So my name is Mike Wang, I'm delighted tonight to be joined by two wonderful faculty, including John Ratliff and Clemens Schirmer. We're gonna talk to you about making telemedicine work for you. This is a AANS webinar offering. You can go online by the way and get this for a small charge with CME, but I imagine right now most people are most interested in this concept with the coronavirus crisis. So let me just give a brief introduction. I'm gonna leave the heavy lifting to John and Clemens. This is a picture of me with my nurses in clinic this week. Prior to this week, I had never engaged in any sort of telemedicine endeavor. In fact, I had never contacted a patient except in person or via a landline, not even by cell phone. And so I was always resistant to come to this concept, but then last week I finally gave up. I said, look, this is gonna be a real problem. So I started to basically engage. And I'll tell you on Monday, I saw 133, I'm sorry, 33 patients, 33 patients on my first day in telemedicine. Everything went great. There was only one patient, the 34th patient that couldn't connect with us. And so I was instantaneously sort of bought in. And I don't have the experience that John Ratliff and Clemens do, so I just wanna turn it over to them. But this was really to introduce you to the concept that even if you've never done this before, there's a lot of promise here. I'm not totally bought in, but I think it could work for you. So John, why don't you take it away? Okay. Thanks, Mike. Sam, if you could transfer control of the slides to me. I'm hearing from some of the comments that the audio is intermittent. And some people are saying it's okay. So I will proceed. First of all, thanks to Clemens and also Mike Wang for really putting together this slide deck in a quite expedient fashion. And putting together this webinar, really in the space of less than a week, we started having a conversation about developing this content one week ago. And here we are today with myself and Clemens giving presentations and Mike Wang, Agnes, our MC. And again, thanks to our faculty for being here. So we're gonna talk about this evening, hopefully in about 30 to 45 minutes, what telehealth and telemedicine mean to neurosurgery. And I am very similar to Mike. I started doing my first telehealth visits earlier this week. So this is brand new to me, just like it is probably brand new to all of neurosurgery. Mike ran a really great AANS podcast where he and I discussed some of the more philosophic issues of telehealth and really discussed what this may mean for our patients and for the relationship we have with our patients going forward. The quick review of telehealth we're going to go through this evening is gonna go and review some of the new CMS regulations and some regulations that were just released earlier this week. We're going to talk about how you bill for telehealth and really whether or not you're gonna get paid. Will this E&M billing actually mean anything? Will you get work RVU credit for doing these telehealth visits? Now, again, why does anyone care? Why are we moving to telehealth? Well, I pulled these slides out, gosh, earlier this week and they are already dated. It was a day when there were only 100 deaths in New York from the coronavirus. But this Atlantic article is a very good visual of how the coronavirus has essentially grounded all of humankind. And certainly here in California, we have had a shelter in place order for about two and a half weeks now. So no kids going to school, no elective surgeries. Our patients are very worried about traveling. We have many patients who come from the Central Valley. So for those of you who are not familiar with Northern California, that's about a four hour one way drive to reach our facility. And patients are worried about that. Now, some of our care though is not elective, meaning that not all of these patients can wait to be seen and wait to be evaluated. So we need to have some means to continue caring for our patients and to continue to provide neurosurgical care for the patients that still need us. So we need to move to remote visits, to using phone calls, maybe emails, and to telemedicine, which is again the point of this webinar. Now, what is this? What is telehealth? So telehealth or telemedicine are just different ways to exchange health information from one site to another, but here using electronic communication. Your electronic health record probably has it. We use Epic. So we use the My Health patient facing portal to do our telehealth visits. Now that's not necessarily the only way to do it. Probably each electronic health platform has some means of doing telehealth. And if not, there are other avenues that you can use to set up telehealth visits in your practice. Now, HIPAA still applies, meaning that we still need to be thoughtful of the potentially damaging nature of the information we will be exchanging. And we need to be very thoughtful about protecting patients' privacy, even though we're using a new and perhaps atypical means of communication. Now, during this period, the Secretary of Health and Human Services has said that the Office for Civil Rights, or the OCR, which acts to adjudicate HIPAA complaints and HIPAA penalties, they've noted that they will waive these penalties during this COVID-19 crisis for providers that are serving patients in good faith. So we should assume that HIPAA still applies, and the OCR has provided a waiver against any penalties being applied for physicians and providers acting in good faith who may inadvertently violate HIPAA. So what if you don't have an electronic health record? There are other options. The California Medical Association developed a partnership with a company called Amwell they got a discounted rate for California physicians for using the Amwell product. This is absolutely not an endorsement for that product from AANS, nor do I even know anything about the product. But there are other things that you can do besides your EHR. And I inserted a link here from the California Medical Association. Your state medical association may have other avenues that you can avail yourself of for setting up telehealth and telemedicine. One of the reasons some individuals say that telehealth previously has not caught on is because of billing. There's essentially very little that we could do previously for billing for telehealth. And reimbursement from Medicare for telehealth was quite restricted to the point where in 10 years of either teaching or managing the AANS coding courses, I think we maybe mentioned telemedicine, but we certainly didn't have any content on telemedicine because it really wasn't relevant for practicing neurosurgeons. That has changed. CMS has very recently relaxed the limitations that they have on billing for telehealth. And this is not just for neurosurgery, it's for all of the house of medicine. And that's from work with what's called the 1135 waiver. And that's section 1135 of the Social Security Act, which gives the secretary of HHS the ability to either waive or modify Medicare, Medicaid, and CHIP requirements. So starting on March 6th, 2020, Medicare said that they would begin to pay for office, hospital, and other patient visits furnished by telehealth before they were very limited in what they would pay for. Now they're essentially saying that they'll pay for everything provided via a telehealth platform. Now that's not just for neurosurgeons, it's for all MDs and nurse practitioners and PAs and clinical psychologists and licensed clinical social workers, et cetera. So this is Medicare relaxing their payment restriction and allowing for telehealth. There are three types of visits that would be relevant to us. There's Medicare telehealth, and that's what we're going to focus on. There are two other types of visits that are feasible and that Medicare, again, is paying for, but in my opinion, they are probably less relevant for practicing neurosurgeons, hence we're going to focus on telehealth. Those two additional visits, though, are virtual check-ins where a patient initiates a quick visit via a telephone call, a video, or an image within seven days of an encounter, but that doesn't generate a clinic visit, meaning an evaluation and management claim or a procedure or other e-visits using an online patient portal. And again, what we'll focus on now is Medicare telehealth because that's the most relevant thing to neurosurgery. The key here is that it uses an interactive audio and video system with real-time communication or a real-time exchange of information. Medicare will pay for these visits the same rate as an in-person visit, and this new policy will apply for the duration of the COVID-19 crisis. Previously, to use telehealth, you had to have an established relationship with the patient where you would be doing telehealth. Medicare has relaxed that now and said that HHS is not going to audit to ensure that there's a prior relationship with the patient where you're providing a telehealth service. Hence, you can do telehealth for new patients, for follow-up patients, for essentially any patient that you would be providing these services for. It also used to be that you had to be licensed in the state where you were providing a telehealth service. So if you're in Philadelphia and you were seeing a patient in New Jersey, you wouldn't be able to do telehealth unless you were also licensed in New Jersey. CMS has waived this, and now they are allowing out-of-state providers, as long as that provider is licensed in the state where they're providing services. So me here in California, if I'm seeing a patient in Oregon, as long as I'm licensed in California, I am fine. I can submit that bill for a Medicare beneficiary in Oregon that may or may not apply to Medicaid. That's a state-by-state issue. Private payers may or may not follow this lead. That applies to both licensure and also coverage for telehealth in general. Here in California, our state insurance regulators are applying significant pressure to Kaiser and to the other payers in our environment to follow Medicare's lead in this space. Your local compliance office, if you're employed, may have their own rules or their own things that they need to look at. So what's some of the etiquette for actually doing this? Now, this is a clinic visit. You may be doing it through a patient-facing portal, but it's still a clinic visit. You need to be professional. You need to have a secure connection, especially if you're working from home or doing telehealth visits, not in your clinic space, but say from your home. So you need a virtual private network, some other secure means of having this communication executed. For some of my physicians, they use a hospital-supplied computer with a VPN that allows them to directly go into their hospital system. And again, while some of the reporting requirements for HIPAA, excuse me, some of the HIPAA requirements are being relaxed, we still need to think about HIPAA and about maintaining patient privacy. You wanna set up an appropriate space for having a clinic interaction with a patient. Think about a neutral background. It needs to be someplace quiet. It needs to be someplace private for you to interact with your patient. So how do you do it? You wanna check with your EHR, at least that's how we did it here at Stanford, and you need to be able to schedule patients with telehealth visits. This will likely require some retraining for your clinic teams, for your medical assistants, for your new patient coordinators, for the individuals who are setting up these visits. And you'll want to be scheduling patients for telehealth. Part of the work of telehealth comes before the actual visit, with making sure that the patient has an appropriate portal to use, and making sure that the patient is able to use that portal to establish a connection with your clinic. For documentation, you wanna document just like you would document an in-person clinic visit. You're going to be paid like it was an in-person clinic visit. You need to make sure you document at the same level, with the same accuracy, and again, to the best of your ability. Some of the unique things about telehealth is that the first thing you need to do with a new patient visit is to confirm their identity. So ask to see the patient's identification to make sure they're them. It's a dumb thing, but you need to do it. Your medical assistant or whoever is setting up the visit can confirm this. And one of the other things you need to do is to get a patient consent. You as a physician need to do that, or someone in your clinical team needs to get consent. And this is a real necessity, even centers with much greater telehealth experience than our own emphasize that telehealth is still new. It's a new means and a new mechanism to provide healthcare services. There are limitations with telehealth. There are potential problems that are unique to telehealth. You may miss things because some aspects of your physical exam are not feasible via a telehealth platform. So you need to tell the patient that, and you need to make sure the patient is aware and that they consent for this format of visit. Now, what does that consent look like? I include two of them here. One is a very basic consent that's built into Epic and MyHealth. The other one is a much more thorough and thoughtful consent that was contributed by Reese Yang. She's one of our neurologists here at Stanford. She's a real expert in telehealth, and she provided this kind of two bulleted video visit consent here on this slide. This will be archived so that you can use this content as you wish. The key would be making sure the patient understands that inability to do an in-person physical examination may limit the clinical efficacy and may increase potential for inaccuracies in your telehealth visit. But again, with our shelter in place, with COVID-19, with the other things that are going on, it's still our best option for many of our patients. So charting. Your medical record keeping should be the same as an in-person visit. So you do the same documentation as if you're seeing the patient in your office. You do medication review. You do review of systems. You do past medical history, et cetera, et cetera, et cetera. You treat this like a normal clinic visit. How do you code it? With the new regulations from this year, you're going to do standard CPT codes for new patient or return patient visits. So for a new patient, the 99201 family, going up to 205, and for return visits, the 99211 family, for Medicare, you need to tell them that your place of service or POS is two, meaning that it's a telehealth visit. For some private payers, they want a 95 modifier put on the E&M, denoting that this is telehealth. Now that's not going to affect your payment, but it's letting Medicare know that this is a telehealth visit or your private payer know that this is a telehealth visit. Now, one of the things that really caught me up as I was developing this slide deck and trying to transition, just as Mike Wang noted earlier, many of my visits to telehealth visit was that how in the world are you going to do a physical exam and document it over a phone call? So the short answer is to do the best you can. The long answer is really just to record what you can record. So you can do vitals. You can ask the patient's height and weight. They can check their own pulse, or you can get the pulse from their Apple Watch. You can do mental status, their cranial nerves, their orientation. you can observe motor status, get them to walk, see what their balance is. So some basic stuff you can do with a telehealth portal. That very basic stuff doesn't really get you that far in terms of bullets for your physical exam. That gets you, what we noted on the previous slide, to an extended problem focused exam, which means a level two visit or a level three for a follow-up visit. So you need a detailed exam, and would CMS audit us if we under-documented or had this wrong? Well hopefully not, but I probably bet the IRS will expect us to pay our taxes at some point in 2020, and if we don't, they may come around looking and perhaps investigate that. Similarly, I think it's better to document correctly in the first place and then not have to worry about exposure in the future. So you can get a lot of the neurologic exam elements via a telehealth platform. You can do memory, you can do gait. Lou Toomey-Allen notes that he'll check tricep strength by having the patient do a push-up. You can look at muscle tone, a lot of cranial nerves, you can evaluate just via observation. You still cannot, however, do a thorough exam. You can't check deep tendon reflexes, you're not going to be able to thoroughly do sensation, you can't assess pathologic reflexes, etc. Now all of this and everything I just talked about changed earlier this week. Medicare brought out a new set of recommendations which were enacted on the 31st of March and made retroactive to March 1st of 2020. In this new list of rules for telehealth, they added a number of additional services where telehealth would be reimbursed at the same rate than an in-person visit, including ED visits, admits for observation, initial hospital evaluations and discharge, and also critical care services. So again, that proposed rule was released for comment on the 30th of last month and made effective on the 31st of last month, even though I think it's still open for comment. The regulations were made retroactive to the 1st of last month. With these new regulations, you select your level for your office or your outpatient visit based on two options, either time or on medical decision-making. Time is an old way to evaluate and value E&M. Medical decision-making is something new, so I want to touch on that for just a few moments. The documentation requirements for the history and the physical exam were removed for telehealth visits. So this is very similar to the new rules that we're going to use for evaluation and management coding starting in 2021. CMS expects you to continue to document as necessary to ensure quality of care, but the checkbox approach of having to have 12 elements from the neurologic or musculoskeletal exam on your physical exam or all elements for a level 4 and level 5 visit, all that's taken off. Now we focus on either time or medical decision-making. Time is pretty easy. Use code based on how long you were interacting with the patient on your telehealth platform. For a new patient visit, a level 3 is 30 minutes, a level 4 45 minutes, a level 5 60 minutes. The times for your follow-up visits are included here as well. You need to document that greater than 50% of your time was spent in counseling and care coordination to code based on time. One of the issues that we always remind the physicians of at the coding courses when they discuss coding based on time is that there are only 24 hours in a given day and level 5 clinic visits are expected to take 60 minutes. So if your clinic takes place over 7 hours in a day, you can do the math as to how many new patient visits at a level 5 intensity you should be performing. And with telehealth, it's even easier since there will be a clear electronic trail as to when you begin that evaluation and when you stop that evaluation. So coding on time is an option. Another option that was offered by CMS earlier this week is to code purely based on medical decision making. Now for coding on medical decision making, there are three different elements that make up medical decision making and then four different levels within each of those elements. The elements are the number of diagnoses or a number of different management options that a patient may have, the amount or the complexity of data that needs to be reviewed for a given patient, and the risk of what you're doing. The risk of complications, the risk of morbidity, the risk of mortality. You must meet or exceed two of the three elements to choose a type of medical decision making. And I'll show this little slide from CPT multiple times to emphasize this. The key would be low complexity medical decision making means a level three new patient or established patient visit. Moderate complexity is a level four. High complexity is a level five. So how do you do that? How do you quantify it? So for the first, the number of different diagnoses or treatment options, it's a little bit confusing. You've got two different definitions, one for established problems and one for new problems. And you add them up to determine how many diagnoses or treatment options you're discussing. So you can have a minor problem, that's one point. An established problem that's stable or an established problem that's worsening. You add those up with a maximum being two. You add up the points and you multiply them together to get how many points you would accrue from seeing that established patient. A really simple example would be if you're a primary care physician, you're seeing a patient who has stable hypertension, but their diabetes is way out of whack and you're adjusting their insulin. So they have an established problem that's stable, their hypertension, that's one point. An established problem that's worsening, their diabetes, that's two points. So that adds up to three. How many problems are you dealing with? Two, the diabetes and the hypertension. So two times three gives you six. So suddenly you're at an extensive medical decision making from that patient. For new problems, you can either have a new problem where there's no further workup that immediately gets you at three points or a new problem that needs workup and that gets you four points. Four points means extensive number of diagnoses, that means high complexity. So a patient with a lumbar disc with a new radiculopathy that you're sending for x-rays, that's a new problem needing workup. How about the amount of data? Much easier. You just add up what you're doing. Independent review of films, which about every neurosurgeon I know of does, gets you two points. Review of old records, that could be review of your MRI referral, review of the patient's primary care notes prior to them being sent to your office, that also gets you two points. The other things that you can use to accrue points for the number of data are outlined here. But you can see for what we do, it's pretty easy to get four points, which leads to extensive, which means high complexity. How about risks of complications? Here you can pretty much jump straight to the bottom of the slide where we talk about high risk, because again, that's what we do. So elective major surgery with risk factors, that's pretty much every surgery a neurosurgeon does. Any emergency surgery, all of that would put you in a high risk of complications strata. Other things that might lead for moderate risk in this area would be major surgery with no risk factors, or a minor surgery with risk factors. The other things that are here kind of outline some of the other things that make up minimal and low risk of complications. With the kind of patients that we evaluate and procedures that we perform, neurosurgery certainly is biased towards moderate and high risk. And I'm going to repeat this slide just for emphasis. To add it up, you look at number of diagnoses, complexity of the data, and risk of complications. You need to have two out of the three at a given level. And how you quantify it between a level five, level four, and level three is noted below. So why bother with all that? So you can make a business plan for setting up telehealth in your practice, you will get reimbursed for doing these procedures. This gives you the foundation to go back to your partners or to your employer. And to say these telehealth visits will at least pay for themselves, along with providing you with the opportunity and the access to continue to care for your patients. Now a few technical issues. What if your system crashes? Probably the easiest thing to assess here is that we're not tech support. I know very little about iPhone maintenance. If you cannot see the patient, probably they have their camera reversed, and they need to hit the little button to flip their camera around. What if you can't hear the patient? Well, probably their microphone isn't active. Or the app that is running on their phone doesn't have access to the microphone to open that up and actually take the microphone so you can hear the patient. So it's okay to take a moment or two to try to fix that. Hopefully, your medical assistants will have dealt with that beforehand. But if all else fails, just call the patient, convert it to a good old fashioned phone call. You will get credit for a telehealth visit, i.e. you bill it like a normal E&M encounter. If you attempt to use telehealth, and the platform for whatever reason fails, it could fail on your end or fail on the patient's end. If you try and it fails, and you convert to a phone call, that's fine. Go ahead and bill it as a normal E&M. I include a page here of some very useful websites. Just because of the length of this webinar, we are really just hitting the high points. And many of these slides I had to change this week, actually earlier today, because so much had changed already. So it would make sense to view these websites and to understand to some degree, this is a moving target. CMS is very devoted to providing telehealth as an opportunity and avenue for Medicare beneficiaries to continue to receive care while sheltering in place. And there may be further changes, and maybe even further incentives for use of telehealth in the future. The AMA has a great web page about this with a very good quick guide. The Texas Medical Association has a site with insurer info for Texas. It's again, a very good website on this. The CMA has a fact sheet that I put here. And the CMS releases on this space are listed at the bottom. And with that, we probably can take questions at the end. Sam, I can turn it back over to Clemens, so he can pick up his slide deck. And I will look back through the text thread, try to look at some of the questions that came through, and see if I can answer them at the end of the session. I really appreciate you guys being here and being part of this webinar. Thank you for your attention. Great, thanks, John. That's awesome. While Clemens is loading up, there's a question from Matthew Maserati about what about telephone only television, television. He said CPT codes 9-9-4-4-1 to 9-9-4-4-3. I'll speak to that. Okay, go ahead. Okay, great. Thanks, Mike and John. I'll hit some other nuances potentially, you know, I apologize if there's any kind of duplication or if this appears to be duplicative. One thing that is probably worth looking at is the notice of enforcement that was mentioned before. You know, this is really an unprecedented relaxation of what we commonly understood as the enforcement of HIPAA and the surrounding privacy laws. And CMS went as far as making a specific list of things that they consider entities that might be able to provide reasonable private communication, such as Skype, Zoom, you know, others. And in particular, they also pointed out three platforms that they do not consider private, such as Facebook Live, Twitch, and TikTok. And, you know, they're not necessarily claiming that this is a completed or comprehensive way of looking at this, especially in when it comes to holding up to an audit or something of the like. But this is really specific guidance that was made available to us. And I think it's worth looking at this, especially if you do have issues with scaling up your own solution to telehealth over the next couple of weeks. Because not everyone has been doing this before, and not everyone has a large health system backing them, just like the, you know, people on this phone call here, for example, that is doing all this work for them. And it's probably also fair to say that, you know, we all work at teaching hospitals. And, you know, at least for my place, we've been doing telehealth visits for postoperative patients over the last six months or so, and have gained some experience with this anyway, which is now helping us quite a bit. Talking about teaching hospitals, obviously, this is a question for some of us, what or how can you use learners, residents, fellows in this context. And this has also been provided by Medicare. There's some specific guidance about this. There is guidance about how we can use our learners in this crisis in general. This is a multi-page document that was provided to us. But just to pick out some things that are pertinent to telemedicine or telehealth, is that basically, we can engage our learners in this context, just like we were doing this before. Teaching physicians can provide services with residents or fellows virtually through audio, video, or real-time communication technology. This obviously does not apply to surgeries, procedural, interventional, or other complex procedures. So in other words, you cannot be home and providing supervision to a resident who's in the hospital by holding up your FaceTime camera, that is not in the intent here. And these things also come with like some nuance. So for one, you know, we can count, you know, resident time and alternate location. So when it comes to, I guess, counting up what residents have to do to qualify for a DME or IME payment, their home location now will count. Basically, in other words, they can also work from home. If the resident is performing activities within the scope of his or her approved program, that hospital may not count, you know, against that patient, I'm sorry, that resident. And if the hospital is paying fringe and salary, then that would continue to work even if these residents are performing telemedicine or other telehealth duties from home. And the teaching physicians have to countersign the visits, just like they would do this otherwise. If a resident or a learner would provide an entire visit without the actual involvement of a teaching physician by themselves, you're supposed to actually call that patient up via telehealth separately and confirm that that, you know, was has taken place. So in other words, you have to touch base with that patient, however brief that may be. But you do have to touch base with that patient and provide that specific touch point before you can countersign that the way CMS wants this. A couple other workload considerations, you know, and this is, you know, one of an example of a ramp up here. I think it's worth noting that the video visits in Teal here are still, at least in our place, being outpaced by the telephonic visits that has a little bit to do with our location, that a lot of our patients do not have highly functioning smartphones or highly reliable connectivity at home and are limited to telephonic visits, which is really useful because CMS has relaxed their rules around telephonic visits as well. So going through this a little bit, the workflow for us has been basically that we verify a couple of things with that patient. This is done by front office staff. And then we make sure that the patient has some basic things in place, such as an email address that we can send them the links for these appointments, have connectivity at home, have a smart device, and have or are in an in-state location at the time of the visit. Now John spoke to this a little bit. This is being relaxed as we speak. For compliance reasons, it may still be important to understand whether or not the patient is actually living out of state at the time of the visit. And then if the answer to any of this is no, then we either reschedule the appointment or we cancel it with an appropriate reason to allow for tracking and potential rescheduling later, or it will be followed up manually to decide whether or not this patient still needs to come in person into the clinic for some reason or needs to be rescheduled. Documentation, as it was pointed out, needs to be just like you were doing as an in-person visit. It does help if you develop standard EMR phrases for some of these things, especially for the consent. And that is really helpful when it comes to going through the script of these. Billing coding is mentioned. The details of that are not captured on the slide. Obviously, John spent quite a bit of time on this. But basically, you have to describe the documentation, should describe the encounter as it was taking place, not more or not less. And that should be the basis for billing of this. Now, when it comes to telephonic visits, there are still basically two types of visits that we can consider here. One is the, shall we say, brief phone conversation that you may have with a patient, calling them to discuss a test result, calls after a face-to-face or so to follow up on a specific question, or calls to perform a brief history prior to scheduling a telemedicine or an in-person visit, like a triage kind of a phone call. Those are not telephonic encounters that will be subject or eligible for billing. However, now there's this new way of doing things, which is the replacement, basically, of a telemedicine visit just via the phone. And that is something that is billable. That is basically a visit that takes place over the phone, has all the documentation and elements that we discussed. And it is important to look at these differences because obviously we have an increased amount of phone calls with patients, both for triaging, managing them, and not all of these phone calls are somehow magically billable in this new environment. There needs to be a patient consent as well, a patient that must agree to a telephonic visit. There used to be the rule until about two days ago that the patient had to be an established patient and needed to be seen within the past three years in your specialty, and new patients were not billable. That has been changed, luckily enough, which makes this whole exercise quite a bit easier. And then telephone billing codes are time-based, so you do need to document the time actually spent with the patient on the phone. And again, the recommendation will be to use a standard phrase that contains Department of Health and AMA CPT verbiage required for billing and must be used for this. So these are the codes that can be used for telephonic billing. This is different for ancillary and nursing staff here on the right. And again, for residents and fellows, telephonic visits, encounters must be teaching physician guidelines. And if this is an entirely unattended phone visit, then you must follow up with that patient as well and phone in order to bill and attest to this visit. So like I said, now we can basically also bill for encounters with new patients, and that is usually something that just needs to be documented. This is a new patient, and that has been really, really beneficial. A couple other concepts, maybe a little bit more advanced. So in-house telemedicine. So the idea is to create a way of creating medical distancing, if you will, separating the providers from the patients. So one thing that we're doing is that we're trying to essentially figure out how we keep the cognitive specialties working remotely and working efficiently. So if a consult is called for one of these specialties, we created the role of a tele presenter and have them bring telemedicine equipment in that patient room. This is not meant to be done for COVID-positive patients. This is right now for COVID-negative patients. And they're there to essentially assist the patient with this telemedicine encounter while that specialist is sitting either in their office or at home and is trying to go through this. They can troubleshoot certain technical details. They can assist with the exam. And they're basically making that encounter somewhat more efficient. We use for our COVID-positive patients a different platform for this, which has more likelihood or likeliness with an EICU platform where we can go over this if someone has particular questions about this. But this has been an interesting avenue into expanding the use of telemedicine on the inpatient side. And you can think about where you want to use this. But there are plenty of consultative specialties that are currently trying to stay out of the hospital and could use something like this. With this, I think I'm at the end of my presentation. So we can go back to what John had said and just open this up to questions from everyone. And we'll see if he picked up some questions. And I'll go through the comments here as well. I'll just quickly touch on some of the valuation for one of the code families that were brought up. And that would be the two different kinds of coding for the telephone visits, 99441, 442, and 443. Clemens mentioned those. They are time-based. These are for telephone services. And they're not for the telehealth. They are time-based. These are for telephone services on a patient that you've already seen. So you've seen them within the previous seven days. But you don't see them again, nor do you do a procedure on them in the next 24 hours. So for 5 to 10 minutes, you'd bill 99441, that's valued by CMS, a quarter of a work RVU, so 0.25. 99442 is for 11 to 20 minutes. That's valued at 0.5 work RVUs. And 99443, 21 to 30 minutes, is valued at 0.75 work RVUs. There are other G codes for the telephone things that Clemens spoke to. But again, I think the real issue are those E&M codes and the more standard codes that we use to report seeing our patients in the outpatient setting. And, John, can non-physicians use that? How about nurse practitioners and PAs, can they use those codes too? There are three different codes for RNs that can be used. If I, hold on, I can still go back here. So here are the ones on the right. So these are totally different codes for nurses. Yeah, I'm glad you put that slide back up. So Clemens, there's a question I think maybe we should get back to as it becomes more relevant about inpatient evaluation. So if someone's in the hospital, there's a consultation, you're not physically seeing them, but you see them via iPhone or something like that. Is there any way to bill for that? I know you kind of brushed around it, but is there actually a way to do that? So, yeah, so we have thought about this quite a bit. And like I said, so we're basically using formal telemedicine equipment from one of our vendors that are based on something that you typically use for stroke care, for example. And actually, I have a person bring that to the patient's room. The reason for that is that, in general, the quality of the is better, a couple of different things. It looks a little bit like a more like a real consultation. And that person's role is to really, I guess, assist in that process, both on helping the patient with certain aspects of the exam, helping the examiner with certain aspects of the exam, and then also making sure that this works on a technical basis. Now, theoretically, could you do this with an iPad? I'm sure you could. And at least in the current climate, with all the ongoing relaxations, you would probably not raise any red flags if you use something like a commercial platform for some of these services. And like I said, the idea here is to try and figure out how you can use your cognitive specialties, both for consultations, but conceivably, you could also think about things like rounding or something like that, to make this as efficient as possible and essentially separate the providers from the patients that just still have to be in the hospital and minimize the contacts for the providers that might come up. And we have a somewhat limited experience with this. I mean, basically, we've been doing this very efficiently in stroke care. And this is something that is pretty common standard when it comes to emergent evaluations in the emergency room for stroke patients or on the inpatient side. You know, that works pretty well. Those consults are obviously billable and are built in a standard fashion. So there is, in my mind, no particular reason other than thinking through some of the details of your locale to scale this up and, you know, use the same concept for other specialties and non-urgent consults as well. Right. Right. But basically, document it, right? So there have been a number of questions. Oh, yeah. You document it just like a regular consult. Yeah. So there's been a lot of questions about imaging and uploading imaging. And I know that that's not the topic of this webinar. I see Vikas Rao has talked about using the software AMBRA, A-M-B-R-A. That's what we use at UM. Do you guys have any comments? A bunch of comments about how do people upload images from the outside of your hospital system? That's like a huge issue. And I saw a lot of those questions go through the chat box too. I don't know that I have an answer for them. Like we have two different solutions that we use. We use Life Image as opposed to AMBRA. It's like who we're contracted with. Life Image has a system where patients can upload their own images at home and then share them with their provider. Then it goes from the cloud to us so we can look at them. That's kind of hit or miss. Sometimes patients are able to do it and sometimes they're not. The other option is just have the patient like mail the films to you. I mean, that's very old school, but we end up doing that a lot. One of the other issues we have is even getting the films. Then when you're talking to the patient, how do you show them the film? Or how do you like share your screen? Like we don't have the Zoom option in our version of Epic that allows us to share our screen with our patients. I don't really have the option of showing a patient a film at the same time I'm describing it and then pointing it to whatever the pathology is. At least at present, a limitation of our infrastructure for telehealth. Clemens, have you guys at Geisinger managed to figure out a way to remedy that? Or is it any better in your guys' environment? My recommendation for the first part of this is to have your staff try really hard to establish where that imaging took place. And then see if you can get to this directly via live image or some different platform. Because this day and age, a lot of places have the ability to actually push or pull these kind of images. And if that's really not possible, then resorting to, like it was spoken to sending the CD or DVD is actually vastly superior than to try and somehow connect via this somewhat difficult connection sometimes to the patient directly and having them show their images to you via phone. I think that becomes really difficult to actually interpret these things meaningfully. On the opposite way, what John was just talking about, to a certain degree, you are, I guess, subject to what you can do with your video or telehealth platform. Hopefully your platform has the ability to share your screen with the patient. If that's not the case, you're a little bit in the pickle. And my recommendation to that then will be to try and see if you can either use a commercial platform that you use with the patient separately that has that ability and do a little bit of a hybrid approach. So there have been a lot of discussion now. I see Joe Chang is here. Joe, hi. This discussion of are these provisions, the sort of more relaxed provisions, going to sunset? And John, do you want to close up by commenting on that? So I just spent about an hour yesterday listening to a webinar by some internal medicine physicians that are real telehealth advocates. And they say that once these changes have been incorporated and once patients realize how convenient it is to do a telehealth visit as opposed to driving hours, waiting like 45 minutes in your outpatient waiting area, then waiting another 45 minutes for the rate of feeling to see their provider. It's just so much more efficient for patients to utilize a telehealth modality. The people supporting telehealth really think this is not going to change. And patients will demand to continue to have this as an option. Now, Mike, you and I discussed this over the weekend. I just, for a lot of what we do, there is great benefit to actually seeing a patient in person. But for some of our follow-ups, for some of our patients, for some of our patients that we're seeing in follow-up, I mean, gosh, telehealth may be all that you need. So I would anticipate, even as the COVID crisis passes, that telehealth is going to be here to stay. And I bet, based on the desirability of this from Medicare beneficiaries, there's a good chance that the payment changes will continue as well. Clemens, what do you think? I agree with this. I think there's going to be a date when some of these regulations are going to be at least formally, I guess, put back into place. But I think there's going to be a different way of looking at this. And at the end of the day, we are experiencing a massive disruption and shift in the way we will provide healthcare in the future. Great, great. And before I wrap up, Matthew Maserati's bringing up this very important thing that I think you need to address, John, for our audience, which is, sorry to repeat, but can anyone confirm that a new Medicare patient visit conducted by telephone only because of technical restraints could be viewed as a video-assisted visit? I think that's a very important question. No, very good question. So if you start out trying to do telehealth, meaning that if you're going to start out attempting to do a telehealth via My Health or Zoom or Skype or whatever platform you're going to use, and it fails, and then you convert to just a phone call, then you can code it as a video-assisted visit, even if it ends up just being a phone call. But again, the idea has to be that you're trying to start as a telehealth visit, meaning you're starting out by using Skype, starting out by using FaceTime, starting out by using a more standard telehealth platform like My Health or whatnot. But as long as you're starting with that and it doesn't work and you convert to a telephone call, you code it out as a regular E&M visit, as a video-assisted visit, not one of the phone call visits. But just to be clear, if your intent is to do a video visit and the patient says, yeah, but I don't have a phone, your intent is not sufficient in that. It has to be an aborted visit or a broken visit in a sense, like you said. If you're never actually connecting with that patient other than on the phone, that just remains a telephonic visit then. Great, great, great. I agree. That's exactly right, Clemens. I agree 100%. We're just about out of time. I wanted to thank John and Clemens and all of you for taking time out of your days. Please be safe. I apologize for any initial AV issues. Feel free to contact us through the AANS as well. And thank you for coming in tonight. Thanks, guys. Thanks, everybody. Appreciate you being on. Thank you very much. Thank you.

telemedicine

coronavirus crisis

telehealth visits

Medicare

billing

patient consent

secure connections

patient privacy

reimbursement options