A Complete Guide to Seeing Patient Virtually
The COVID-19 pandemic has thrown telehealth and virtual services into the spotlight. Prior to March 2020, the complexity of billing, lower reimbursement, limitations on use, and privacy and security concerns stood in the way for many providers. Now, much of that has changed for the duration of the pandemic, and it is likely that some of these changes are here to stay.
With everyone moving so fast to get telehealth and virtual services in place, it’s easy to choose quick-fix solutions or make mistakes. For long-term success, however, there are many strategies to help ensure success.
Use these steps to get it right before you go too far.
How will you use telehealth and virtual visits?
There are several ways to conduct telehealth and virtual visits. The different types of visits include:
- Telehealth visits: Real-time, synchronous audio and video telecommunications technology. Select services can be performed using only the telephone.
- Telephone visits: Encounter between patient and provider—traditionally via phone.
- Virtual check-ins: Brief (5-10 minutes) check-in with patients via telephone or another device to decide whether an office visit or other service is needed. Review of patient recorded video and/or images submitted by a patient (aka, store and forward).
- E-visits: Asynchronous office visit between patient and provider traditionally through a patient portal or secure email.
- Remote monitoring: Remote monitoring of physiologic parameter(s) through medical devices.
Aside from choosing the actual tools you will use for these types of visits, you also have to decide what types of visits can be conducted through telehealth. This requires setting some clear clinical guidelines about which chief complaints qualify. During a time like the COVID-19 pandemic, those guidelines may be broadened, but that should still be defined by clinical leadership to ensure that quality patient care remains the priority.
Also, consider your workflow and what will be most effective for providers and patients. Will you need to make changes to your workflow? What will they be? Can you support that with existing resources and technology? Are you more prepared to support one type of visit over another? For example, perhaps you can do telephone visits more easily now or have a two-way text tool that enables text-based check-ins but are not yet set up for video visits. If you want to add video, what else will you need to do to support that? Finally, are these changes sustainable post-COVID?
How do I choose the right telehealth tools?
Many factors go into choosing a telehealth tool or tools. Once you decide to move ahead with telehealth, you’ll need to determine what type of visits you will offer. If it includes video telehealth, you’ll need to consider several factors, including:
- Implementation: Is it easy to set up? How long will it take? Does it require additional software installation? Or is it cloud-based? Especially right now, you need a solution that can be up and running almost immediately. Therefore, a cloud-based system that can be turned on quickly and easily is a good choice.
- Cost: Some systems come with many added costs like equipment, set-up, training, ongoing upgrades, and support. Or they have a limited number of licenses and the cost increases considerably as more are added. Look for a system with a subscription fee that is by practice or by provider that covers all costs for one price without additional add-on fees.
- Support: Will the vendor help you set up your system and provide support at no additional cost? Is support available through a variety of channels like chat, online community, phone, and email? Will you get the support of additional best practice education and resources?
- Technology features: Is the system secure, HIPAA compliant, and high-definition for video? Are there features that support the overall workflow (scheduling, reminders, intake forms, follow-up surveys, etc.)? Is it mobile friendly? Does the vendor support any other virtual services like text check-ins with photos and videos? Does it integrate with other systems?
- Security: HIPAA was mentioned above. Is the system secure? Does it protect patients’ privacy and their data? Rules may be relaxed for a little while, but ultimately, you will need a system that is compliant. If you are choosing a system now, make sure it is one that can support your telehealth and virtual visit workflow for the long term. Will you need to get a new Business Associate Agreement to ensure long-term compliance?
Implementation and training
With any technology, the main reasons for failure are often poor planning and inadequate training. This can be compounded by lack of goals or unrealistic or poorly defined expectations. These can be addressed with the following best practices.
- Clearly document the goals and intentions of the use of telehealth. There should be a set of welldefined goals that have been agreed upon by the key stakeholders. If that goal is simply, “We need to see patients during the pandemic,” that is ok, but know what you are doing and why. The bestcase scenario is that you have a set of success metrics you are working towards.
- Document the workflows for the telehealth process.
- How will appointments be scheduled? By phone, online scheduling, and/or text? And are the correct appointment types set up in your practice management system to ensure appropriate coding, billing, and tracking of telehealth and virtual visits? The appointment type may be one of the most important things to ensure everyone knows what type of visits and therefore what the workflow is and help ensure you get paid.
- How will you gather intake forms and complete registration for appointments? Can you send electronic forms? Do you have a process for a staff person to collect details and vitals before the provider does the visit for video or telephone encounters?
- How will you get details to patients about their appointment? Links, instructions, how to get help if there is a problem, etc.?
- How will you collect payments from patients? Do you have a virtual billing process or will you need to send statements? Removing paper processes is critical during this pandemic and may make sense as a long-term solution to reduce costs, improve accuracy, and support different visit workflows.
- Can you send out surveys to follow up on the appointment and the new virtual workflow and assess patient experience?.
- Do you have the knowledge to correctly code and bill these visits?
- Engage all impacted staff in ensuring everything has been covered in the goals and workflows. Getting buy-in is critical to success, and buy-in is much easier to get when everyone feels their needs have been considered.
- Once you know that workflow, make sure all staff are fully trained on any changes to the way they do things in the face-to-face visit environment. This may require additional training from vendors or training materials for the various audiences affected by telemedicine, including, but not limited to schedulers, medical billing staff, MAs & RNs, and providers. Training may need to cover processes as well as clinical guidelines, coding and billing processes, etiquette, and much more.
- Make sure you have tested your workflow and your technology with your staff before your first visit.
- Have a contingency plan in place in the event of connectivity issues or user error. How will you quickly switch gears to fix the issue, move to another modality, or reschedule with minimal impact to patient care and experience?
- If you are going to do video visits then you have to consider bandwidth. Verify that your internet connectivity can support this. Also, consider your patients and where they live. They may not have access to high-speed internet. Be ready to offer an alternative to them if needed.
- You may need to get additional malpractice coverage for telehealth services. While some malpractice insurance will cover virtual visits, they don’t all offer the same coverage. Contact your malpractice insurance carrier to verify coverage and purchase additional coverage as needed.
How will you get paid for these telehealth virtual visits?
Reimbursement has been one of the biggest barriers to the use of telehealth and virtual visits for many years. The COVID-19 pandemic has changed all that. You need to see patients through these visit types for their safety and safety of your staff. As a result, the Centers for Medicare and Medicaid Services (CMS) have changed the rules for the use of telehealth and expanded reimbursement. Commercial payers have followed suit. During the COVID-19 crisis, you can get paid the same rate for telemedicine through two-way audio and video and for some telephone visits that you were paid for face-to-face in-person visits. However, to ensure you get paid, there a few things to do:
- Licensure: While reimbursement regulations have been relaxed, medical licensure requirements still may apply at the state level. For example, CMS said providers could now use telehealth across state lines and practice at their highest level of training. However, in some states, like California, they are not allowing out-of-state providers to do this.
- Patient consent: Depending on your state’s statutes or the requirements of the payers, patients may need to consent to this form of care verbally or in writing, and processes need to be in place capturing that consent was obtained. You’ll need to verify requirements for your state and payers. Consent has been loosened up during this crisis. CMS says they can give verbal consent at the time of service. It appears that most payers are following suit, but it is good to confirm. The consent can be given once annually. If you would feel better getting written consent, be sure you have a digital process to do so.
- Coding and billing: The rules and regulations around telehealth reimbursement have and will continue to change frequently. Someone will need to verify guidelines and reimbursement with each payer and continue to monitor for changes. Some experts recommend creating a spreadsheet to track the requirements for all your payers and document details such as requirements for modifiers, place of service, or documentation. To be safe, document everything!
The following are common codes for coding and billing along with some resources that may assist in the process. This is not a substitute for expert guidance.
Dental Scenarios and Billing
Triage or evaluation
D0140 - Limited oral evaluation - problem focused
D0170 - Re-evaluation - limited, problem focused (established patient; not post-operative visit)
D0171 - Re-evaluation - post-operative office visit
D9992 - Dental case management - care coordination
D9995 - Teledentistry - synchronous; real-time encounter
D9996 - Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review
Additional Information: COVID-19 Coding and Billing Interim Guidance (ADA)
Vision Scenarios and Billing
Virtual Check-Ins - Brief 5-10 minute check-in
G2012 - Telephone (Medicare code)
G2010 - Captured video or image (Medicare code)
Online Digital Evaluations
99421 - Online digital evaluation and management service - 5-10 minutes
99422 - Online digital evaluation and management service - 11-20 minutes
99423 - Online digital evaluation and management service - 21+ minutes
Depends on the insurance company - not covered by Medicare at this time
Additional Information: COVID-19 and Medicare Telehealth Services (Webinar from American Optometric Association)
Medical Scenarios and Billing
Telehealth visits - Real-time, synchronous audio and video telecommunications technology. Select services can be performed using only the telephone. There are now over 200 codes for telehealth. Get codes here.
Virtual check-ins - Brief 5-10 minute check-in
G2012 $14.81 for 5 - 10 minutes (verbal)
G2010 $11.91 for 5 - 10 minutes (text, images, video)
E-Visits - Asynchronous office visit between patient and provider traditionally through a patient portal or secure email.
Physicians and advanced practice providers: 99421 $15.50 for 5-10 minutes
99422 $31.04 for 11-20 minutes
99423 $50.16 for 21 or more minutes Other healthcare professionals:
Telephone - Encounter between patient and provider traditionally via phone. Physicians and qualified healthcare professionals:
99441 $46.19 for 5-10 minutes of medical discussion
99442 $76.15 for 11-20 minutes of medical discussion
99443 $110.43 for 21-30 minutes of medical discussion Qualified non-physician healthcare professionals
98966 $14.44 for 5-10 minutes of medical discussion
98967 $28.15 for 11-20 minutes of medical discussion
98968 $41.14 for 21-30 minutes of medical discussion
Remote Patient Monitoring - Remote monitoring of physiologic parameter(s) through medical devices.
99453: $18.77 for initial; set-up and patient education on use of equipment.
99454: $62.44 for initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
99457: $51.61 for treatment management services, initial 20 minutes of clinical s taff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/ caregiver during the month.
99458: $42.22 for each additional 20 minutes; frequency limitations apply. For additional information, see this document.
How will you get your patients to use telehealth and virtual visits?
You may be surprised to hear that this part isn’t as hard as you might think. Seventy-four percent of patients say they are happy to use telehealth and virtual visit services. In addition, one study showed that patients feel that about 85 percent of the time virtual care resolved their concerns as well as an in-person visit. It’s really more a matter of communication. Patients need to know if you are changing their visit from face-to-face to virtual. They also need to know how to participate. So make sure:
- When the patient calls to schedule, you are clear about the type of visit it will be. This should be defined in your clinical guidelines. If they have a choice between telephone and video encounters, ask them which is better for them. You can encourage face-to-face video but listen to their concerns. They may not have access to reliable internet. Then, tell them how they will participate. Will the provider call them or vice versa? Will they get a link and instructions via text or email ahead of their video visit? If they can’t get on the video visit, how do they get help?
- Make sure to address other important considerations at scheduling or in a communication before the appointment. These would include:
- Does patient need to download app?
- What technology do they need or can they use? Computer, smartphone, tablet, etc.
- Do they have reliable internet?
- If it’s a phone encounter, let patients know what number/phone you’ll be calling and from what number you will be dialing from.
- Be thoughtful about patient privacy. Suggest the patient be prepared in a private and quiet space for the visit.
- Address any accessibility issues when you schedule the visit such as language barrier, hearing issues, etc.
- Ask if a primary care partner needs to be included as well.
- Remind patients to be prepared—insurance cards, pen and paper, symptoms/concerns.
- It’s a good idea to have a superuser, or small team of super users (depending on the size of your organization), who can provide any needed support to patients before or during video encounters. Make sure patients and staff know who to call or text for help if there is a problem.
- Be sure that when you speak with patients, you verify their contact information and do your best to get preferences for communication and consent as needed. In this world of virtual workflows and rapid changes, you need to be able to reach patients, sometimes at very short notice.
How else can you make this the best experience for patients?
The truth is that remote care is different from face-to-face care. Patients are open to it, and it can be just as effective, but you do need to take a few additional steps to make sure that it is all it can be. So, consider these telehealth and virtual etiquette tips along with everything else we have covered so far:
- Adjust the camera so the provider fills the screen and the patients can’t see a bunch of other distracting things like posters. If the patient can see surroundings, keep them clear of clutter.
- Wear solid neutral colors. Try to avoid fluorescent colors, bright reds, and white. In other words, drop the lab coat. No bold patterns or big jewelry. Check yourself in the mirror before each visit.
- Check the lighting and close blinds to avoid glare.
- Always introduce yourself with your name and the practice you are calling from.
- Speak slowly and clearly and look at the camera not your own reflection in the monitor. Speak in your normal voice and don’t shout.
- Do not place papers or objects near the microphone. Check to be sure the microphone isn’t near a fan, A/C unit, or open window.
- If using a desktop or laptop, move the video screen just under the camera so they get the feeling the provider is making eye contact with the patient.
How will you track your success with telehealth and virtual visits?
Don’t fly by the seat of your pants. This whole process should have started with some clear goal-setting. You want to know how you are doing in executing telehealth and the impact it has on your providers, your patients, and your bottom line, especially during times when most visits need to be moved to telehealth and virtual visits. There are many possible metrics to track. Look at your goals and choose the ones that make sense.
Visits: These metrics help you see what types of visits make sense for your patients and how well they are being adopted.
- How many visits overall
- What type of telehealth or virtual visits
- Growth of telehealth and virtual visits over time
- Average duration of video and telephone visits
Patient metrics: To be successful, you need to know how patients are responding to and engaging with telehealth and virtual visits. Also, whether or not the service appeals to current patients as well as potential or new patients.
- New patients to your practice
- Returning users of telehealth
- Wait time to get an appointment
- Wait time before the appointment
- Patient visit time
- Patient satisfaction/experience
- Patient willingness to recommend
- Patient retention
Staff metrics: Staff metrics are a great way of determining if the current solution and workflow are sustainable.
- Staff satisfaction
- Total hours worked
- Break times being honored
Provider metrics: This is just as important as gathering patient experience data. If providers don’t like it, it won’t be adopted long-term.
- Clinician satisfaction
- Clinician work time
Financial metrics: You should look at the same financial metrics you use for in-person visits but if nothing else, be sure to look at:
- Reimbursements by visit type
- Costs by visit type
Service metrics: Service metrics will show you how well your system is working overall. Poor performance won’t lend itself to long-term success.
- Deliverability or sessions completed
- Are texts being received and sent?
- Are emails being received and sent?
- “Bounce rate”
- Service uptime/downtime
- Service issues/bugs
Also, you should be tracking the same clinical and outcomes data you already capture for various incentive programs. Compare your outcomes data from the telehealth visits to those from in-person visits. You’ll want to work to close any gaps in quality of care if you plan to leverage telehealth and virtual visits for the long-term.
These are unusual times and you can’t take the same time to prepare and execute on the use of telehealth that you might have before. When adopting technology like telehealth, expert guidance can be helpful. If you don’t want to navigate this process alone, consider a consultant who specializes in telehealth. If you don’t opt for expert help, consider identifying someone to be your internal expert and leader in the telehealth transition.