Chad Ellimoottil, MD, MS

Dr. Gadzinski is a senior fellow and acting instructor of urologic oncology, University of Washington, Seattle; Dr. Ellimoottil is assistant professor of urology, University of Michigan, Ann Arbor; Dr. Odisho is assistant professor of urology, University of California, San Francisco; Dr. Watts is assistant professor of urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Dr. Gore is professor of urology, University of Washington, Seattle. 

 Dr. Odisho had a prior consulting relationship with Vsee from January 2019 to January 2020.

In response to the COVID-19 pandemic, multiple emergency measures have dramatically changed the policies and requirements for telemedicine in the United States. On March 13, 2020, Secretary of Health and Human Services (HHS) Alex Azar authorized waivers and modifications under Section 1135 of the Social Security Act, retroactive to March 1, 2020, to lift telemedicine restrictions. Medicare Part B beneficiaries are now eligible to participate in video visits from any location, including their home, 

We aim to briefly summarize these changes, provide resources for urologists (from 

), and give practical guidance for quickly launching or scaling a telemedicine program. We primarily focus on video visits, which are live simultaneous audio and visual interactions with patients via a videoconferencing platform. (Also see a summary of updated Medicare Part B policy on video visits in the table below.)

Given that most urologic outpatient visits are non-urgent, almost all in-person visits should be eliminated out of appropriate concern for COVID-19. Continuing urologic care now will mitigate the later surge of patients needing care once this crisis is over. Video visits may also provide some financial stability to urology practices during this time when surgical reimbursements will be greatly reduced. Finally, with uncertainty surrounding the duration of the current State of Emergency and the enacted telemedicine changes beyond this emergency period, investing in telemedicine now will likely benefit urologists in the long term.

Several platforms can be used to perform video visits. Most insurance companies require that the visit has an audio and visual component for real-time communication. A desktop, laptop, smartphone, or tablet can all be used as long as they have a webcam and microphone. The visit should be performed through a reliable and secure platform, which can be integrated into the electronic medical record or be a stand-alone product. Many platforms, such as Skype for Business, Updox, VSee, Zoom for Healthcare, Google G Suite Hangouts Meet, and Doxy.me meet HIPAA compliance requirements.

During the COVID-19 pandemic, the HHS Office for Civil Rights announced that providers can use non-HIPAA-compliant tools to deliver medical care. Because this federal rule may not impact individual state's laws, providers should prioritize a HIPAA-complaint platform. This will allow for sustainability of new telemedicine programs post-pandemic.

Billing and documentation for video visits

Physicians should follow standard guidelines for documenting and billing video visits, with three key differences. First, the physical exam for video visits will be limited. Although established patient billing criteria does not require a physical exam, the absence of a physical exam limits the ability to achieve Level 4 and 5 billing for established and new patients. Therefore, it is generally recommended that time-based billing be used and documented. Second, the claim should include a Place of Service = 02 or a modifier code (GT/95) to indicate the service was performed using telemedicine. While Medicare does not require a modifier code, several private payers require this code. Lastly, provider documentation should include that the visit was conducted via a live face-to-face video conference, the location of the patient (originating site), and the provider’s location (distant site).

Insurance reimbursement for video visits varies among payers. Most will reimburse for video visits, but coverage is limited to select locations. Historically, payers required patients to be physically located in a rural medical facility or a designated Healthcare Professional Shortage Area during the video visit. This requirement has been relaxed by many private payers, and coverage from any location (including the patient’s home) is common. In 29 states, Medicaid does not require patients to be in a specific location for the visit.

More states are permitting visits from home during the COVID-19 emergency (

see this page from the Center for Connected Health Policy

). Medicare has historically been the most restrictive on this requirement. However, during the COVID-19 pandemic, 

 and allows patients to connect from home.

Most states have specific policies regarding telemedicine use. These include documenting informed consent for telemedicine visits in the visit note, limiting some medication prescriptions (mainly narcotics), and requiring a medical license in the patient’s state of residence. The Center for Connected Health Policy 

 lists each individual state’s laws and policies alongside emergency laws during the COVID-19 crisis. Providers should understand their state’s policies prior to performing telemedicine visits. Although 

 that providers with an active non-restricted medical license can provide interstate care without a license in that state, 

some states require providers to submit an emergency application

 prior to practicing telemedicine in their state.

Providers should familiarize themselves with their video conferencing platform. We recommend conducting a mock visit to practice initiating and ending a visit and to test screen sharing to display radiology images or diagrams. Patients will invariably have some technical difficulties, and knowing how to troubleshoot with patients is crucial (eg, helping patients turn on video or unmute their microphone). Providers should conduct the visits from a secure location to ensure privacy. Headphones or earbuds may be needed.

Logistical workflow also requires thoughtful implementation to prevent frustration for patients and providers. We have our office staff contact the patient when scheduling the appointment to ensure that the patient understands how to download needed software and log in for the video visit. There are several 

 to walk patients through telemedicine setup. Many platforms allow for multiple users to join a visit, which can be used to involve family members or a professional language interpreter.

In some circumstances-the patient may not have the capability to perform a video visit, a scheduled video visit may fail, or a health system may not have invested in video visit infrastructure-a phone call may be used in lieu of a video visit. Due to the imperative to keep non-urgent patients at home during the COVID-19 pandemic, many providers are opting for telephone calls. Phone calls can be billed CPT 99441-3 and must include a time attestation. Typically, Medicaid does not reimburse telephone calls, though 

some states have made emergency exceptions

. For Medicare, G2012 is the appropriate code for telephone services 5-10 minutes long; there is no higher level for longer conversations.

The State of Emergency for the COVID-19 pandemic has created an environment where urologists can continue to safely provide care through telemedicine. We hope this article helps urologists successfully implement telemedicine and video visits. This will maintain safety both for our patients and for the health care workers in our offices.

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Articles

"Given that most urologic outpatient visits are non-urgent, almost all in-person visits should be eliminated out of appropriate concern for COVID-19," advise Drs. Gadzinski, Ellimoottil, Odisho, Watts, and Gore.

Telemedicine in urology: A crash course during the COVID-19 pandemic

	Telemedicine is considered the fastest-growing segment of the health care market. Defined as the use of telecommunications software to diagnose and manage medical disease, telemedicine can be implemented through modalities such as video-conferencing software, mobile applications, and wearable devices. While telemedicine has been around for decades, a recent boom in utilization has occurred as physicians and health systems invest in the technology and payers increasingly provide reimbursement.

	Among the many areas of telemedicine, a key opportunity exists for urologists in video visits, or “direct-to-consumer” telemedicine. Video visits (also called virtual visits, televisits, or evisits) have increasingly captured the attention of many physicians as an alternative to the traditional clinic visit. A video visit occurs when a physician conducts a medical interview or counseling session with a patient using video-conferencing software, such as Skype. At the University of Michigan, members of our faculty have used video visits as a way to expand capacity in our ambulatory care clinics without compromising quality of care.

While telemedicine has existed for decades, legislative and policy changes have facilitated the growth of video visits in a new way-

Until recently, most commercial and government payers required that video visit patients be located in a health professional shortage area and that the visit be conducted from an approved medical facility. As one can imagine, these burdensome requirements once dampened the growth of video visits.

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	However, in the last several years, many of the nation’s largest commercial payers (eg, Blue Cross Blue Shield, Aetna, and UnitedHealthcare) have started to reimburse providers for conducting video visits with patients located at home. In addition, Medicare has waived some of the burdensome restrictions for physicians at health systems that participate in alternative payment models.

	The Department of Veterans Affairs (VA) is widely recognized as a national leader in telemedicine. VA hospitals spent $1.2 billion and conducted two million telemedicine consultations in 2016 (Federal News Radio [May 8, 2017]; 

Investment in telemedicine at the VA has been supported by multiple studies that have demonstrated high levels of patient satisfaction and convenience 

Since April 2016, the urology department at the University of Michigan has implemented video visits in the outpatient urology clinic. Patients are scheduled for video visits using the same methods used for our standard clinic visits (eg, call center, front desk). At the time of scheduling, patients are given the educational packet that explains the requirements for the video visit. At our institution, the requirements are simple. The patient needs to use a smartphone and download a HIPAA-compliant application. Shortly after scheduling a video visit, patients will receive a phone call from our “patient engagement officer,” who reiterates the instructions given to the patient in the clinic and offers troubleshooting advice.

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	Providers who conduct video visits in our clinic will use an iPad that is mounted to our clinic desktop computer (figure). The iPad can be placed in any available clinic room, consult room, or even in the physician’s office. Once the clinical encounter is complete, the physician will take notes in the patient’s medical chart in the same way that he/she would document a standard clinical encounter.

	Multiple urologists and a physician assistant are currently using video visits for encounters that involve postoperative care (especially after transurethral procedures), counseling (eg, metabolic workup results for kidney stone prevention), and follow-up for results.

	Video visits offer benefits to both the physician and the patient. Physicians benefit from video visits in the clinic in several ways. First, turnover time between patients is minimal. This means that physicians can see more patients in clinics. For example, in some clinics at the University of Michigan, the mean appointment cycle time for a 15-minute appointment (ie, time the patient spends waiting, being placed in a room, seeing the doctor, and checking out) is approximately 70 minutes. In contrast, the average appointment cycle time is approximately 24 minutes for a video visit.

	Second, video visits can be conducted without nursing and clerical staff. Accordingly, physicians can hold clinics after hours without paying for additional staff. Finally, the efficiency gained by utilizing video visits for low-complexity patients allows physicians to spend more in-person time with patients who have complex needs.

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	Video visits also have several obvious benefits to the patient. Patients avoid travel, traffic, and parking. They can avoid taking time off work or school. These benefits are equally important for caretakers who may be burdened with bringing their loved one to the clinic.

Next: Status of regulations, reimbursement

	Regulations and reimbursement for video visits vary greatly from state to state. Physicians must be licensed in the state where the patient is located. In addition, some states have regulations on informed consent and on establishing a relationship with the patient prior to the video visit.

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	In the last several years, many large commercial payers have started to reimburse video visits from home. In most cases, the provider bills a standard office visit CPT code (99211-99215) and adds a GT modifier to the claim. Many states have telemedicine parity laws, which legally oblige commercial payers to reimburse video visits at the same level as face-to-face visits. However, Medicare does not currently reimburse for video visits conducted with patients from home. Medicaid reimbursement varies by state.

	This author strongly believes that video visits will eventually become a natural extension of the physician’s clinic. With the rapid move toward digitalization and patient preference for on-demand services, it is possible that up to 50% of patients may be seen through video visits in the future. However, health systems will remain cautious in investing in video visits (and other telemedicine services) until Medicare begins to reimburse for such services. Fortunately, several active congressional bills are focused on liberalizing Medicare’s reimbursement requirements. The future of video visits, as with many things in medicine, will depend greatly on the potential for reimbursement and patients’ demand for the technology.

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Among the many areas of telemedicine, a key opportunity exists for urologists in video visits, or “direct-to-consumer” telemedicine. 

Chad Ellimoottil, MD, MS

Articles

Telemedicine in urology: A crash course during the COVID-19 pandemic

Video visits in urology: How clinicians, patients benefit