By Ben Cobb, MD

Department of Anesthesiology, Division of Obstetric Anesthesia, the University of North Carolina at Chapel Hill School of Medicine

The COVID-19 outbreak has led to rapid changes throughout the health care system as hospitals and providers pivot to address the mounting community demands in the face of this pandemic. In addition to the medical needs of patients diagnosed with, or a patient under investigation status for, COVID-19, routine medical care also may be affected by the changing health care landscape. With implementation of social distancing and quarantines to prevent infectious transmission in order to “flatten the curve,” telemedicine is perhaps one of the most rapidly changing facets of medical practice in the face of this crisis.

National and institutional revisions to billing and supervisory descriptors have been made to encourage telemedicine services in the face of the pandemic, creating opportunities to ensure patient access to those affected by the COVID-19 outbreak. Telemedicine is a timely tool to ensure outpatient high-risk obstetric anesthesia (OBA) consultation services for women affected by the pandemic.

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A variety of telemedicine modalities are available in electronic health record software, utilizing an array of terminology for these tools. As one example, Epic Systems offers three types of telemedicine services. First is the E-Visit, which is a structured template of 10 questions for a patient to answer in MyChart, the patient portal. The E-Consult is for provider-to-provider interactions, which could potentially replace “curbside consults” and “in basket” peer-to-peer patient communication. Finally, the Video Visit (VV) is for scheduled video appointments between a provider and patient using the MyChart software. The provider logs into their virtual clinic in Epic and is able to engage the patient in the virtual waiting room. Documentation may be entered in the same way as in-person outpatient appointments. 

Traditionally, most payors have not reimbursed for VVs. Previous barriers for effective implementation of a VV format for high-risk OBA outpatient consultation have included reimbursement challenges and concerns about the existing Medicare teaching rules. Another billing challenge for Medicare patients is the requirement for physical exam documentation. Medicaid has traditionally required pre-authorization and “with a significant distance” qualifier between the provider and patient for VVs. Even in instances in which Medicare billing for these visits has not been considered a priority or not applicable to the patient population, institutional guidelines may be based on conservative Medicare billing criteria, further limiting routine resident and fellow participation in telemedicine services.

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CMS Changes for Telemedicine

On March 17, 2020, the Centers for Medicare & Medicaid Services (CMS) released a fact sheet outlining an expansion of Medicare coverage and payment for virtual health care services during the COVID-19 pandemic. These changes were made effective as of March 6, 2020, and for the duration of the public health emergency. The revision considered “Medicare telehealth visits” (similar to VVs) to be “the same as in-person visits and paid at the same rate as regular, in-person visits,” but noted that this applies to established patients.1 

While obstetric patients are not Medicare recipients, the revisions to Medicare billing by CMS may warrant reconsideration about the acceptable role of trainee participation in VVs, as well as the broader billing opportunities for outpatient consultation outside of Medicare during the health care crisis.

Given these timely regulatory changes, the Accreditation Council for Graduate Medical Education (ACGME) issued a letter March 18, 2020, similarly calling for an “accelerated implementation of telemedicine services.” In effect, they “accelerated an anticipated revision to Common Program Requirements rewording trainee supervision for telemedicine visits.”

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Additionally, “the ACGME will permit residents/fellows to participate in the use of telemedicine to care for patients affected by the pandemic” and allow for “appropriate telecommunication technology” as a type of direct supervision.2

Navigating the Change in CMS Rules 

Given these developments, at the local level our institution is rolling out a virtual outpatient high-risk OBA consultation option given that we are not able to interact face-to-face in our current clinical environment. We are reaching out to patients whose consultations have been canceled and will schedule future consultations affected by the COVID-19 outbreak for VVs. 

Obstetric services face an array of challenges with the COVID-19 pandemic similar to other acute care units, such as the ER and ICU settings, one of which includes maintaining a capacity for caring for the usual workload in addition to those directly affected by the pandemic. Maintaining early OBA communication and planning for high-risk parturients becomes perhaps more important in a rapidly changing health care environment, and VVs may prove to be an effective tool to ensure this service. While some institutions may offer VVs for OBA consultation, all institutions may benefit from considering telemedicine in this new environment, and may draw from the experience of others already employing this technology to care for patients.

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In a survey of U.S. academic medical centers, up to 38% of respondents reported high-risk outpatient consultation services.3 While there are no published reports of telemedicine being utilized in this setting, there are studies reporting encouraging findings in patient and provider satisfaction with telemedicine visits in diabetes telemedicine clinics.4 Video Visits may similarly lend themselves well to enabling early anesthetic planning and multidisciplinary communication for high-risk parturients. At the very least, they warrant consideration as a way to optimize patient access and experience given the rapidly changing health care landscape. Future studies may categorize and optimize patient outcomes in telemedicine OBA consultation. 

Perhaps the emergency measures employed to care for patients during the COVID-19 health care crisis could yield long-term benefits for patients by reducing barriers to care via telemedicine services.

References

  1. Medicare telemedicine fact sheet.www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. March 17, 2020. Accessed April 29, 2020.
  2. Nasca TJ. ACGME response to the coronavirus (COVID-19). www.acgme.org/Newsroom/Newsroom-Details/ArticleID/10111/ACGME-Response-to-the-Coronavirus-COVID-19. March 18, 2020. Accessed April 29, 2020.
  3. Butwick AJ, Tiouririne M. Evaluation of high-risk obstetric patients: a survey of US academic centers. J Clin Anesth. 2016;33:460-468.
  4. Fatehi F, Martin-Khan M, Smith AC. Patient satisfaction with video teleconsultation in a virtual diabetes outreach clinic. Diabetes Technol Ther. 2015;17(1):43-48.

CMS Updates Rules for Telemedicine Care Again

On April 30, the Centers for Medicare & Medicaid Services (CMS) announced temporary changes to the rules for providing telemedicine services, in an ongoing effort to address the needs of health care workers and patients during the COVID-19 pandemic.

As part of a series of waivers, CMS has expanded providers of telemedicine services to include practitioners such as physical therapists, occupational therapists and speech-language pathologists. Previously only physicians, nurse practitioners and physician assistants were permitted to provide those services.

In addition, hospitals are now allowed to bill as the “originating site” when offering telemedicine services to Medicare patients who are registered as outpatients, even when they receive that care at home.

The waivers will also ease the process for adding new telemedicine services to the approved Medicare list using a “sub-regulatory” method for approval.

And, in accordance with the Coronavirus Aid, Relief, and Economic Security Act, CMS will allow rural and federally qualified health clinics to provide telemedicine services as well as receive payment as “distant sites.”

Medicare beneficiaries also will be able to access telemedicine services using audio-only devices. CMS has waived the video requirement for certain medical evaluations. This change comes as the agency acknowledges that not all Medicare patients will be able to access or want to access telemedicine using video.

These temporary changes apply immediately and will last until the end of the public health emergency declaration.

—ORM Staff