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Telemedicine Moves From Niche to New Normal

      GRAPEVINE, TEXAS — In a world where there is a shortage of practitioners and specialists, as well as tight budgets and growing pressure to keep patients out of the hospital, telemedicine increasingly is a promising tool to enable quality, cost-effective care.
      “Telemedicine has the potential to be the new norm,” said Steven Handler, MD, CMD, chief medical and innovation officer for Curavi Health, during a session at AMDA — the Society for Post-Acute and Long-Term Care’s Annual Conference.
      Dr. Handler defined telemedicine as “the use of telecommunication and information technologies in order to provide clinical healthcare at a distance.” He referred to four types of telemedicine: interactive services (synchronous), store-and-forward (asynchronous), remote monitoring (self-monitoring), and mHealth (mobile devices).

      CMS Says “Yes” to Telemedicine

      The Centers for Medicare & Medicaid Services has only fairly recently embraced telemedicine, and now there is a whole list of Medicare-covered services that can be provided via telemedicine, including nursing facility subsequent care visits, advance care planning, follow-up visits, annual depression screenings, and caregiver health risk assessments. CMS has acknowledged the role of telemedicine to provide such services and has made recent significant changes in telemedicine billing. Practitioners should be aware of these coding issues for the types of services most commonly provided in PA/LTC:
      • For subsequent nursing facility services, use the Subsequent Nursing Facility Care CPT E&M codes 99307-10 and include the GT modifier. As of January 2017, practitioners must use Place of Service (POS) 02: Telehealth. Ensure that the resident’s history and physical records meet all requirements for that particular CPT E&M code and that this is documented in the nursing home medical record. The use of this code is limited to one visit per resident every 30 days.
      • For advance care planning services, use CPT E&M codes 99497 (first 30 minutes) and 99498 (each additional 30 minutes). Include the GT modifier and POS 02 for telehealth. Ensure that the resident’s history and physical records meet all requirements for that particular CTP E&M code and that this is documented in the nursing home medical record. There is no limit on the number of times advance care planning can be reported for a given beneficiary in a given time period.
      • For psychiatric diagnostic evaluation only, use CPT E&M code 90791, and for psychiatric diagnostic evaluation combined with medical assessment, use CPT E&M code 90792.
      As a condition of payment, “you must use an interactive audio and video telecommunications system that permits real-time communication between you at the distant site and the beneficiary at the originating site,” Dr. Handler said. Asynchronous “store-and-forward” technology, he said, is permitted only in federal telemedicine demonstration programs in Alaska or Hawaii.
      CMS has some specific technical specifications for telemedicine:
      • A standard system should include a mobile medical cart with the ability to hold a PC, supplies, diagnostic medical equipment, and a rechargeable battery.
      • The system should include real-time interactive audiovisual — not store-and-forward — technology.
      • All the equipment should be connected using a Health Insurance Portability and Accountability Act of 1996 (HIPAA)–compliant, secured wired or wireless system.
      A facility practicing telemedicine also requires a full-duplex speakerphone, at least one high-performance optical zoom camera, low light, a pan/tilt/zoom camera, a high definition webcam, an electronic stethoscope, a digital otoscope, and a PC-based resting 12-lead system.

      See and Say: Sites of Service

      An originating site is defined as the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunication system occurs. Originating sites authorized by law are physician/practitioner offices, hospitals, critical access hospitals (CAHs), rural health clinics, federal qualified health centers, hospital- or CAH-based renal dialysis centers, community mental health centers, and skilled nursing facilities.
      Professionals who can receive Medicare reimbursement for telemedicine services as distant site practitioners are limited to physicians, physician assistants, nurse practitioners, nurse midwives, clinical nurse specialists, clinical psychologists, clinical social workers, and certified registered nurse anesthetists.
      “Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a county outside of a metropolitan statistical area, or a rural health professional shortage area located in a rural census tract,” Dr. Handler noted.
      Dr. Handler conducted two studies about nursing home providers’ perceptions of telemedicine and found that there is tremendous support for the use of telemedicine in this setting. For the first study, he surveyed 435 physicians and nurse practitioners who attended the 2015 Society Annual Conference. The responses suggested “that there is potentially unmet demand for telemedicine and that nursing homes may be receptive to appropriately designed solutions.”
      “There is a clear need to focus on the sociotechnical aspects of implementation and continued use of telemedicine to ensure its continued use through a high structured change management process,” Dr. Handler said.
      The goal of Dr. Handler’s second study was to determine the perceived utility of providing specialty telemedicine in nursing homes. For this, he surveyed 522 physicians and nurse practitioners at the 2016 Society Annual Conference. The respondents identified five specialties that they would refer to telemedicine: dermatology, geriatric psychiatry, infectious disease, neurology, and cardiology. The majority of respondents agreed that telemedicine could help fill an existing service gap, improve the timelines of resident care, increase access to appropriate care, decrease hospitalizations, and increase the overall quality of care.
      “There is good evidence on the use of telemedicine for condition-change management. We see opportunities for new ways to manage patients in place with telemedicine.”
      Telemedicine holds great promise for enabling practitioners to care for residents on site when they have acute changes, Dr. Handler said. “There is good evidence on the use of telemedicine for condition-change management. We see opportunities for new ways to manage patients in place with telemedicine.”
      Dr. Handler acknowledged that telemedicine would not replace face-to-face interactions, but “it can be particularly useful for after-hours and weekends when there isn’t a practitioner in the facility,” he said. Instead of sending a patient to the hospital based on information from a phone call, the telemedicine “visit” can enable the practitioner to make a more accurate assessment regarding the potential to manage the change onsite.
      Dr. Handler noted that advance preparation is necessary before adding a telemedicine component to a nursing home facility. For example, he recommended facility credentialing for centers that provide telemedicine service. Practitioners also need to be licensed to practice medicine in the states where the telemedicine services are being offered, he said. He noted that it is possible to apply for cross-state licensure; however, each state has its own requirements, so it is essential to know the rules in any state where you will be using telemedicine.
      Practitioners and facilities will face some ethical issues if they adopt telemedicine, said Dr. Handler, such as who should be in the room with the patient during the interaction and what diagnoses or conditions should not be treated via telemedicine.
      Joanne Kaldy is a freelance writer in Harrisburg, PA.