longer.  In March 2020, the WHO issued guidance that in a hospital environment, the COVID-19 can become aerosolized and be airborne, which poses a heightened risk for healthcare workers.

Without a cure for the virus, the U.S. government has urged people to stay indoors as much as possible. People are being told to avoid social gatherings and work from home for the next few weeks. The hope is that restricting social contact will slow the spread (i.e., flatten the coronavirus curve). That will give the country’s healthcare system the ability to cope with existing cases and the time it needs to ready itself for handling many more.

While doctors and nurses want to care for patients, they must also safeguard themselves and other people visiting medical offices and hospitals. In such circumstances, the use of adequate PPE (personal protective equipment) and adopting remote healthcare services such as telemedicine has become imperative to delivering safe medical care.

Recognizing the criticality of delivering medical care swiftly and safely, on March 6, President Trump signed into law the, Coronavirus Preparedness and Response Supplement Appropriations Act of 2020.’The law accorded Department of Health & Human Services’ (HHS) Secretary Alex Azar the authority to ease restrictions for U.S. physicians and hospitals to offer Medicare telehealth services.

Easing of restrictions in telemedicine billing to tackle the COVID-19 crisis

For information on coverage and payment related to COVID-19 Medicare, refer to this CMS.GOV factsheet.

If you are authorized to offer Telehealth services for Medicare beneficiaries, now is the time to encourage patients to use virtual medical checks. Anyone who shows flu-like symptoms such as fever, headaches, and cough should be encouraged first to contact you via telehealth. A telemedicine visit will allow you to advise the patient on the precautions they need to take when they come to your office, or when they visit a hospital for further diagnosis.

If you have been on the fence about offering telemedicine, now is the time to act swiftly to adopt the technology. 

In the weeks and months ahead, telemedicine will be essential to –

  • Offering medical consultations to as many people as possible 
  • Safeguarding your other patients, yourself, and your healthcare staff 
  • Reducing your work stress as your client base expands
  • Lowering the cost of operation for physician practices
  • Ensuring business continuity of your practice, both now and in the years to come

Practices that want to implement telemedicine will undoubtedly have many questions.

  • How will the practice benefit from implementing telemedicine? 
  • How will patients benefit? 
  • What are the steps to implementing telemedicine? 
  • And, most importantly, how does one bill for telemedicine?

The following sections in the handout will help answer these concerns. 

So let’s begin unlocking the world of telemedicine and the promise it holds for physician practices of all types and sizes.

What is Telemedicine?
The World Health Organization (WHO) defines telemedicine as “Healing from a distance.”

Telemedicine involves providing healthcare services to a person who is not in the same physical location as the physician during the consultation. Telemedicine services include exams, consultations, diagnosis, follow-ups, medication management, and specialist consultation without an in-person visit by the patient using secure real-time video calls.

A telemedicine appointment typically involves the patient downloading a telemedicine app and sharing their medical history prior to the actual telemedicine appointment. At the scheduled time, both the patient and physician access the telemedicine app, and the evaluation begins. At the end of the virtual appointment, the physician advises the next course of action – such as recommending an over-the-counter medication, filling a prescription, recommending further testing, or an in-person visit for further evaluation.

If you look at the definition per se of telehealth and telemedicine, then yes, there is a difference between the two terms.

Telehealth is a broader term than telemedicine.

Telemedicine is the delivery of medical care by a physician without an in-person visit by the patient. On the other hand, telehealth refers to the electronic and telecommunication technologies and services used to provide telemedicine. In the early days of the technology, telehealth also included services such as remote medical education, training, and administrative meetings.

However, today the two terms – telemedicine and telehealth – are pretty much used as synonyms. Other terms for remote medical consultation are virtual care, tele-visit, and eCare.

Types of Telemedicine Technologies

There are three categories of telemedicine

  • Real-time telemedicine:These telemedicine apps allow physicians and patients to communicate in real-time. The patient could be at home using an app such as Doxy.Me or any other video conferencing software that complies with HIPAA regulations. Real-time interactive videos are the most common interpretation of what constitutes telemedicine.

As mentioned in the introduction, you can now (until further notice) use apps like Facetime and Skype under the revised Medicare claim conditions introduced to combat the coronavirus outbreak.  

  • Remote patient monitoring – Physicians use remote patient monitoring to track a patient’s vital signs ( temperature, blood sugar levels, blood pressure) and activities. Remote monitoring is often used to monitor high-risk patients who have been recently discharged from the hospital or patients who suffer from chronic conditions such as diabetes.
  • Store and forward telemedicine– Known also as asynchronous telemedicine, this is when physicians use a secure portal to share patient information like lab results, imaging studies, videos, and other patient data. Store and forward telemedicine facilitate collaboration between general physicians and specialists.

Here’s an interesting infographic on the history of telemedicine (by eVisit, a telemedicine company).

Telemedicine – Rising Star of the U.S. Healthcare Industry

While the coronavirus pandemic has brought telemedicine into the limelight, statistics show that telemedicine has, for some time, been the rising star in the U.S. healthcare industry. 

Here are statistics in support of that statement.

Benefits of Telemedicine – Patients and Providers

The growth of the U.S. telemedicine industry points to one thing – the way we deliver medical care is going to change fundamentally, for practices of all types and all sizes. Providers that fail to adopt this technology will be ill-prepared to meet patient expectations on standards of medical care.  

Telemedicine is already being used effectively for the following types of medical services – 

  • Follow-up visits 
  • Chronic disease management 
  • Post-hospitalization care 
  • Preventative care support
  • Assisted living center support
  • Offering medical care for schools 
  • Common health issues such as cold and flu, insect bites, sore throat, diarrhea, and pink eye

Here are the crucial benefits telemedicine offers for patients and providers. 

Benefits of Telemedicine for Patients

  1. Affordable medical care – In-person consultations tend to be more costly as the doctor is more likely to prescribe further tests or follow up visits. Also, there are now telemedicine apps that offer online consultations with physicians at affordable rates; such services are highly beneficial for people with limited insurance cover.
  2. Greater convenience – In virtual consults, patients save on the trouble of traveling to the physician’s office. Some benefit from not having to take time off from work to see a doctor. For households with young kids, it’s the ability to connect to a doctor without worrying about a baby-sitter.
  3. Save time: Telemedicine consultations tend to be of shorter duration than in-persons meetings with a physician. Both the patient and doctor are more likely to stick to discussing the medical issue and avoid making small talk.
  4. Greater accessibility. Websites like Teladoc, American Well, and Doctor on Demand offer access to a physician around-the-clock. It makes it much easier for patients to consult specialists located in other states. Telemedicine makes healthcare more accessible for patients with mobility issues, mental health issues, or issues with substance abuse. 

Benefits of Telemedicine for Providers

  1. Compliment face-to-face medicine: The aim of telemedicine is not to replace the doctor-patient relationship, but to supplement it by making it easier to do follow-up visits, prescribe medication, alleviate interim concerns, and offer medical care at the convenience of patients.
  2. Treat more patients – Telemedicine gives a physician greater geographical presence, lowers the per-patient time, and makes it easier to handle special care patients; this in turn, allows the physician to treat more patients.
  3. Future revenue growth – With tech-savvy customers expecting greater convenience, you will lose patients and fail to attract new ones if you don’t offer the convenience of telemedicine. 
  4. Increased patient engagement – Telemedicine makes it easier for patients to stick to recommended routine health checks and therefore stay in better health. Patients are less likely to cancel an online appointment because they can take that call from anywhere. 
  5. Operational efficiency – Offering telemedicine consultations is highly cost-effective in comparison to the overheads of staffing and space required to handle the same capacity of in-person patients at your medical office.
  6. Improve patient experience – Offering telemedicine as one of the channels of consultations is highly likely to improve patient’s perception of your medical practice. Even those who don’t use the service would like to at least have the option of exercising a telemedicine visit at some time in the future. In fact, telemedicine apps that include services such as appointment booking and medical history are known to positively influence patient assessments about the continuum of care.
  7. According to a 2015 study shared by the National Center for Biotechnology Information, telemedicine patients tend to have fewer hospital admissions and are more engaged in their healthcare.  
  8. Stay competitive – With an increasing presence of round-the-clock physician websites, brick and mortar practices cannot afford to ignore telemedicine as a channel of service. While the low levels of Medicare reimbursements for telehealth calls were a deterrent in the past, that is no longer the case; do check with your medical billing company on the revised billing rates for telehealth calls. 
U.S. Telemedicine Adoption Trends as Per Specialty

Despite the business numbers and the benefits of telemedicine for providers and patients, the use of telemedicine has remained an exception rather than the rule. According to a J.D.Power July 2019 press release, almost 75% of Americans say they are unaware of or lack access to telehealth options. 

According to a 2016 Physician Benchmark Survey of the AMA (American Medical Association), specialists most likely to use telemedicine are radiologists, psychiatrists, and cardiologists. Specialists who are least likely to use telemedicine are allergists/ immunologists, gastroenterologists, and Ob-Gyns. Emergency physicians, pathologists, and radiologists are most likely to use telemedicine to interact with other healthcare professionals.

A more recent study on the use of telemedicine by specialty was published by Doximity.com in July 2019. The study looked at applications received for telemedicine jobs as per specialty to evaluate which medical specialties were more likely or least likely to use telemedicine.

Outdated Concerns on the Use of Telemedicine

Technological advancements over the last decade, have made telemedicine easy to implement and affordable. Yet the rates of telemedicine use by U.S. physicians is nowhere where it should be. Some of the reasons why U.S. physician practices have been vary of telemedicine are as follows –

  • Concerns about the compliance of telemedicine software with HIPAA regulations for electronic transmission of medical information.
  • The requirement to have a practicing license in the state where the telemedicine client is located.
  • The need to have an established face-to-face doctor-patient relationship before offering telemedicine to be able to claim insurance.
  • Lack of understanding of what medical services can be provided via telecommunication.
  • Lack of clarity on how to bill telemedicine.
  • A belief that telemedicine insurance claim rates are significantly lower than in-person visits for the same medical purpose.
  • Additional risk of malpractice lawsuits.

However, many of these concerns are no longer relevant.

  • A physician practice can consult a medical billing and revenue management company that understands telemedicine billing. The medical billing company can train the physician staff on state-specific telemedicine regulations and the billing codes for claiming telehealth calls.
  • Most telemedicine apps available today are HIPAA compliance certified.
  • As for the risk of malpractice associated with telemedicine, most insurance providers are willing to offer coverage options.
  • The reimbursement rates for a medical issue are now almost the same for telemedicine calls and in-person visits.

With the COVID-19 crisis (and the concomitant easing of telehealth claim restrictions), the adoption of telemedicine is poised for its highest levels of growth since the technology was introduced almost seventy years ago. Those in the U.S. physician community who have been reluctant to offer telemedicine will now find that telehealth services will become a must-have.

Teledoc Health CEO Jason Gorevi, in a recent interview with CNBC, confirmed that the company received 100,000 patient visits in the first week of March 2020, and more than half of the virtual visits were from first-time users of the portal. As of March 2020, Doctor-on-Demand, a portal that offers online physician advice at $50 to $70, was looking to recruit about a hundred doctors to keep up with the demand for telemedicine consults.  

Even if the present surge in telemedicine is due to the coronavirus outbreak, it is unlikely that the demand for telemedicine in the U.S. will ever drop back to the pre-pandemic levels. Once a person has used telemedicine, they are highly likely to continue to use it for future scheduled medical checks and minor ailments. Therefore, telemedicine will have a direct and significant impact on practice revenues now and in the years to come.

Five Steps for Effective Telemedicine Implementation

With telemedicine poised to become a primary channel for delivery of healthcare, every brick and mortar physician practice that is not currently offering this service must now prepare to do so. The following are the X steps for implementing telemedicine for a physician practice:

Step 1. Assess Your Telemedicine Requirements

Normally, you would need to assess the types of queries that can be successfully migrated to telemedicine consultation. But in the scenario of coronavirus pandemic, the question to ask is not ‘what,’ but ‘how’ to manage the bulk of your patient consultations via telemedicine. 

List the types of consultations you can migrate to telemedicine. What volumes of telemedicine do you anticipate? Do you want a stand-alone telemedicine app or an app with advanced features such as integrated medical records?

Assess your patient base by age group, medical conditions (e.g., chronic diseases like diabetes or high blood pressure), and geography. Depending on this information, you may want to target a particular group first for telemedicine migration. To encourage the use of telemedicine, the style and mode of communication you use for different patient groups will have to differ. For example, for chronic illness, mental health, and substance addiction cases talk about the importance of regular check-ins and ‘anywhere’ access. For patients over 65 years and those with reading disabilities, make phone calls or share audio content explaining how to use the telemedicine software.

  Step 2. Get a Market View

As you review your processes, take a look at what the competition is doing in your area. What types of consultations are they offering via telemedicine? Ask other physicians in your network who have implemented telemedicine in their practice on the challenges faced both with the internal customers (staff) and external customers (patients) in switching to the new technology. What were the concerns voiced by these groups? Did they face any problem with billing? Which telemedicine software are they using, and how easy was it to implement? 

   Step 3. Create a Migration Team

Leadership and accountability are essential to the successful implementation of telemedicine. For smaller practices, there is likely to be only one physician and a handful of support staff. But for larger group practices, nominate one person in the leadership role for the migration to telemedicine. Ensure that you include representations from all departments (nursing assistants, IT, finance, legal, and front-office), and your medical billing vendor in the telemedicine implementation team.

   Step 4. Compare Telemedicine Applications

Once you have an understanding of what others in the business are doing and the specific needs of your practice, it is time to choose a telemedicine application that works best for you. Before you scour the market, check with your medical billing company for existing telemedicine functionalities in your billing software. Also, what telemedicine apps does the medical billing company recommend for your practice?

As you evaluate the available telemedicine applications options, compare the following:

  • What is the cost involved? Upfront implementation cost could be desktop and laptop units with high-quality cameras and microphones. The recurring costs could be additional bandwidth for quality video streaming, the app subscription fee per user per month, and the cost of additional IT security measures.
  • Training support from the telemedicine company. You will need to train staff as well as ensure adequate support for patients logging into the telemedicine app for the first time.
  • Telemedicine company reputation. Read online reviews about system functionality, ease of use, frequency of software updates, and troubleshooting support provided by the company.
  • Time to implement the software.
  • Does it work seamlessly across all types of mobile devices?
  • How many users can the app support? (Relevant for large practices)
  • Apart from HIPAA compliance, what state-of-the-art security features does the app have to protect patient data such as medical records and credit card information? What additional security features does the app offer for portable devices such as laptops and mobile phones?
  • Does it integrate with your EHR software, or is it a stand-alone telemedicine system?
  • Any add-on-features (e.g., does the platform have a patient portal?)

     Step 5. Develop an Implementation Plan

Once you have selected a telemedicine app, chart an implementation plan. Here are some pointers:

  • Have regular review meetings with the staff to ensure preparedness and buy-in.
  • Schedule staff training sessions.
  • If you work with an external medical billing company, seek their inputs early on and involve them in the system testing and staff training.
  • Conduct test telemedicine calls (with your staff and medical billing vendor) before you go live with telemedicine consultations.
  • Decide on when you should start communicating the new service to your clients.
  • Prepare the patient communications – emails and telephone call spiels for staff.
  • Once you go live with the telehealth service, agree with the medical billing company for a period of close monitoring; this is important for ensuring that you have adequate support to handle unforeseen issues.
Three Telemedicine Apps That Work For Every Practice

As a medical billing and revenue management company serving physician practices across America for the last sixteen years, we recommend the following three telemedicine software.

AdvancedMD – It is a comprehensive EHR Software that includes practice management, electronic medical records, patient engagement, telemedicine, reputation management, financial analytics, and business reporting. It works on Mac and Windows operating systems. The system can be accessed via an iPhone, iPad, and Android mobile app. The AdvancedMD telemedicine app is ideal for small and medium-sized physician practices. The company does not have standard pricing and has to be contacted for a quote.

AdvancedMD features other than telemedicine are –

  • iOS Mobile Apps
  • High-priority checkbox
  • Electronic-faxing
  • E-prescriptions
  • EPCS
  • Clinical decision support
  • Clinical charting
  • Patient portal
  • Physician dashboard
  • Customizable templates
  • Immunization reporting
  • MACRA and MIPS compliant
  • HIPAA compliant e-prescribing
  • Automatic reminders
  • Customizable health plans
  • Parameter-based triggers
  • Secure document exchange
  • Customizable reports
  • Visual note designer
  • Handwriting recognition
  • ONC-ATCB compliant

eClinicalWorks – Another popular integrated EHR software that includes televisits, population health, financial analytics, patient engagement, customizable documentation options and charts, data analysis, credit card on file payments, and interoperability.

eClinicalWorks features –

  • Runs on Mac, Chrome, and Windows
  • Integrated EHR, Population Health and Patient Engagement
  • Health and Wellness Tracking Data
  • Integrated Telehealth Visits
  • Intuitive UI
  • Patient Charting
  • Patients Portal

Cost of software –

  • EHR Only – $449/month/provider
  • EHR with practice management – $599/month/ provider
Watch Practice Forces CEO Kunal Jain interview Dr.Eunus on the ease of use of Doxy.Me

Doxy.Me  

Many of our physician clients who want a simple, affordable telemedicine solution opt for Doxy.Me. It is a telemedicine app that allows patients to log in to the telemedicine call by clicking on a link shared by the physician via email or text. Physicians can view appointments, check patient queue, patient history, and send communication to patients via text, video, and images. Apart from the ease of use, the other attractive feature is the pricing. 

Cost of software –

  • Individual providers – $35/month/provider 
  • Clinics – $50/month/ provider 

Upgrade plans are available for both individual physician providers and clinics. 

Billing for Telemedicine
Documentation requirements for telehealth insurance claims are the same as an in-person claim. However, you need to ensure that you use the code 02 (in-office consults) for the place of service, along with the modifier 95.  

Under normal circumstances, telemedicine reimbursements vary as per the state, practice and payer. Also, the state regulations are in a constant change of flux. Therefore, it’s imperative that you understand the guidelines for medical coding and billing for telemedicine calls for your practice before you go live with telemedicine.

For billing purposes, to indicate the telemedicine consult as a non-in-person visit, append the E/M (evaluation and management) code with a modifier. The rest of the procedure is the same as for any other claim. Here is the comprehensive list of codes for Medicare telemedicine services.

As a result of the COVID-19 crisis, sweeping changes have been made in restrictions that existed (under normal circumstances) for billing telehealth calls.  

At the time of writing of this telemedicine paper, those easing of restrictions are materializing. Therefore, it has never been easier to bill telehealth calls

Here are useful resources for billing of telemedicine during the coronavirus crisis –

Conclusion

The COVID-19 healthcare crisis has confirmed one thing – we are all connected as human beings. A disease that originates in one part of the world can quickly travel across the globe and affect us all.  The coronavirus impact is not restricted to the physical aspect of our lives; it has had major social and economic ramifications for billions across countries. The pandemic has rendered millions of Americans jobless, and consequently, left them with limited or no access to healthcare. Environmentalists and health experts predict that the coronavirus is the start of a new kind of dangerous virus invasion that humans will see more of as we overpopulate and overconsume.

Looking ahead, the U.S. healthcare industry must prepare itself to deliver medical assistance with greater agility, precision, and affordability.  Telemedicine is a technology that will be crucial for physician practices, clinics, and hospitals to be more accessible and effective at delivering healthcare.

Do you need help with implementation of telemedicine?

Do you have concerns about how telemedicine can boost your practice revenue?

Do you have any questions on telemedicine billing?

We would be happy to help. Book a free consultation on telemedicine implementation and boosting your medical billing revenues in a challenging economy. Contact us today.