How relaxing of Medicare rules has affected telemedicine adoption

The COVID-19 pandemic has had wide-ranging effects on the practice of medicine. These include cancellations of in-office visits, surgery postponements or cancellations, social distancing in the office, and the explosion of telemedicine. As a result of the pandemic, the federal government has instituted emergency measures that lift restrictions on the use of telemedicine. This Urology Times® webinar, featuring experts in telemedicine, practice management, and coding and reimbursement, examines the impact this public health emergency has had on the practice-related aspects of urology and how urologists can prepare for the future once the emergency declaration is lifted. (To view the webinar in its entirety, see bit.ly/uttelemedwebinar.)

The panelists were moderator Jonathan Rubenstein, MD, chief compliance officer, Chesapeake Urology Associates, Towson, MD and clinical associate professor, department of surgery, University of Maryland School of Medicine, Baltimore; John Gore, MD, MS, professor of urology, University of Washington, Seattle; Aaron Spitz, MD, a urologist in private practice at Orange County Urology Associates, Laguna Hills, CA and assistant clinical professor of urology at the University of California, Irvine; and Eugene Rhee, MD, regional coordinating chief of urology at Kaiser Permanente Southern California.

In this segment, the discussion centers on the relaxing of Medicare rules regarding telemedicine and how this has affected its adoption.

Rubenstein: Let’s discuss how Medicare relaxed its rules regarding telemedicine and just start with Medicare for now because the private insurers have been either half a step ahead or half a step behind Medicare. I think the big driver was the buy-in from Medicare. We'll start with Dr. Gore. When Medicare relaxed its rules, did that make a big change for you in an academic setting?

Gore: It absolutely did. Personally, about 55% of my practice is Medicare patients. In recognition of the pandemic, personally in my own practice, I had made a decision to large-scale convert to telemedicine, irrespective of payer. But it became a no-brainer when Medicare massively relaxed the regulations, especially around place of service so patients could be in their own home.

One of the big things that Medicare said is that they're not going to audit whether a patient has been seen in your clinic before. They're not really explicitly saying that they're giving you permission to do new patient visits, but they're also not going to try hard to look for it. It allowed us to continue to see new cancer patients that were Medicare patients without having to be concerned about reimbursement.

Related: Pandemic forces rapid switch to virtual visits

Another big factor is that the University of Washington is the only university-based academic center and comprehensive cancer center for what's called the WWAMI region, which is Washington, Wyoming, Alaska, Montana, and Idaho. One big limiter in our provision of telemedicine for our catchment were the interstate rules around telemedicine, and some relaxation of the interstate rules by Medicare was also a great boon for us to continue to see some new cancer patients and to continue to have touch points with our established cancer patients.

Rubenstein: Dr. Spitz?

Spitz: The lifting of regulatory and payment constraints by CMS was absolutely revolutionary. I think it set the state of telemedicine ahead by many years. Payment is the biggest barrier to entry to telemedicine for most doctors. It's not that telemedicine is so difficult to do, it's that, why bother if there's no reimbursement for it and you have to spend time communicating with your patient and providing care.

Now that that disincentive has been removed, it has basically enabled so many of us to adopt telemedicine and it's certainly enabled my practice to adopt it. Fortunately, Medicare has now explicitly said that they will pay for new and established patients. This has enabled our practice to partially remunerate ourselves for the lost income that we're all suffering with the stay-at-home orders.

The fact that Medicare is willing not only to reimburse but reimburse on par with in-office and remove allowing that reimbursement to be based on medical decision-making and not on a physical exam, which of course we can't accomplish telemedically, has dramatically improved our ability to provide care for our patients while continuing to maintain some fraction of our compensation. Of course, as proceduralists, there is a significant amount of care that we cannot provide telemedically and likewise a significant amount of reimbursement that we cannot capture.

There is really no way around the fact that there is economic hardship, particularly for those of us in private practice that don't operate on grants or have larger institutional funding, but Medicare is certainly reaching across that divide to us with the reimbursement for telemedicine, with the advancement of Medicare payments, and also the government in general with the CARES Act. It has been absolutely critical to see this lifting of the payment restrictions.

The lifting of the HIPAA requirement is equally important because many of my patients either don't have the sophistication to engage with my commercial telemedical platform that is HIPAA compliant or there have been glitches in the system. But the majority of my Medicare patients use FaceTime or Skype to speak with their family members, their grandkids, what have you. To be able to toggle over to that immediately in real time has been fantastic.

For those that can't really accomplish either the HIPAA-compliant or non-compliant audiovisual platforms, Medicare is paying for telephone calls, albeit at a reduced rate. But nonetheless, this is a dramatic improvement from the previous situation in which phone calls were not covered. They've really given us the tools to, at the very least, have a continuity of care. It's not perfect. There are definitely patients who still require hands on visits, and our practice still sees patients in the office and in the hospital for urgent needs, but it has been a huge Band-Aid.

Rhee: I'm going to make a big assumption that the level of telemedicine sophistication of the audience today is starting out. I don't want to intimidate folks. What's happened is really an enormous amount of relief for all of us who've been doing this for a long time. It’s really about the four Ps. One is the providers. A lot of people-even clinical social workers-can be doing telemedicine. Two is the patients. Not only established patients, but it’s new patients, that can be seen. Third is the payers. The payers are now seeing the relaxed compliance and ability to bill in order to make this happen. Four is the privacy issues. The privacy issues that were really hitting a major wall have really opened up now in a way that it’s easier for our patients to be seen, whether it’s a phone visit or a video visit.

There's a lot of detail in each of these. But simply put, everything has been lifted in a way that's been an amazing, remarkable transformation. The genie is out of the bottle.

Rubenstein: Coding and reimbursement are my expertise, and I wanted to make sure that the correct codes are conveyed here. I'm going to talk primarily about Medicare. In the table below, you can see that Medicare will pay for CPT codes 99201 through 99205 for new patients and 99211 through 99215 for established patients.

As Dr. Spitz said, Medicare was trying to remove any incentives to bring a patient out of their home and into the office. They wanted patients to stay at home for the good of the health of the country. Medicare wanted to make the same payment whether the patient was seen in the office setting or at their home. Therefore, we'll be using the same codes.

Now, doctors and practice managers need to realize that, when you’re billing and coding, you'll use the place of service of the location that you would have seen the patient if they had come into your office. For example, if you see somebody in the office, use place of service 11; no longer use place of service 02. Place of service 02 for Medicare was used when a patient was in an originating site and the doctor was in a distant site. You would just get the facility payment in that case for the distant site, which is a little bit less than a regular office payment. So make sure you use place of service 11, whether the patient is at their home or if they came into the office.

Medicare also took away the need to perform a comprehensive history, and they took away the need to perform a comprehensive physical examination. So when you're choosing a code, level 1 through 5, the correct code is purely based upon medical decision-making. Use the same medical decision-making chart as we've used with 1995 and 1997 guidelines, whether it's a new patient or established patient. Once again, if the patient has the medical decision-making of being a level 4 or 5 but you can't hit all the buttons to get the physical exam to that number, it doesn't matter; you do it purely based upon medical decision-making.

Medicare also changed billing for time. Typically, when billing for time, it was total time, face to face, when more than 50% was counseling and coordinating care. Currently, the pre-service work on the same day can be added to the amount of time you're spending with the patient on the visit as well as the amount of time that you're spending minutes-wise after the visit. Type that all into your note; the total summed time is the time that you will use. Please make sure you put it in a note.

Regarding phone calls, Medicare will pay for phone calls. We probably all have seen a patient who does not have a smartphone or does not have a computer with appropriate hookup to get some of these video features. Phone calls themselves pay a little bit less, but you can do an evaluation management service by phone call also.

I want to make sure everyone understood those nuances because if you don't read every single word in that huge interim rule document that Medicare laid out, you may miss some of those little nuances.