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

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. Disclosure: 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, CMS announced.

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We aim to briefly summarize these changes, provide resources for urologists (from the AUA and CMS), 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.

Technology and equipment

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.

Next: Billing and documentation for video visitsBilling 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).

Reimbursement for video visits

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.

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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, Medicare has eliminated this requirement and allows patients to connect from home.

State-specific laws and policies

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 (www.cchpca.org) 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 CMS proclaimed 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.

Next: Telemedicine ImplementationTelemedicine Implementation

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 tip sheets available online 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.

Telephone visits

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.

Summary

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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