In recent weeks many medical practices have been forced to leverage new or existing telehealth programs, opting for digital rather than in-person care to adhere to social distancing guidelines. As a result, telemedicine is set to replace the majority of outpatient and routine medical visits for the foreseeable future across specialties, including dermatology. According to the latest data, demand for virtual consultations has skyrocketed, with significant surges in phone calls and patient portal messaging as well as a rise in remote monitoring used to support the chronic disease population.
While virtual visits are essential for maintaining patient health, the introduction of telehealth can prove difficult and time-consuming in practice. As a result of the COVID-19 pandemic, significant changes have been made to regulations concerning the practice of telemedicine that aim to ease the process of implementation. In addition to lessened restrictions, specific guidance has been issued to support the reimbursement of online medical appointments conducted during this time.
Latest Guidance and Information Resources
Several healthcare organizations have issued guidelines and resources to assist medical professionals in providing remote care and establishing an online practice, including the American Medical Association (AMA) and American Academy of Dermatology (AAD).
“The AMA is laser-focused on ensuring the viability of physicians’ practices that are being impacted by the pandemic and will continue providing tools and resources and aggressively advocating on their behalf,” Patrice A. Harris, MD, President of the AMA told Dermatology Times.“We launched the AMA’s COVID-19 resource center to serve as a hub for physicians to find information to meet the daily challenges of managing a practice during the pandemic as well as the latest evidence-based guidance for treating patients.”
With the help of educational resources from the AAD and turnkey solutions recommended by the American Medical Association, clinicians can easily and rapidly adapt their practice to support the safe practice of teledermatology.
Implementing Telemedicine Into Clinical Practice
Eligibility for Teledermatology
First and foremost, clinicians should determine whether they can practice teledermatology per state and federal laws before they begin seeing patients virtually. According to the AAD, practitioners can treat a patient using telemedicine in the same state as their medical license, however, they are advised to check individual state laws regarding telehealth services – particularly in the case of emergency. CMS has temporarily waived these licensing requirements for Medicare patients, although practitioners should check if the patient’s state of residence has any additional regulations. Finally, clinicians are advised to check with their malpractice carrier to determine whether they have the appropriate coverage prior to implementing teledermatology services.
Choose Appropriate Patients
It is up to providers to determine which patients are eligible and appropriate for telemedical care in accordance with local, state, or hospital guidelines. Patients with symptoms that may be difficult to assess without being physically present should be referred for an in-office visit.
To ensure a successful telehealth visit, both patients and providers need to have access to a smartphone, tablet, laptop, or desktop computer as well as stable internet connection. Before the appointment, healthcare providers or their assistants will need to email patients a link with conference information or other online meeting details and ensure they are equipped with the necessary tools to conduct an online visit.
Implementing Telephone Visits
Dermatologists can utilize their existing scheduling system to list virtual or phone visits. While diagnostics will still require an in-office visit, clinicians can e-prescribe, place orders, educate, and counsel patients over the phone as part of a teledermatology visit. Clinicians are urged to document the visit using their current EHR system or standard templates and to bill by the duration of the visit. In order to protect their privacy, medical professionals may want to block their personal phone number using *67, an equivalent smartphone application, or using their healthcare facility’s phone line.
To ensure clear, uninterrupted communication with their patients, clinicians may choose to set up space in their office dedicated to conducting telemedicine visits, such as an exam room or quiet office space, and specialized vendors to ensure standards of digital care can be met.
Using Video Conferencing
Video conference visits conducted via an appropriate, HIPAA-compliant telehealth provider can allow for a more comprehensive experience for both patients and providers than phone appointments. Before searching for an appropriate telecommunication provider, physicians should check with their existing EHR vendor to see if there is any existing potential telehealth functionality. Otherwise, video communication services such as Skype for Business, Updox, VSee, Zoom for Healthcare, and doxy.me are HIPAA-compliant conferencing systems that work effectively for conducting virtual visits. Additionally, the AAD has compiled a list of vendors offering such services which can be accessed here.
Physicians should approach conducting a virtual visit as if it was occurring in person, save for the physical examination – which can be replaced by asking patients to demonstrate physical symptoms if needed. As with phone visits, video conference visits can be used to e-prescribe, place orders, educate, and counsel patients. Diagnostics will still need to take place during in-person visits. Another important consideration is data privacy; clinicians need to make sure they understand who has access to and owns any of the data generated during the online visit.
More resources from the American Telemedicine Association are available to help identify vendors, regulatory changes, and other essential information for implementing telehealth as well as the AAD, located on their COVID-19 Teledermatology page.
Telephone Visit Billing
Coverage and payment structures can vary across insurance companies, although the latest changes to federal regulations hope to alleviate telemedical billing concerns. Lifted restrictions allow dermatologists to bill for telehealth visits for any Medicare patient in any location, for both new and established patients. Precise documentation of virtual visits is necessary to ensure providers capture work done during the pandemic and can be reimbursed appropriately.
Real-time virtual visits, store-and-forward, and telephone visits can all be used and billed on the basis of new billing codes. To help clinicians determine which code to use, the AAD has created a flowchart for telehealth encounters, which can be found here.
To help clinicians navigate the policy and payment landscape, the AMA has provided guidance based on the latest updates from the Centers for Medicaid and Medicaid Services. In addition, the AAD has developed a document tracking payer policy updates as they become available.
Changes Easing Implementation
As per updated federal regulations, Medicare will pay for office, hospital, and other visits provided via telemedicine across the country. Teledermatology visits conducted as part of the Medicare program will be reimbursed at in-office rates during the COVID-19 outbreak. A wide range of providers may choose to offer telehealth services according to the latest guidance, which offers greater flexibility for specialty practitioners. The U.S. Department of Health and Human Services’ Office of Inspector General has initiated an effort to reduce or waive cost-sharing for telehealth visits paid by federal health care programs to further ease telemedicine implementation.
Additionally, the CARES Act has removed the requirement of an established patient-provider relationship for the practice of telemedicine. Now clinicians providing care to Medicare beneficiaries can qualify for a telehealth waiver for virtual visits – which can occur via voice-only communication, another amendment to regulations.
Prior to offering telemedicine services, practitioners should ensure that their malpractice insurance covers remote visits to avoid potential liability. Although regulations loosening state border restrictions are anticipated, telehealth encounters are currently considered to take place at the physical location of the patient not the provider. Thus, providers must comply with the laws and regulations set forth by the professional licensing board within the patient’s state.
Further, documentation requirements for telemedicine remain the same as those pertaining to an in-person visit, although, documentation should additionally include language outlining that the service was provided digitally. In addition, clinicians should ensure they have their patient’s consent for telemedicine interactions in advance of the visit and to document it in their records.
It is important to note that all of these considerations may be modified as a result of the dynamic pandemic landscape; providers are encouraged to check with their legal and insurance providers for the most up-to-date guidance.
With the latest regulations and considerations in mind, clinical dermatologists can use actionable solutions to take their practice online, providing medical care as well as maintaining their patients’ health while prioritizing their safety. While the widespread shift toward telemedicine may be a temporary for the duration of the COVID-19 outbreak, virtual visits are expected to continue growing in popularity as more medical practices and healthcare facilities expand their telehealth programs to fulfill growing demand from patients.
Changes to regulations allowing for the easier implementation of telemedicine in practices across the nation are expected to continue emerging as the U.S. healthcare system transitions into a digital care model throughout the COVID-19 outbreak. In the meantime, clinical dermatology practitioners looking to integrate telemedicine into their practice can benefit from the quick guide recently published by the AMA – which can be found here. Further guidance can also be found on the AAD’s COVID-19 Resource Center website, accessible here.
As an additional resource, the AMA recently launched an online discussion forum for healthcare practitioners to share their experiences, ask questions, and get answers from telemedicine experts, located here.