SPEAKER_01 0:00

On this episode, Telehealth, an essential foundation for healthcare in the future. Stay tuned. Today's episode is brought to you by ModMed. Do your EHR and PM adapt to your style of practice? The ModMed, EHR, and PM do, with benefits like remembering preferences and automatically suggesting documentation and billing codes. Urologists voted ModMed the number one urology-specific EHR and PM solution available. Built by urologists with input from yours truly. Stop wasting 60 minutes and 200 for each of your open or no show slot. Go to modmed.com slash PRS Network, set up an appointment with the team at ModMed Urology, and shift your urology practice into high gear. Imagine a solution on a tablet or the web that works seamlessly with revenue cycle management, analytics, telehealth, payment processing, patient engagement tools, and much more. ModMed is transforming healthcare by placing doctors and patients at the center of care.

SPEAKER_00 1:09

Welcome to episode 302 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, Dr. Ray Painter. And on today's episode, we want to talk about telehealth. It's been a big topic of conversation over the last five years, six years, and sounds like right now, from the rules and everything, we have something at least fairly stable through the end of next year for Medicare in telehealth through 2027. But we want to make sure that everybody understands what's going on, and we have a few questions and scenarios to go over as we go through this, just to make sure everybody's on the same page of telehealth as it is an essential foundation for healthcare future. So we want to make sure that everything is understood and what you're doing in telehealth is on the right track, and you're making sure that you're capturing all that you need to capture. All right, and we are releasing our telehealth category page, and you'll be able to find that on the PRS Urology Coding and Reimbursement Hub. If you go to PRSnetwork.com forward slash urology hub, you'll be able to find that telehealth category page up in the next week. All right. Mark, you wanna go over telehealth? Where are we?

SPEAKER_01 2:48

Alright, so let's start where we are, and then we'll move a little bit into proposed rules, and then we can flow into the reason I think it's foundational for healthcare in the future. So let's start with where we are. So we know statutorily, and that means that this was passed by Congress. So it's not something that Medicare can change their mind on with the final rule. It has to be followed as a regulation that was passed by Congress, and that is that audio only and audiovisual services can be provided to patient to Medicare patients through the end of 2027. So we've got another, what's it, about 16 months that are covered under this rule set we have right now. The way that telehealth is reported to Medicare, and we'll kind of use these terms as telehealth, meaning audio and visual visits, and then audio-only visits are those visits that are provided via phone only. So those rules are set, and essentially all of these services are going to be billed via with ENM codes, and I probably shouldn't say all. That always gets me in trouble. Always, never, and I just said it again. But anyway, we can't say all visits, but most visits, like a typical, those visits that would replace a standard office visit or other outpatient visit, can be reported using your standard office visit codes, the 99202 through the 99215, depending on the level of service you provide. Those can be the level of service. So first the code set is chosen whether it's new or established. Now, the guidelines that we have based on the interpretation really are set around the old COVID rules, which allows for new patient visits. But there are some recommendations or guidances put out by Medicare that really focus on the established patient as the most appropriate type of patient encounter to be provided via telehealth. They left open the door with the new patient side and the new patient side, really primarily to take care of those one-off cases or those cases that really support rural health. So I think those are really those two kinds of areas, those individuals who are in essentially healthcare deserts or health professionals shortage areas, and then those circumstances really where maybe the physician is sick and they really can't deal with the patient who's in the office. So emergence situations. Those are new patient sides. But the established patient part of this is something that we've noticed many of your many of our urology practices using routinely. And that's a, I think, a big part of some practices and how their patient mix is. And there are some considerations that need to be dealt with as far as documentation relative to those particular codes. Now, when we look at picking the level of service, we're still basing that based on medical decision making or the time that is spent overall. So just like an office visit, we're going to follow those same documentation guidelines. So documentation guidelines are the same, with a couple of as far as picking the level of service. The exceptions as far as like detailed documentation for each visit, whether it's new or established, you have to clearly document that the patient has consented to be treating by to be treated by or remotely in either telehealth or audio or audio only. You need to document clearly what modality was used and that it was HIPAA compliant or the tools you're using are HIPAA compliant. You need to make sure that the station the patient is located in a state that you're licensed to practice medicine and state that in the record. And then you document that clinical piece of the encounter as you would normally. Now, with audio-only visits, we should clarify there's a little bit of a rule that really needs to be followed. And that is that the patient needs to be offered an audio-visual visit and chooses an audio-only visit, or that an audio-visual visit was attempted and failed, and the patient agreed to continue to proceed with an audio-only visit. So that's the those are some of your documentation requirements. So all that stuff needs to be in the record. Choose the level based on MDM or time, and of course the category based on whether or not it's new or the patient is new or established. We also have the capability under these rules to provide telehealth services to patients in the hospital. It's important to note that when you provide telehealth services to a patient in the hospital, once again, the patient's location drives the code selection. If they're an inpatient, you're going to need to use inpatient codes even if you're not there. The place of service for a patient who is at home or not in a facility is place of service 10. The place of service for a patient who is in a Medicare-approved facility, like a hospital, is place of service 02. And we still do not, and I'm going to go out on a limb, and I don't think it's a weak, thin limb, stating that even past 2027, we are going to see telehealth allowed in both locations, both in the facility and in the patient's home, even in urban areas. So we're not going to go back to the old rules that require that the patient's part of a health professional shortage area. We're not going to see rules that require the patient to be in a Medicare-approved facility. They're going to be able to get telehealth services from their home. What we don't know in the future is what type of regulations they're going to place around where the physician needs to be, what codes they're going to use, because you may recall that CPT has a brand new set of codes for telehealth and audio only codes that are in the 98000 through 98016 series of codes. So that may change in the future, not again for Medicare, not until the earliest January 1, 2028. Now, but that may be an issue that you come up against with your private sector payers. So their coverage, of course, is optional. Most private payers are covering telehealth services, as are most Medicaid programs. They may or may not follow Medicare rules relative to using the EM codes 99202 through 99215. They may require the 980 codes. So both Medicare and commercial payers, you're going to want to double check which set of codes to use. But the list of issues that I covered earlier of consent, a clear description of the modality, and a the location of the patient. And then the other piece that I'm going to add on there that really fits under to the consent rule is the patient does need to understand that this is a medical visit and they will likely be charged a copay. So this is a there is a financial consideration for the patient that they need to be aware of, and that needs to be documented as well. Ready?

SPEAKER_00 12:14

Comments, questions?

SPEAKER_02 12:16

Nothing to add at this point.

SPEAKER_00 12:19

All right. I have a question. So have you seen any commercial payers using the 980 codes? Have you experienced any of that? So not much, but yes. And Medicare has put a value on those that are lower than the 992 12s through 15s. Are they those that you have seen, they're using those lower values?

SPEAKER_01 12:54

So lower values, yes. So they might actually be higher than Medicare payments, but they are lower relative to the in-person visits under the same contract in most circumstances that we've seen those used. So the proposed rule has included in it a group medical visit. We talked a little bit about this when we talked about the proposed rule. And this again can be done audiovisual. So this is one of those additional areas that Medicare really is at the moment lengthening the leash of what they can do. And I think a lot of this has to do with the restricted access that patients have to getting medical care. So a group medical visit, as it's proposed by Medicare, allows up to 25 patients to be in the same visit. It does allow it to be in-person or audiovisual, just like EM visits. But the parameters that they proposed really indicated that they expected most of these group visits be to be to have between two and ten participants, and that the visits would last typically between an hour and two hours. They would require that a physician and likely an administrative support person, well, I should say a QHP, so a physician andor an NP or PA, so an APP, and then an administrative person. And they expect that both the video and the in-person visits would allow for the group to be together, but would also have accommodations for individual breakout visits that could occur during this entire group session. They are going to require that all the patients sign a PHI release because, of course, they're going to be discussing their illnesses with other individuals and some of their personal information. They also indicated that they thought this was a great idea, not just for the access in all of this, but also for potential of patients to share information amongst each other as part of a discussion. So kind of the way it's written, they're thinking about, and I'll just use the urology example that popped in my head was maybe you've got a group of patients that have bladder cancer, and maybe they're in various stages, some with recurrence, some with first-time experience with bladder cancer. And you would convene the group to go over what's going to happen with a TURBT and what is the next step in that treatment. How does follow-up care work? Are you going to look at maybe it's non-minimally invasive and invasive and fits the criteria for Zysduri? So some folks may have an option of a TURBT and drugs. Some may not have that option. Some may be thinking about cystectomy. So maybe that group is together to talk about cystectomy and the pathway from there. So they're thinking that again, that the information, the clinical information can be uh imparted by the physician or the QHP, the APP, and that discussion would be led. Maybe some of the information presented to the group, the group could discuss maybe where they were on the pathway, what their concerns were, answer any of those questions, and really kind of lay out plans of care. And then, of course, the breakout rooms would be available, and I'll use rooms and air quotes, like a video breakout room or a regular exam room, would be available for a patient to actually spend a little more time with the clinical team to actually talk about their specific case. So, and there is a proposed code and a payment there that you would actually charge to each individual patient. So this would be something you would provide to the patients as an opportunity to maybe get some additional perspectives on how you are as an individual at treating those patients, maybe what their experience has been, or to talk with each other about their fears, those types of things, and take less time than it would to actually run each of these patients through individually. So that's kind of exciting as well. And again, shows Medicare's long-term commitment to telehealth and expanding those types of services.

SPEAKER_00 18:16

And do you think that's does it look from the preliminary that would be financially more advantageous as well? Just from I mean, obviously you're not gonna be able to bill 10 individual EM codes, but you're only spending one hour or two and treating two to ten people. So that looks like a good financial decision to make this uh incorporate this into your practice. Uh is that what your recommendation is? I guess devil's in the details, the fine the final rule, but is it looking that way to you?

SPEAKER_01 18:52

So I can certainly see it based on a minimum number of patients. So if you look at the potential of we'll just take an hour and let's say an hour-long, an hour window of six individual patients, each one of them receiving a level four visit, the payment that they've set at an uh of $117 puts it at about the same level as a level four visit. So six level four visits versus six patients in this particular group visit seems like it's about equal in the overall revenue side of the equation. So it's just about break-even when you look at those from that particular level. So I think that's what they were thinking of when they put that payment rate in. Obviously, if you have 10 patients now, and the visit still lasts an hour, now you're ahead by four level four visits. So I think it's a combination in the analysis of time and number of participants from that straight financial perspective. Now, from the marketing perspective and the value perspective, that has yet to be determined. We really need to kind of see where that fits in the overall scheme of things. I could see it being more valuable to the patients, more valuable to the physicians overall, in the amount of mental effort it takes to go through an hour long versus six individual visits. But again, that's something we're gonna have to find out.

SPEAKER_00 20:40

And obviously, there is the technical side of things that need to be figured out for those that aren't at that tech savvy level yet.

SPEAKER_01 20:48

So absolutely true.

SPEAKER_00 20:50

Another consideration.

SPEAKER_01 20:51

Correct. But even in person, without the tech, there's something there. So obviously we're overlapping a little bit and outside our telehealth scope, but you've got all those options as well.

SPEAKER_00 21:02

Yeah, the logistics of getting them added to the group, the blah blah blah, all that stuff. All right, Ray, thoughts?

SPEAKER_02 21:10

It's intriguing to think that Medicare is now really uh embracing the group. And it's gonna take a lot of organizing on the part of the docs to figure out which patients they want to do that. And I see it just in thinking about I see it happening more on the front end of a patient's journey than on the back end because of the how personal the major treatment is like cysteomies, chemotherapy, and so forth. But it'll be interesting to see how it's used.

SPEAKER_01 21:48

Yeah, as we're looking at some of the lean in, and I'd say this is why I kind of brought this up of maybe a patient with recurrent cancer coming into a group. Visit. We've got BCAN out there. And we also have the Medicare who has leaned into the potential of patient trained assistants or navigators to help the patients move through the journey to have that sharing of things. And I then, of course, you've got the internet back and forth of all the craziness and value, both, that patients look at across the board. So I think this is a step towards embracing where we truly are with healthcare, where patients are, they do have at their fingertips a lot more information than they used to have. So I think this really is leaning into what we've what we're where we're at, meeting the patients where they are and what they can do in self-treatment, self-diagnosing, determining their own pathway from Claude and Chat GPT and all those other things. And putting that human, introducing the human element back in is something that I like this concept overall and see this as a continuation of kind of where Medicare was, has been going.

SPEAKER_02 23:22

Yes. And there's the patients need a lot of help that they're not getting. And so if they can get it organized to get that help in this method, that'll be great. And when I say help, I'm talking about information, decision making, and all of this. It's tough on patients right now. The healthcare system is just too busy to take care of patients.

SPEAKER_01 23:50

Yeah.

SPEAKER_02 23:51

In many instances.

SPEAKER_01 23:54

This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitomycin for intervesical solution, is indicated for the treatment of adult patients with recurrent low-grade intermediate risk non-muscle invasive bladder cancer. Please visit zesturi.com for more information.

SPEAKER_00 24:17

Yeah. All right. Well, let's transition into some questions and then we want to hear a little bit about the future. But I know Ray, you had a question, and I've got one as well.

SPEAKER_02 24:32

Oh, you're talking about the hospitalized patient?

SPEAKER_00 24:36

Yep.

SPEAKER_02 24:37

All right. Now, there was I had an incident where I was in the hospital, and my primary care had set up a teleapointment for me at that time. And when I told him I was in the hospital, he was ready to hang up because he couldn't get paid for that visit. But Mark afterwards was telling me that he could have gotten paid and was telling me how. And then it came up with the question if I have a patient in the hospital that I need to talk to, but I can't go see right then, could I do a telehealth appointment from my office or my home to a patient of mine in the hospital?

SPEAKER_01 25:26

Yeah, so there is no restriction in the way the billing works for provision of a telehealth visit to a patient in the hospital. Now, you've got to again, like we always do, where the patient is when they receive the service determines the appropriate code. So if the patient is an inpatient, you would have to use an inpatient visit. And in this case, likely would be a subsequent visit for that particular patient encounter. And of course, the visit needs to meet medical necessities. So I don't want people to think that they can essentially skip the rounding on patients if they do need physical touch examinations that are there. But certainly this is something that would fit. The place of service would be zero two. And the visit could be conducted with audiovisual means as long as it's HIPAA compliant. So whether the hospital has that technology to do that, or you can do that with your phone and doximity or some tool that has HIPAA compliant connections, and you got enough of bandwidth within the hospital to do it, then you could provide that service for that patient. And in your case, the visit was from a physician who was actually not caring for you for that particular encounter, but providing you general care overall for your health during an episode in the hospital. I don't see how that doesn't fit the medical necessity side of the equation and could be reported under the inpatient visit side with a different diagnosis and based on the medical decision making charged as a subsequent visit, as a one or a two for your visit. A one because he tried to jump off too soon. Yes.

SPEAKER_02 27:41

The world is changing.

SPEAKER_00 27:43

It is changing. All right, I got one one last question, then we can go on to kind of why this is so important for the future. So a lot of urologists treat elderly patients that may winter in a different state. You've already answered that question that they have to be licensed in that state. But what is what responsibility is it of the physician beyond asking them? And what if the patient isn't straightforward with where they're located because they just want to get the treatment, even though they may be in Florida and you may be in Colorado as a physician? What's your responsibility?

SPEAKER_01 28:25

Well, the responsibility is to ask the questions and record the answer. Now, if you're in, let's say, Idaho, and you have an audiovisual encounter and you can see the patient has palm trees and a beach behind them, that may be one of those areas that you can't ignore that you're providing advice in a different state and that you know it. And it and that's one of those things that could be pierced in a medical legal case. So this is something that you've not just got to think about the reimbursement picture, but also the licensing that you have because that is potentially not covered by your malpractice. There are some of those issues that you need to consider as well. So I would say don't just take the cursory effort, make your actual best effort to figure out what's going on. There's more to it than just the payment for that visit at stake. But and I would also add though, I mean, if you're in a state or you have a number of patients that winter somewhere else, we've got a lot of states that have that participate in the multi-state medical license program, which does have a fee to it. I think last I heard it was around $750 a year. So it's probably not worth it for one or two patients. But boy, if you have $15 to 20 and you could keep that pace, those patients' appropriate touch points and follow-up care going through the summer months and be available to them via telehealth, that might be a great investment to allow you to treat beyond your own state line. So it's that balance piece, and then that's kind of leaning into the future. Let's look at where your patients are. What makes the most sense for you and can and can you qualify for those multi-state licenses that meet your patients or meet your patients' needs.

SPEAKER_00 30:37

Yeah, that's a good solution. All right. Let's hear about the future. What why is this we're all seeing the benefits of it and kind of understand with the new leaning into the group visits and there are a lot of advantages that that the communication technology allows us. So why do you think it's even the foundation of the future?

SPEAKER_01 31:06

Yeah, so so number one, I would expect that at some point in time we're gonna see a change of the reimbursement so that the telehealth visit, for Medicare at least, is not paid at the same rate that an in-person encounter is. The argument's been put forth a few times that you're not using uh the same personnel for the same amount of time. You're not using the same disposables that you have for an in-person visit. So those are just two obvious arguments that could be used to say eventually we're not going to pay at the same rate as the in-person. So that's one thing that I would consider, and this is something that we look at in a lot of the new technology as it comes in, how we see that first those first adopters really get paid a little bit better. And that to me makes it important to jump in the bag at the bandwagon now, because I do see telehealth as a big part of the future of healthcare. Number one on the list, we've already mentioned multiple times, is access. We we've talked about this in some of our AI talks, and we've talked about it in looking at scribes, all those types of things. I mean, bottom line is that physicians are very busy, and getting in to see a physician is difficult. And if you've got that extra hour capability or something, plus you've got that additional reach that telehealth allows for your patients who are not as mobile, maybe not maybe far away in all the things that as far as their actual location, this really helps with that piece of it. And if you can make that happen while the reimbursement is a little bit higher, you've got the ability to fund that. The other piece that I will add into that entire consideration is because telehealth is not going away for just that access point, to me, is enough. I would also add in that true adoption of telehealth really does need to be treated more like a business line. I think the biggest complaints that I heard about telehealth through COVID and then immediately afterwards was I had to fuss with the patient, trying to get them on board, do all that stuff. If you invest in it like it's a line of business, now you can A, get better with your own technology so it's easier on you, but B, set up the inf the support infrastructure within your practice. Take some of your MAs, turn them into virtual MAs that really understand what needs to be done to help connect the patients. Teach them how to room the patients to collect all the necessary information to get the documentation requirements all checked off and documented in the chart, just like you would an inpatient or a patient that you're seeing in person. Collect all the necessary updates on what's going on. So build that process. And then the other part is really making sure that scheduling-wise, you've got this really blocked out within your schedule. I mean, we've seen folks do this very, very well, where the MA, the virtual MA, rooms all the patients while the physicians may be with the last patient of the day. And five or six patients are set up in the virtual office. Physician gets finished with the in-person visits and then spends an hour and runs through five or six patients who are all ready to go on the line. The efficiencies are there from a time perspective. All of that makes a lot of sense. And then the other part of it is, of course, making sure that you're scheduling patients who really would benefit medically from a telehealth visit as opposed to an in-person visit in the scheduling time frame. So you're looking at head and saying, this pay the patient who has a positive prostate biopsy, I probably just saw I've got all the data I need. I don't need to do any more physical examination with them. That's perfect for a telehealth visit. I want to tell the patient that it this is going to be a telehealth visit, not give them the option to choose that just because they want it. So it's about, again, building that infrastructure, really talking to your patients about what happens on those, getting comfortable with the tools and technology so that you can provide the patient a glimpse if they need it of the biopsy or the MRI that you're going over, so that you can make this much more like an in-person visit and do it efficiently. So there's a lot to this that you'd want to build that infrastructure while there's a little extra payment coming in the door. And then the second thing that I'm going to add to this is really looking at what's coming down the pipeline. Now, we've talked about some of the new technology that's already out in the marketplace, like audible Euroflows. We've got the technology-based, home-based Euroflows. What could we do with follow-up of those BPH patients who just started their meds and instead of bring them in the office for a quick Euroflow, have them do it at home. Get back onto a telehealth call and change their meds if they need to change their meds. Really find out what their score is and back it up with data. And we have, we're just beginning to see the reach of technology and what's going to be available to us to provide care. We've we could potentially, and actually, we do have the capability to do remote UAs or remote clinical analysis on urine. So there's a lot of things available out there that will allow us to cover more of our patients while they're at home with some of the tools and diagnostic pieces coming down the pipeline for telehealth and remote services that could easily be added into the mix. And that's coming in a big way. And that's the other part of this that I'd look at this as foundational that eventually you are not going to be able to get away from having telehealth in your practice. Why not do it now and utilize it now? Because it's workable now, but it's going to be even better in the future as we move forward. So jump in now, take advantage of the extra reimbursement, build your foundation so you're ready for the next step of health care. Ray, your thoughts.

SPEAKER_02 38:50

Well, Mark, we know it's very convenient for patients in many areas, and patients are accepting this as well, as are better in many cases than an inpatient. So when you talk about the business model, what do you see about patient demand in the future as far as demanding telehealth as their visit?

SPEAKER_01 39:18

Well, we're already seeing it. So it's just going to grow as it becomes more a part of healthcare. And I also think that as we consider these remote testing things, those are going to drive up that particular piece. And then the last one, I'll circle back to where I started, and that is access. Your patients' problems don't go away because you don't have a visit slot for them. So can you reach them while they're in need because your office is full and you don't have to shuffle patients around or stack everybody in and overstress your staff. You just schedule them in the end of the day on an audio visit or a telehealth visit and handle their issues as they crop up, giving you a less disruptive way to meet the patients and their needs when they need it.

SPEAKER_02 40:20

I was just thinking, as you were talking about all this remote stuff, the Apple Watch can tell you so much about this. You think you can tell a urologist, be trained to tell a urologist how much the patient is straining to urinate?

SPEAKER_01 40:36

Not yet, but I don't know.

SPEAKER_00 40:40

All right. Well, let's wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience. Also, we want to thank Eurogen, manufacturers of Zezduri and gel mito. You can go to gelmito.com or zezduri.com for more information about those drugs. Okay. Any more final thoughts? Mark.

SPEAKER_01 41:17

No, I think I've kind of been my on my bully pulpit throughout this particular episode. I you know, obviously I was early to the telehealth game. Probably even we talked about telehealth a lot and the technology that I thought should be used even before it was fully reimbursed. And of course, now I've now that it is reimbursed and it actually makes sense from a financial side, I'm all in. Time to really look at all of this stuff.

SPEAKER_00 41:48

Yep, that's true. And the pioneers of the telehealth before COVID, you were on the board with that, along with uh Dr. Finkelstein and others in that area. So give a shout out to them.

unknown 42:02

Yeah.

SPEAKER_00 42:03

Ray, final thoughts.

SPEAKER_02 42:06

Well, keep in mind that it is a big convenience for many patients. So it's not only a good business, but it's good patient care.

SPEAKER_00 42:18

So true. Okay. That's it for this episode. Want to remind you that we do have a Labor Day special going on for our Urology Advanced Coding and Reimbursement Seminar. You can go to PRSnetwork.com. Right there on the home page is a seminar registration button and you get a 20% discount. That's good through September 11th. And also want to, as I mentioned earlier in the podcast, we do have our coding and reimbursement hub up and running. If you go to prsnetwork.com forward slash urology hub, that has information on coding and reimbursement, not only for the categories of urology, but also a lot of individual urology products. So we encourage you to check that out. All right, that's all we have for today. Thank you all for listening. Take us out, right? Happy telehealth coding. Thank you for listening to the Urology Coding and Reimbursement Podcast, where we help urologists and their staff maximize income and efficiency so there's time and energy for patient care and a happy life. Special thanks to Hello Painter for the music today. You can find his music on Spotify under his record label.