key: cord-0972174-chfb4i15
authors: Bulman, Julie C.; Moussa, Marwan; Lewis, Trevor K.; Berkowitz, Seth; Sarwar, Ammar; Faintuch, Salomao; Ahmed, Muneeb
title: Transitioning the IR Clinic to Telehealth: A Single-Center Experience during the COVID-19 Pandemic
date: 2020-06-30
journal: J Vasc Interv Radiol
DOI: 10.1016/j.jvir.2020.05.008
sha: 9669cdbe59367c435bc61c85f1d9ced6cc0cfbb1
doc_id: 972174
cord_uid: chfb4i15

Telehealth has not previously been widely implemented as a result of regulatory and reimbursement concerns; however, in the current national emergency of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services has relaxed many of its rules, allowing increased adoption of telehealth services, improving the safety and access of outpatient health care. A complete understanding of the regulatory requirements, technologic options, and billing processes of telehealth is required to initiate a successful clinic. A model is presented here based on a single institution’s experience with implementing telehealth in the outpatient interventional radiology clinic.

During this unique time in medicine amid the coronavirus disease 2019 (COVID-19) pandemic, advances in telemedicine have been drastic and occurring rapidly in the absence of regulatory roadblocks and stakeholder interest that previously hindered implementation. In response to the inevitable need for ongoing outpatient care, the United States and many European countries are now more widely sanctioning and reimbursing for telehealth (1, 2) . Telehealth is defined by the Centers for Medicare and Medicaid Services (CMS) as a "two-way, real time interactive communication between patient and practitioner at a distant site" (3) .

As of March 6, 2020, Medicare expanded telehealth options on a temporary and emergency basis to include office, hospital, or other visits by telehealth, including the provider and patient's home. Additionally, it is no longer imperative that there be an established relationship between the physician and patient (4) . In its intended form, Medicare telehealth visits represent the equivalent of an in-person clinic appointment or consultation and were previously conducted via video platform only (5) . However, in response to patient accessibility and preferences, CMS recently ruled audio-only visits to be a valid form of telehealth (6) .

Before the COVID-19 outbreak, telehealth was most broadly used in the primary care setting, particularly rural health, although its use has also been reported in many medical and surgical subspecialties (7) (8) (9) (10) . There has been no guidance in the literature regarding the implementation of telehealth visits in interventional radiology (IR). A singlecenter experience with the creation and employment of an outpatient telehealth IR clinic model is presented here.

Regulatory and reimbursement hurdles previously faced by institutions inhibited widespread implementation of telehealth. With the loosening of regulatory requirements by CMS in March 2020 and with the broadening of the telehealth definition, there is an opportunity to widely implement this in IR practices. This single-center model from a large urban tertiary-care academic medical center was established with joint efforts from IR practitioners and a large physician group employer, who provided compliance oversight and frequent billing updates. Compliance, licensure, billing, reimbursement, and insurance coverage varies from state to state and from institution to institution, and careful attention to regulation is required on behalf of every practice. Some specialty societies, as well as the American Medical Association, have released toolkits for assistance with implementing telehealth and can also be used for guidance (11, 12) .

On March 30, CMS released interim rules that allowed for place of service to be coded as if the visit was face-to-face, as opposed to for traditional telehealth (code 02), with the added necessary modifier of 95, allowing for higher rates of reimbursement (13, 14) . Modifier 95 denotes synchronous telemedicine services using interactive real-time audio and video telecommunications; however, some commercial payers use this modifier generically to denote telehealth for both video and audio-only visits. At the time of writing, current outpatient video telehealth Current Procedural Terminology codes are billed the same way as if the visit were conducted in person and are reimbursed the same by CMS. Even though audio-only visits were previously not recognized as true telehealth, and therefore had lower reimbursement, CMS will now reimburse audio-only visits (Current Procedural Terminology codes 99441-99443) similarly to traditional outpatient visits (from a range of $14-$41 previously to $46-$110). These payments of near-parity are retroactive to March 1, 2020 (6,14) . Even though most major insurance companies follow Medicare reimbursement guidelines, commercial insurances remain highly varied in telehealth reimbursement and most require place of service to remain as "telehealth" with code 02. Many reimburse equally for telephone and video visits under traditional outpatient Evaluation and Management codes (99201-99205, 99211-99215) rather than the telephone Evaluation and Management codes used by CMS (99441-99443; Table 1 ) (12, 14, 15) . Modifier CR ("catastrophe/disaster related") may also be appended to CMS bills for services rendered during a waiver period, including the COVID-19 public health emergency. As a result of the variation and evolving coding and billing requirements in the current environment, a dedicated telehealth billing department may be needed to assist with navigating this critical component.

From a medicolegal standpoint, malpractice policies should be reviewed or expanded to ensure telehealth services are covered, specifically for out-of-state patients. Additionally, surrounding states' licensing requirements must be reviewed, as each state has varying conditions regarding virtual visits. During the current state of emergency, some states, like New Hampshire and Maine, are issuing Emergency Licenses for a 90-day period to cover practitioners providing telehealth across state lines, whereas other states, like New York, have eliminated the licensing requirement completely. When the current state of emergency has passed, full licenses may be needed in adjacent states for providers if telehealth is to remain a sustainable practice option.

Adequate documentation to support billed codes is needed, and therefore visit templates are useful to ensure uniformity and compliance (Appendix A [available online on the article's Supplemental Material page at www.jvir. org]). Medicare requires patient consent for telehealth services to be obtained and documented in the medical record before proceeding with a visit, and for the locations of the patient and physician at the time of the visit to be documented. Even though the provider and patient can be at any location during the visit under emergency regulations, documentation of location remains necessary and develops best practices for telehealth in the future.

There are several considerations for information technology infrastructure that can improve the quality and 

Clinic staff require appropriate preparation and training before commencing a telehealth program. 

As clinic transitions to a virtual platform during the current pandemic, all established clinic visits are reviewed at least 1 week before an appointment by the assigned IR attending physician for evaluation of whether a virtual visit is appropriate. Any new clinic requests are evaluated at the time of the request for telehealth suitability. Although some patients may require urgent in-person evaluation, most patients seen by IR departments are appropriate for virtual visits. New consultations and follow-up visits previously had same-day imaging performed. Even though nonurgent testing is being delayed during the pandemic, preprocedure imaging and laboratory testing for new patients is performed on the day of the procedure when possible, accounting for impact on procedure-day workflow. For follow-up visits or for new visits in which testing would drastically change management (ie, interventional oncology, complex inferior vena cava filter removal), necessary imaging or laboratory testing is performed before the virtual visit. Testing can be performed at any location more convenient to the patient if results are sent to the clinic or made available electronically by network hospitals.

Because videoconferencing has traditionally been the more accepted form of telehealth by state licensure boards and insurance companies, and allows for performance of a "no-touch" physical examination, it is the visit type preferentially offered to patients. However, not all patients have access to computers with Web cams and Internet, and availability of video conferencing platforms may vary for different smartphones and tablet devices. Therefore, when making a visit appointment, the clinic staff is responsible for asking patients if they have access to the equipment needed for a video virtual visit and providing detailed written and verbal instructions for setup (Appendices C,D [available online on the article's Supplemental Material page at www.jvir.org]). An electronic invitation to a unique video meeting with the physician is sent to the patient, and healthcare proxies or next of kin are encouraged to join. For patients unable to set up a video visit, a telephone visit is offered. If the physician is not on site at the hospital, to protect the physician's private information, a third-party HIPAA-compliant application that masks the provider's personal phone number (Doximity Dialer; Doximity, San Francisco, California) is used. The use of this platform . Telephone visits are initiated by the physician calling the patient at the designated appointment time. If a procedure is planned as a result of the visit, procedural consent is obtained verbally with a witness. If a witness is not available to cosign a consent, a verbal discussion is had with the patient regarding risks and benefits of the procedure, and written consent is obtained on the day of the procedure. Presedation evaluations are occurring the day of the procedure; however, all patients are screened for indications that may require anesthesia services per institutional standards, such as the presence of obesity, sleep apnea, use of continuous or bilevel positive airway pressure, and previous difficulties with endotracheal intubation. Some patients who have not had a presedation evaluation may not meet sedation criteria when evaluated on the day of the procedure (ie, Mallampati class 4 airways, undocumented obstructive sleep apnea, undocumented medication contraindication). Should this occur, it is anticipated that this would be a small minority of cases, and single-drug analgesia or anxiolysis will be offered. The authors expect that it will likely be unnecessary to reschedule a patient with anesthesia services as a result of the inability to perform appropriate sedation. Intermittent clinical practice review will be helpful in identifying patients who required rescheduling with anesthesia services to reduce patient rescheduling for this reason.

After the virtual visit is completed, a telehealth note is documented in the patient's medical record by using a telehealth template with Medicare-required verbiage for patient identification and consent for telehealth. The master list is updated regarding necessary follow-up visits, additional testing, or procedure planning, which is reviewed daily by clinic staff. After the visit, the attending physician will code appropriately based on time spent with the patient, and the visit is billed ( Table 1) .

Multidisciplinary clinic (MDC) is a vital part of the comprehensive clinical care offered by IR. Virtual MDC requires high levels of organization given the number of specialists involved. Imaging and laboratory testing are still required for MDC, and therefore not all community contact can be eliminated. Patients can again obtain imaging and testing at a location convenient to them and send this to the MDC group before their virtual visit. MDC virtual visits can be conducted in multiple different manners, as a coordinated effort by all involved physicians or at the discretion of the individual physician. Coordinated efforts offer the most convenient option for the patient and embody the intent of an MDC most closely. If visits are conducted over the telephone, patients are given a 2-hour time slot, during which they are told they will receive multiple phone calls in a round-robin fashion. A central leader (nurse navigator, administrator, or nurse practitioner) documents who has been seen and by which specialty. There is an open concurrent videoconference for the clinic physicians that is staffed by the central leader to assist with coordination as well as the joint review. A telephone-only model can lead to difficulties with coordinating the joint review and maintaining conference call etiquette (ie, avoiding talking simultaneously).

Along these lines, MDC may be better suited for video visits, in which the online meeting serves as a virtual "clinic room," where physicians can "enter" and "exit" by joining or leaving the meeting without being disruptive to the patient, who stays present in their virtual clinic room. Some video platforms also have the benefit of a "waiting room" or "breakout rooms," where some meeting members can privately discuss a plan while the patient is in a separate part of the meeting. A virtual MDC allows a significant advantage in the realm of outreach for patients and will likely remain an asset to practices in the future.

In the current environment, trainees are at a particular disadvantage, having lost the clinical education provided by staffing an IR clinic. In this single-center model, one senior trainee is assigned to clinic at a time. In lieu of inperson hospital-based IR clinic, this fellow is included in any telehealth visits during their rotational week. There are multiple workflows a practice could use if incorporating trainees. Trainee and attending physicians can join their video or telephone visit at the same time with the patient. To maximize educational potential, the trainee conducts the telephone or video virtual visit under the supervision of the attending physician, who remains on mute or not visible for the trainee portion of the visit while listening in on the conversation. When the trainee has completed their initial discussion, the attending physician actively joins the visit and provides their recommendations and plan to the patient. This allows the trainee to hone their clinic skills and receive feedback from the attending physician on historytaking without prolonging the appointment for the patient unnecessarily. An alternative method would be for the trainee to join the video meeting or call the patient before the attending physician. The trainee obtains a history, reviews pertinent testing, and then mutes audio and video while contacting the attending physician to present the patient. The attending physician then joins the videoconference or the trainee merges telephone calls between the patient, trainee, and attending physician to discuss final plans. This would follow the more traditional model of a trainee seeing a patient first, then presenting to the attending physician outside of the clinic room. This method allows trainees to formulate an assessment and plan independently of the attending physician, although it often results in longer clinic visit times. In both scenarios, clinic checkout is then performed by the trainee. When using time-based coding, attending physicians may bill for only the duration of the visit in which they were present on the video or call, which must be carefully documented if a trainee joins a video or telephone visit before the attending physician.

To maintain equal accessibility to all patients, telehealth is offered via a hospital-based interpreter services network to any patient who prefers to conduct their care in a language other than English. Future appointments by telephone or by video are booked with interpreter services before the visit to ensure availability.

Telehealth has quickly become the main delivery method of outpatient health care during the current COVID-19 pandemic. As health care has broadly seen its benefit in continuity of care and new outreach, it is anticipated that this will remain a valuable tool in medicine long after the current emergency has passed. The institutional experience described here can provide a framework for other IR groups to embrace this transformative practice opportunity to remain accessible to patients and referring providers. From the email invitation, click the link under "More ways to join your meeting" and select "Web browser" Allow your browser to access your camera and microphone Enter your name and clinic "Join Meeting" For additional details, see https://support.starleaf.com/ using/joining-a-meeting/joining-from-a-web-browser/

We encourage you to log in 5-10 minutes prior to your scheduled visit to ensure technology is working. If you have technical difficulties, you can:

Visit https://support.starleaf.com/using/ Email our clinic at IR@bidmc.harvard.edu Leave a voicemail with our clinic at 617-754-2523 and a staff member will call you back.

Thank you for allowing us to participate in your care!

Before Your Scheduled Visit

Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: a call to action

Coronavirus preparedness and response supplemental and appropriations act

Medicare Telemedicine Health Care Provider Fact Sheet | CMS

CMS General Provider Telehealth and Telemedicine Tool Kit

Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic | CMS

Utilization of telemedicine virtual visits in pediatric spinal deformity patients: a comparison of feasibility and patient satisfaction at a large academic center

A prospective clinical, cost and environmental analysis of a clinician-led virtual urology clinic

Tele-critical care: an update from the society of critical care medicine tele-ICU committee

Center for Medicare and Medicaid Services Medicare Learning Network. Telehealth Services-MLN Booklet

Digital Health Implementation Playbook

AMA Quick Guide to Telemedicine in Practice

Medicare and Medicaid programs; policy and regulatory revisions in response to the COVID-19 public health emergency (CMS-1744-IFC)

Special coding advice during COVID-19 public health emergency

List of Telehealth Services

Notification of Enforcement Discretion for Telehealth. HHS.gov

Test your video equipment (ie, microphone, headset)

Pick a location with a consistent Internet connection that is quiet and private Minimize background noise (ie, children, machines like a printer/refrigerator, barking dogs) Be sure who is or is not in the room with you. You and your provider may discuss personal and private matters that you do not want shared

may be asked the following questions about your medical history

1. Trainee writes note using appropriate telehealth macro 2. Attending physician cosigns note, using attestation at end of note 3. Attending physician codes visit and signs billing through e-ticket. a. Physician can only bill for time attending spent with patient. If option 2 was chosen above, only the portion of the visit during which the attending physician was involved is billed.If interpreter is needed:If patient needs an interpreter, both phone visits and video visits are supported and are booked via the hospital Interpreter Service Request Hub. Clinic staff: From the portal, interpreter service request is placed for a "future appointment" with interaction type of "phone call" instead of "face-to-face" Inform MD that interpreter needed and note on Outlook and OMR schedule Interpreter will call number provided for MD or for the video conference at the booking and make call to patient. The interpreter will join only video conference appointments with audio.

Your interventional radiology (IR) physician would like to perform your IR clinic appointment via virtual visit using StarLeaf. Below are instructions on preparing for your appointment.

Prior to your visit, you will receive an email invitation for a StarLeaf appointment from a member of our clinic staff If you agreed to a video visit but did not receive this invitation prior to the day of your appointment, please contact our clinic via email at IR@bidmc.harvard.edu focused on the camera. The worst thing is having your audience look at the top of your head because you are typing or looking down at notes-or worse-at your cell phone. 5. Raise your PC monitor/camera or laptop so that you are not facing down to the camera. Camera should be almost level with your eyes. 6. Be courteous to other participants: introduce yourself before speaking so that everyone knows who is talking and can address you by name. Take note of the other speakers so that you can also address them by name. Last, turn off the sounds on your cell phone and avoid texting. 7. Keep body movements minimal: large movements can distract your audience and do not transmit as readily as still images. 8. People sometimes fail to remember that everything that they do is seen on camera. You cannot hide whispers, winks, etc., and everyone will see you checking your phone! 9. Wait for an opening in the conversation. A good rule of thumb in a virtual meeting is to wait 2 seconds after a speaker has completed a thought in order to avoid speaking over each other.