Good evening, welcome to the second webinar of the AOSSM Fellows webinar series. The title of tonight's webinar is Understanding and Implementing Telehealth. My name is Meredith Herzog. I'm the Senior Manager of MOC and Fellowship Education at the AOSSM. Joining me on the webinar tonight are our two presenters, Dr. Brian Piscone. He's the Chief of Division of Sports Medicine at UMass Memorial Medical Center. He's Associate Professor at the University of Massachusetts Medical School, and he's also the Chair of the AOSSM Accreditation Task Force. The Accreditation Task Force covers fellowship program accreditation requirements and works closely with the fellowship programs on updates and with ACGME. Lisa Warren is also joining us. She's the Chief Executive Officer at Andrews Sports Medicine and Orthopedic Center in Birmingham. She is also the President of the Alabama Chapter of Orthopedic Executives. This webinar series started last week on April 7, introduced by the AOSSM Fellowship Committee with education designated for orthopedic sports medicine fellows during this COVID-19 pandemic crisis and the halt of elective surgeries. This will continue every Tuesday at 7 o'clock p.m. Eastern Time through June 30. The ACGME has permitted residents and fellows to participate in the use of telemedicine to care for patients affected by the pandemic. The ACGME has accelerated the use of the common program requirements for supervision of telemedicine visits carried out by residents and fellows, which was originally scheduled to go into effect on July 1, but is now effective immediately. More information may be found on the ACGME website on their COVID-19 information section. Tonight's webinar will outline the clinical and administrative processes and requirements to implement telehealth successfully. It will specify clinical and business processes that should be part of your checklist. From coding, billing, and compliance to patient care via telehealth, you will learn to incorporate this effectively into your role as fellow while programs are meeting the ACGME common program requirements. The last 15 minutes of the session will be designated for questions. This is how you submit a question. To submit a question on the GoToWebinar panel on your screen, click the Questions drop-down arrow on the right-hand side of the panel. This slide here shows where you input your question and click Send. I will now turn this over to Dr. Brian Busconi. Thank you. Thank you very much, Meredith. Welcome and thank you for attending the second educational webinar provided by the American Orthopedic Society for Sports Medicine. AOSSM and its leadership, Dr. James Bradley, its president, and Greg Dummer, chief executive officer, is dedicated to providing you, our fellows, as well as members who may be listening with the resources, tools, and educational information to help bring some normalcy during these uncertain times with the COVID-19 pandemic. Tonight, I'm honored to not only be able to present on this material, but also I'm speaking with Lisa Warren from the Andrews Institute. She is a spectacularly smart, energetic, and bright CEO of that institute and will help guide us with some of the pre-visit, visit, and post-visit information that we need to know as orthopedic surgeons. So again, Lisa, I can't thank you enough for joining us and being part of our educational seminars. I'm glad to do it. So my disclosures can be found on the AOS Orthopedic Disclosure Program and within the AOSSM website. COVID-19 has really changed our lives. It's really changed the way fellows are operating on an everyday basis, how we as providers and patients. Key to this is safety and communication. You heard from our last webinar series, just what can happen when the pandemic crisis gets out of control, and my heart goes out to all of us, all providers and healthcare professionals who are currently helping patients through these times. You can see in the bottom right-hand corner, it's completely changed what we're doing in clinics. And here I'm with one of my fellows, Dr. Mowry, talking to our patients during an everyday normal event, managing to be six feet apart and communicating with our patients to help decrease some of their anxieties. And of course, over these holiday weekends, a lot of us were doing different forms of communications that we may never have communicated with before. ACGME has recognized that telehealth and telemedicine must now be incorporated into our training. And as Meredith already indicated, Dr. Naska, who's truly been a friend to our society, has indicated that as opposed to waiting till July of this year to implement telemedicine, we need to go ahead and do it now, especially during this pandemic crisis. These new program requirements are necessary and that it allows faculty members to provide direct supervision of our fellows through telecommunications technology. One of the purposes for this is not only to educate our fellows and members of AOSSM, but also to allow you to get the educational credit that you need as a fellowship program for understanding telecommunication, especially in these times and in 2020. What is telehealth or telemedicine? Well, telehealth is the collection of means or methods for enhancing healthcare, public health and health education. Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. And that's the key, is this without an in-person visit. It allows physicians and extended care providers, either nurse practitioners or physician assistants, to have patient interaction. Keys to all of this is understanding some terminology as terminology is always important in terms of billing and coding. The originating site of a telemedicine visit is always the location of the patient. Lisa will talk about this a little bit further, but the provider must be licensed for the state for that person, for the location of that patient, for the physician needs to be licensed in that state to have a legitimate telecommunication interaction. The distant site is the location of the provider, whether it's a hospital or an office or even their home. However, we've struggled at our institution to make a home, a place where we can bill at. This also allows telemedicine for physician-to-physician interaction. The platforms can have the terminology of synchronous, which means that either real-time audio video is going on at different locations or just audio with a telephone communication. Synchronous communication is considered, you know, patient portal sites, MyChart, things like that, which are not in real time. These are important codes that will go into our coding a little bit later on. The history of telemedicine is not something that's new. In 1925, funny if you actually look at the history of this, this gentleman, Dr. Gernsback, he imagined a tool with robotic fingers and radio technology so that the physician could get a teledactyl type of situation. So this was never a concept that came up, but this idea of telemedicine came about strongly in the 1960s, especially with the investment of NASA and their astronauts. The Department of Defense recognized that if indeed we're going to deploy people over large distances, that telemedicine is something that we're going to need to do. This became very prominent in my life. I'm a retired colonel from the Army. I've done three tours of duty, and during each one of these tours, telemedicine became more and more of a prominent role in terms of taking care of our injured soldiers on the battlefield. In the National Guard situation, we were transitioning injured soldiers back to their home, and we created these community-based health care organization hospital sites, which had large regions. And what we did is that we were allowed to get our soldiers home, but we telecommunicated with them to make sure that they're getting the appropriate medical care, and they would do regular check-ins with us. So the military had been using telemedicine quite a bit over the years. Today this field is changing, and with our fellows, this is going to be something that is going to be innovative for you, and we expect you to be able to develop this program as time goes on even better than it is today. Why is it important? Because it keeps the physicians, health care workers, and patients safe amid infectious disease outbreaks. It supports physical distancing. It supports anxious patients, meaning that it allows us to continue with patient care. It allows us to triage, support follow-ups. It saves on our frontline resources, especially with masks and gloves, as you can see in our picture. Taking care of our patients decreases the amount of that that's needed. It extends access beyond our normal clinic hours. It reduces patient travel burdens and, honestly, increases practice efficiency. The workflow is a significant change in your life, however. Whereas you could normally see two patients in a 15-minute slot, these workflows need to drastically change because you have workspaces now which are different. They are with a telephone, they're audio. You need to make sure that you have appropriate bandwidth. Appointment scheduling has changed. Staff time has changed. Patient needs have changed in terms of making sure that they answer their phones, which is probably one of the largest things that I fight with, is that even though we set up these appointments, patients sometimes don't answer their phones or they do not have the technological capabilities to have an audio call. These are constantly changing. My key and my discussion point here is that you want to make sure that you minimize your workflow disruptions and that the most important thing is for you to be able to continue on with your patient care is to preserve the patient-clinician relationship. Barriers to success have been the adoption of technology, you know, physicians not wanting to go audio or patients not wanting to go audio or visual, inconsistency in changing reimbursement guidelines Lisa will help us out with. These are ever-changing, so you can't be frustrated. What we talk about tonight may not be something that is actually applicable when you guys get into your practice, but it will be close to it. There's a lot that goes on in terms of capital and staffing costs, legal and regulatory issues in terms of your licensure, what state you're in, who you're calling. Concerns of privacy, security, and confidentiality are very important. You know, you've heard about the amount of people hacking into Zoom discussions. And on an IT side, we really need to make sure that we can prevent that so that we're not giving out specific patient privacy information. There is a little bit of a lack of evidence on the success of this. However, as this increases, so will the studies showing that this can be successful. And that also it's a little bit of a logistical space challenge in terms of making sure that all the officers and everything are outfitted so that you can continue on with these conversations. The key here is that we need to continue to partner with the patient during their entire telehealth life cycle. So you need to think about what's going through the patient, their anxiety at home, that inability to come in and not knowing what's going to happen with the next stages of their care. And that Lisa will help us out very much as to how she, within the Andrews Institute, sets up the pre-visits, how to get them on board, accessing the platforms, communicating, especially with value propositions that will be a lot of people that may be going out into practice may need to have in terms of a marketing tool. Finally, I'm going to go over what happens within the visit. How do you develop the discussion? And then finally, post-visit coding, both Lisa and I will share some of our secrets to success. Again, this is a team effort. Telehealth implementation requires the clinicians, the clinical environment to work well, the finance, administrative, IT, legal risk management, all of these things need to be important. And also connecting with your vendors, the vendors that are going to provide the audio platforms to be able to do and Lisa will help us out with that as well. So without further ado, I'd like to introduce Lisa Warren, who was brought in by Jeff Dugas, who's our fellowship committee chair and so graciously offered her expertise to help us out tonight. And again, Lisa works in a very different office setting than I do. I'm in an academic center. Lisa every day worries about money flows, every day worries about patient and marketing, and she's got a lot of excellent hints and suggestions as to how to make this very successful. So again, Lisa, I can't thank you for taking time out and Jeff owes you big time in terms of you being here and helping us out. Thank you. Well, thanks. I feel like this is an obligation to help you guys succeed when you get into private practice. So what I want to do is just give some examples of what we've done in our office that you're welcome to use, take to your office, whether it's where you're currently doing your fellowship or when you go on to your big dream job. I'm more than happy to share what we've done here. So one of the biggest things about telemedicine that Dr. Buscone talked about is it's not new per se, but what is the big difference is how we are implementing it. In our practice, we frequently would talk to patients on the phone and we would frequently look at MRIs, get a consult, informal, whether it was with a provider or patient, but typically we wouldn't bill it. But given this COVID crisis, we've had to readjust the way we practice and we've really aggressively tried to figure out how can we do this, provide value to the patients in this environment as well as getting reimbursed. So he's right. I wake up every day trying to figure out how do we provide quality care and still maintain our reimbursement. So we'll start out just important considerations, we've kind of touched them on already. One of the big ones is check with your malpractice carrier because what we've found in talking to other practices is that your malpractice carrier may or may not cover telemedicine or they may cover it in different ways. Some may only cover it for established patient visits. Some may only cover telemedicine if it is with an audio and visual component. Some malpractice policies don't cover physician extenders. So it's important before you start practicing telemedicine that you check with your malpractice vendor and find out what type of things are covered. The second piece, and again we've touched on this, is location and licensure issues. This is particularly pertinent when you go to small states like Massachusetts that are surrounded by multiple states or even in Alabama where we have patients that travel from various states and distances to come see us here. I've included a link on the web where you can go and see which states do the concurrent licensing. What you can do is go on this link. If you decide, say, you're in Alabama and you want to receive a Georgia license, Tennessee license, Mississippi license, you can apply through this website and it should arrive within a few days or up to a week rather than going through the long licensure process. So this is the reciprocal licensing that we've talked about in sports medicine for a long time. But I would encourage you, we have not done it because of this crisis situation, but I think if we continue to practice the telemedicine the way we are today, we may consider it. Radiologists have been doing this for years when they read films across state lines for various hospitals. So take a look at that website if you do plan on pursuing this over time. One of the biggest things, and we talked about this, was being trained on the technology. The physicians, while they are very technical in the ORs, often have struggled with the basic using of their phones, their laptops, or their iPads. So we've had a lot of training sessions on how to actually use the technology and to get in. We've talked about rules and reimbursements for telemedicine are literally being updated daily. I send out, I have a list of payers and I update it daily to my staff about who covers what. For example, Blue Cross of Alabama decided they'd only cover telemedicine through April 16th. It's April 14th. We haven't received an update. I have an inside track. I know they're going to extend it to May 1st. And so we are constantly having to update telemedicine. And I wonder after this crisis what the next step is, whether the payers will keep these rules or whether they'll go back to what they were doing before. Because historically, the commercial payers have been very restrictive on telemedicine and they've opened it up through COVID. So I do wonder long-term what's going to happen with telemedicine and this may be the opportunity to change the way we practice long-term. I think the telemedicine and requirements workflow change that is, has been one thing that we, I feel like we've been running 90 miles an hour to get implemented and now we're working on it and have been able to take a breath. One of the other big things was educating the staff that our staff, particularly schedulers and non-clinical people have never experienced this. And we had to educate them on how do you educate the patients? Because the reality is the people talking to your patients are your receptionist and your appointment schedulers. They tend to be the least educated people in your clinic and you need to get them up to speed on how to sell it to a patient because they're your front lines on selling telemedicine to a patient and getting them to book the appointment. And so then the last piece is patient education. We've touched on this. What is telehealth? They need to understand what kind of services we can provide and why this is a good idea. And then patients need to be educated on the technology themselves because many of them can barely operate their phones and computers. And so now we're imposing a new paradigm on them. So if you look to the right, you can see this is one of our Instagram pages. So we've done lots of telemedicine education and posting as things have gone on. So this is our Instagram post that we did, I guess, at the beginning of the week last week. And my awesome marketing guy has had that man in the picture on that computer is actually one of my doctors. So he photoshopped one of my doctors into our marketing ad as well. So I'll kind of go back. I skipped that one. Let me go through. Okay. Now I'm going to tell things not working right. I'm sorry. I'll have to go backwards. Hey, Meredith, I can't get it to go backwards. It's only going forward. One second. Let me see, Lisa, if I can get it to go back. That's perfect. That's where I need to be. So our first piece of education started as an overlay on our website. And this we had this COVID-19, the COVID-19 overlay, and it educated people about we're changing the way we practice and then on the click learn more, this is what appeared. So this is where we talk about the difference between telemedicine, which we're calling purely on the telephone. And then you've got the virtual visits where it's actually an interactive audio. So what we did with this particular piece is this was on our website, but we also did a constant contact blast and we emailed this to all of our patients that were seen in our office within the past six months, assuming that they would be the ones most likely to come and see us in the most recent couple of months. So we sent this through constant contact. I also used our appointment reminder system, and we sent this to all patients that had appointments going forward in the next 30 days. We were unsure how long this COVID situation would last. And so we wanted to start proactively educating them. So when we called them to rebook their appointment, they at least understood what was going on. We had a pretty good open rate on our emails, it was almost 58%, which I feel like is pretty good. And I think it really did help with educating our patients when we called to rebook their office appointment to a telemedicine appointment. This is an example of the guide. So when after we booked the appointment, we would send a link on how to get into the telemedicine program. We use Doxy.me, and I'll show you an example of that a bit later, but this is a pretty thorough Q&A of how the virtual visit will work. We also posted this on our website as well. So the workflow, we've talked about the patient eligible for telehealth, we've done a lot of post-op checks, we've done a lot of established patient rechecks with chronic injury, illnesses and injuries. We have started doing this for new patient visits as well. Typically, those are screened by a doctor to determine, do they come to the office or are they eligible for telehealth? We set the appointment on the schedule, and I'll show you an example of this. This is important for us. So again, the doctor knows what's going on, but he begins our workflow and our billing checks and balances to make sure we're capturing charges. We do email a consent. We have a written consent as well as you document verbal consent, and we'll talk about that in a minute. And we email them new patient paperwork, because all of the review systems and all that pre-patient paperwork that you use to help document a visit, you need to have it in order to be able to document it in a telehealth environment as well. So we email them the packets, and in theory, we'll get them back before we book the appointment, or we tell them we must have them before the appointment. We pre-register them. This is important, again, to make sure we capture their insurance information. We also need their home address if we built home as a place of service. And then we verify their insurance to make sure that it's current. What we are not doing right now, which we do in the office, is collect copays in advance. In the office, they pay their copay before they see the doctor. Right now, with the regulations changing so dramatically, we have not, we decided we are not going to try to collect copays on telehealth visits, even though when you read the guidelines, they often say that they will be billed, or that they may be eligible for copays. But the payers are changing that constantly, and it appears now that most payers are not charging copays for the telehealth visits. We'll do the encounter. We'll do the documentation, and then we'll bill and submit the claims. This is a phone script. So this is when I was talking about how do you get your staff to educate patients. This is a phone script. It's going to be provided to our receptionists and our front desk staff. And so they are able to have a guideline on what they say, how do they handle it, and what they do next. So it's a pretty long phone script, but we'll go through to the next one, if you guys, again, can use this example in your practice. Can you guys get it to move? There it goes. There we go. So that's the second page of the phone script. Go to the next one. So this is a sample schedule, and you can see how we set it up in our office. The little 47s that you see right here means it's a telehealth visit. The number twos mean it's actually done in the office. You can see just basic descriptions of type of things that we are doing. You can see where we make notes of, we've emailed them the paperwork, they know what they're supposed to do, and this is how we're keeping track of it in our office. For minute details, that 47 also leads to different things in the billing system and the insurance system to match the appropriate place of service, whether it's number two in the office or number 47, it's telehealth. Okay, next one. This is an email template, so when they're booked with their appointment, they go through, and I think we need to go back one. Oh, my goodness. I have included in your packet would be a template and where we send to the patient, so it gives them their link, it gives them their instructions. I've also included in here, you can see this is a consent, and so this is the consent for telemedicine that I talked about that we actually get in writing if we can. So we've done this both in our new patient packets that we email the patients, and then in our packets when patients come into the office, we have a kiosk registration system. We have actually added this to our kiosk, so going forward, patients will be consenting to telehealth as well. Okay, I think we can move to the next. All right, that takes care of that. My piece. Thank you for your help. Thanks, Lisa. So now that we understand that pre-visit, now we're moving into what do we do when it comes time for the visit for the patient. And there are some certain things that people need to know about telehealth. First and foremost is the overall etiquette in terms of what you do and what you need. You need to make sure that you have a HIPAA private area to do it. Avoid background noise and make sure that there's good lighting, especially for the audio portion. Make sure you have an appropriate background. You don't have something to make sure it's visually pleasing. The equipment you need, whether or not you use a desktop or tablet, you need to make sure that you have good high speed internet with wifi speed of 1.5 or above. That's very important as it maintains a consistent picture with the patient. You need to have a good webcam, which needs to be at eye level, a good microphone. A dual screen is very helpful for documentation so that while you're discussing with the patient, you can do other things or you can be looking at an MRI at the same time and make sure you close the other background programs. Dress, you know, same level of professional attire you do during the visit. Make sure that when you're communicating that you're reviewing the patient's past medical records, there are dates, PT scripts, adjust everything so that you're having a good clear conversation with the patient. You need to be careful with what you're saying in terms of and make sure you do a good job of verbalizing and clarifying the next steps, especially for the treatments of the patient's care. Pause for transmission delays. Remember that as you're doing this, it takes some time sometimes for that to get across to the patient. So just be patient with the, with that time delay, speak clearly, make sure that you end, you have a good conclusion, that you make sure that you follow, you have a good follow-up appointment, schedule, prescription orders, next appointments, PT orders. And again, thank them for the telehealth partnership. It's very important that you begin your conversation with a consent and you end it with thanking them for being part of the telehealth communication cycle. How do I do it? A little bit different than what they do at the Andrews Institute. We have Epic, you know, and here's a typical half day schedule for me. And you can see my patients in the third column over, you'll see that it will say telehealth scheduled in that the location as Lisa had indicated as being a two indicates the location being in my office. The next thing, if you're on Epic or you're on a device is that you want to start your visit. So you hit start visit. And then you come into getting your notes as you would normally do them. And then you have your blank template. Once you have your blank template, what's very important is that you go and you get a telehealth communication. And what that means is that at the end of my note, if you notice at the bottom of my note under plan, it is, it is a note which says that I have performed a telehealth visit between myself at my location and the patient's location. This specifically needs to, and you, and you folks will have a copy of this talk. This specifically will show you that the telehealth interaction occurred. And you'll see in my last documentation, what this note looks like when it's all done. So during the examination, what you're doing is you're getting your standard history. You begin saying that this is a telehealth interaction either by video or telephone, patient needs to give their verbal and visual consent to proceed. It's very important that you need to document as much as you can, so we can get paid. So utilize reviewer systems in your note, put whether or not they have had, you know, fevers, chills, any aches, any problems. These are all important points to be able to collect for billing data. Your physical examination is a subjective patient reporting findings that you can see on your audio examination. Or what's been very important is that I've gotten my PT scripts of the patients. If the, if the patients are going to PT, they send me them. So they give me their most recent up to date knowledge in terms of their range of motions. You can take a look at their appearance of their skin incision sites. Patients can talk about whether they're using ambulatory devices, but all of this information is very important to dump into your physical examination portion of your note. Finally, the assessment plan, document the treatment plan as you normally would. And again, you want to put your attestation of the telehealth documentation. And this is what I currently use. And again, everybody is welcome to utilizing this. This is what my telehealth documentation is at the end of every note is that it says I performed this visit using telehealth between myself, my location, my office and the patient's location. The patient requested and scheduled this visit. Very important that they consented for this. Prior to the beginning, the patient's informed verbal consent was to be used to perform. All the medical records were reviewed. I've informed the patient that in this case they felt they needed to be seen in person would set that up. If there was something emergent going on, I make that indication. And the final thing, which is most important is time spent. 15 minutes of which were greater than 50% was spent on counseling and care coordination because that ultimately allows you to get paid for your visit. Again, here's my, here's my final note. There's a patient we saw that's seven months out of status post an ACL reconstruction. You can see the physical examination came from what the patient states. The mother state is this was a a patient under the age of 18 and also their PT notes. And then at the end is my attestation, a time of which was spent 15 minutes and it was 15 minutes. 50% was a general counseling for the patient. Okay. Sorry. Just trying to get the slide to go forward here. So Lisa we use Epic and I'm hoping that you can talk about what it is like to use a dictation based system and also some other caveats that you have. If indeed you don't have an EMR system like the one we use. We do. We have a dictation based system and that the doctors love and hate at the same time. We do have templates set up in the dictation. And so what they would say is they would say use telehealth template and it would pull in the similar disclaimers that that Dr. Busconi used, but actually I like him better. So I may start, I asked him if I could copy his into my templates, but we'll have some sort of standard telehealth template piece and then they will dictate the note as well for us because we have to pay for dictation. Every character slash line, as I referred earlier about our forms and so we have a review assistant form that the patient completes. So we would say things like the review systems forum signed and reviewed by me on this date. And that way we don't have to pay for all of those review systems dictated, but we get the credit and the documentation piece. So in the dictation piece, part of a system and a note, again, we're trying to refer back to as many notes as we can so we don't have to pay to have them tight. But we can still achieve the levels of service that we need. So with the dictation piece, it makes for really pretty notes and it's easy for outside physicians to review, but it is a little bit more work on the physician side. Okay. Let's see if it'll go forward. So this is an example of what our telehealth platform looks like. We use Doxy.Me, which is actually a HIPAA compliant platform. And so what will happen is the patient will get a link and you see it says, welcome Dr. Ortho. This would be the patient's email address right here. And you can invite via text message where they can click on a link or they could get the link inside their email. And one of the reasons why we chose Doxy.Me instead of some of the other platforms is that you do not need to install an app. We felt like that was an additional step for patients that they would find frustrating. And so by using Doxy.Me, it is an app that directly links them to our quote waiting room and they don't have to install a new app on their phone. And so over you can see where this is a list of the waiting rooms. So there can be multiple patients in the waiting room. When the doctor's ready to see that patient, they click on Susie and Susie will then dial in. They can see a picture of her. This is actually the picture of the doctor. And what he's seeing similar to how we do webinars now. And so the doctor would see himself here and then Susie would pop up on the screen. The way our workflow works as using fellows and staff is that a lot of my doctors prefer to do these in their office rather than doing them at home. Some of that is because they have technical support here at the office where they don't have technical support at home. Some of that is that they also have staff support at the office where they don't have staff support at home. So often what happens is that the doctor may be off to the side dictating or reviewing notes and the staff person is actually inviting the patient, dialing them up, having a little small talk, doing some of the initial assessment evaluation. If it's a fellow, they're doing what a fellow would typically do in an exam room, talking to the patient, getting a history and that type of thing. If it's a staff person, they're doing a little more chatty while the physician finishes what he's doing in the other room. You can see down here where we have send Susie a message. One of the nice things about that is that if you have multiple people in the waiting room, you can then message those people and say, we'll be with you in 15 minutes. We're running behind. And you can communicate real time with the patients in the waiting room so they don't wonder what's going on, which I think is probably a step up from what happens in the office because often they're in the waiting room wondering what's going on. Um, and we're, we're in the back, not communicating at all. And so that is how our doc CV works. We have had good response with it. Um, the big challenges we have, and we'll talk about this in a minute, is that internet speed is a challenge, particularly in rural Alabama. Some of those areas, it's been a challenge. It's also a challenge when you have two children trying to do their, um, their zoom conferences at school, you have a husband working at home, and then you're trying to do your zoom conference with your doctor. Um, the bandwidth, the general at homes itself has struggled, I think, to handle, um, all of the multiple modalities dialed into the, um, to the internet at home. So that has been one of our big struggles as well. But overall, doxamine has, um, has performed well. It's not particularly expensive. You can have a month to month prescription, um, or you can have our subscription, or you can do it, um, an annual basis. So we use doxamine and that's kind of how it looks. So documentation tips, again, document, verbal consent, document video versus telephone only. That's really important because some payers require video. Some payers are agnostic. They'll take video or telephone. And then if you do telephone only, some payers are very particular about which codes you can bill. So be sure to document whether it's video, whether it's telephone only and how you're communicating with the patient. Um, tell where the patient is, if they're at home, if they're in rehab, indicate that there's another person in the room. If it is, if the patient is a teenager and the parent is in the room with them, you need to document that the parent was also in the room with them while they were having the discussion. Note all components of an exam. I've stressed to my doctors, please don't be lazy when it comes to telemedicine documentation. It needs to be as robust as it is when the patient's in the office. Um, points of frustration, the payer guidelines. Again, I feel like I have to update it every 24 hours and some payers want to do one thing. Some payers want to do another. And it's frustrating for the staff and the physicians to keep track of the positions. One of their beats has been that they're now it support for the patient. So if the patient is struggling, trying to get their, their docs you need to work, then the doctor is often the one who has to sit there and try to help them work it through. And he's thinking, this is not an efficient use of my time, which is why we've morphed into letting the staff kind of make the initial contact and what work the patient through all the technical difficulties. When those are fixed, then they call the doctor to the screen and let them treat the patient. Um, I talked about for internet and the doctors have complained that the visits actually take longer than they would in the office. The patients don't have some of the nonverbal cues like backing up, touching the doorknob, the things that you can have in an exam environment, um, as well as everybody's shut in right now for COVID. And the doctors feel like they have nothing else to do, but visit. And so there's been a little point of frustration that they end up taking a lot longer on visits than they would in the office. I feel like in one of the things we've talked about, that this is important from a marketing standpoint. And Dr. Busconi had talked about this as well to thank them for their visit, because we need to keep the contact with these patients. So when the time comes, we can see them in person that they come in and have their surgery, that they continue to recommend us to their friends and family. So telemedicine certainly is a billing thing, but I feel like it's a marketing thing to keep you in front of the patient and be able to, um, to keep the relationship going. Thanks, Lise. So, um, we just want to go over a little bit of what all of this means for us and how to code. Uh, this becomes very important in our lives. And in actuality, this is how our practices are functioning right now. So telephone or visual services, uh, in management services by a physician or, and these can also be by other qualified healthcare professionals. You need to make sure you have an established patient parent or guardian, uh, that's going to receive the communication. They need to originate from a EM visit provided that hasn't been provided within the last seven previous days and also not leading to an EM service or procedure within the next 24 hours. So these are very important guidelines. It would go over some of these guidelines and also coding, um, codes and modifiers. Uh, you need to know, uh, Lisa had indicated that the, uh, a place of service code is a zero two for telemedicine. And you can see that is on her, uh, uh, her, uh, snapboard for her patients who they're seeing. Uh, very important is the modifier 95, which is a synchronous telemedicine visit. And that should be part of all of your coding for every one of these. Uh, a GQ modifier is an asynchronous telemedicine visit. Uh, interesting enough that a lot of us do not charge for our, my chart evaluations, but there are ways to do that. But basically the coding is all about time. And to put it simply because this is changing all the time. It is very frustrating for us is that if it's less than 15 minutes, either audio or visual, it's a G a two zero one two code, which is a brief technology visit. So these are visits that are five to 10 minutes. Uh, and, uh, the, the amount of money that you receive is significantly less than if the, uh, if the conversation with the patient is 15 minutes or greater. And these are our standard nine, nine, two, one, one to nine, nine, two, one, five established visits that we can do. Um, and again, uh, those are your established visits, uh, by telehealth, uh, new patient visits, uh, for telehealth or nine, nine, two, one, one, and nine, nine, two, one, five. The question is, in the state of Massachusetts at this point in time, we're not doing a good job of getting back, uh, what it is, uh, to get paid for this. So we've done a good job of recouping our money for our established visits, uh, for our brief technology visits, but our new patient visits, uh, there seems to be a slippery slope in terms of evaluating new patients, not being able to, uh, to do it by a visual means, but not being able to lay hands on them. So I really don't have a good way to tell you how to get reimbursed for that. It will come with time. Lisa may have some points to give us, but it's been a difficulty. So covered services, again, where our sweet spot is where we want to be are these nine, nine, two, one, one, two, nine, uh, two, one, five visits. Uh, these are the ones that are getting paid regularly. Um, in terms of the UMass system, these are the ones, uh, hints that I'm going to give you. Uh, again, the total time spent with the patient and direct communication and reviewing the patient medical records, uh, is very important in terms of you getting paid and coordinating what you can bill. Um, other things that are key is that again, the G two one one two codes for five to 10 minutes of medical discussion. Again, I put this in multiple things. You need to append everything with a modifier 25. Uh, so after you've done your billing, whether or not it's a G two one, G two, one, two code or nine, two, two, uh, two, one, five code, you need to modify that within 95, which allows your billing cycle to be able to bill for those visits. And again, here are those codes and new patient telehealth codes as written down as well as your established, uh, uh, patient telehealth, uh, visits as well. What's interesting is that in some States, um, you know, you get paid for, uh, it needs to be a visual examination and some patients it can just be an audio examination. So at least we'll tell you that in her state, in Alabama, it's required that it's a visual communication. They can't do it just audio. So it's going to be state to state. It's going to be, uh, as time moves on. So it's a very frustrating, uh, in ever changing environment for us to receive our monies. Again, nine nine two O O three is a new patient level three visit. Nine nine two one three is an established patient level three visit. And in our institution, we are regularly getting paid $54 for that. So we're getting $54 reimbursement across the board with our insurance companies for this established patient level three visit for the G two O one two codes, the brief five to 10 minute discussions. Notice that that we have been getting regularly $14 for each one of those visits. So you can see that that time spent in documentation for an established level three is where you want to go. Again, remember that modifier 95 for all your telehealth. Uh, and you can see, uh, uh, this is an alert that came across our board, uh, and comes across everybody's board that if you're going to build nine nine two zero one to nine nine two one five, uh, that you need to have real time audio in video for it to occur. So you're going to have to look at your insurance providers in terms of how you're going to get paid. And this is what our weekly, um, changes that occur to us. Uh, all of our providers, you can see on the left side, send us the CPT codes, phone, audio, and these are constantly changing all the time. So if you think you're confused, so are our billers as these continue to get updated and the codes continue to get changed. So recognize, uh, the things that I just talked about in terms of the regular established visit, 15 minutes, we're getting regularly paid for with those visits and the established we're waiting to see how our new visits are going. Uh, and again, for your postoperative patients, it's all within the global period. But the most important thing is Lisa indicated it's our connection to our patients. That's worth all the money in the world in terms of making sure that our patients feel comfortable, uh, that we are continuing to follow their care during this crisis period. Software platforms are a lot of them out there. Uh, you've heard about doxy me, um, other ones that are out there. Can continue to be used a lot within the orthopedic fields is video AM. Well, we currently have the AM well platform. Uh, it's a platform with which we're allowing our patients to use on their phones. And again, it's all about the, the, uh, band connection. If they don't have good band connection, it can be very difficult to continue on with those conversations. Software platforms out there need to be remember HIPAA compliant. You need to have some sort of an agreement with everything. And again, you need to be very careful about your HIPAA compliancy and what's going on. Time for creativity innovation. I, I ask all of our fellows out there, uh, that, you know, now we need to think about how do we use this telemedicine, uh, you know, for sports coverage, triage, uh, consultations. Again, radiology has been doing this for a long period of time. Uh, Chip Douglas loves his teleconditioning. Um, I, I think that the bottom line is we need to be able to be creative with our athletes. We need to be creative with our patients in terms of how we're going to monitor their Medicare, a medical care going forward and how we continue to make them better. And I think that AOSSM is going to be a leader in this in terms of being able to come up with ideas and innovations that are going to really kind of rock the world and take care of our patients going forward in the future. So in summary, telemedicine training is now required by ACGME, uh, and it's increased its escalation because of COVID. You need to be fast deal with both audio and visual visits. You need to understand and need to care for the patient. Uh, we, you need to know and understand your institution's coding and billing procedures. You need to know how to document your telemedicine visits. Very important. This, however, what you have to understand and what AOSSM recognizes that this is the ideal way to keep our patients, providers, and safe, uh, staff safe during communication during this COVID-19 pandemic. I hope everybody is healthy. I hope you understand the importance of social distancing going forward in the future. I think the first webinar really showed the importance of that. And we will get back to some sort of normalcy. We don't know where it is, uh, but recognize the AOSSM leadership, uh, is going to be dedicated to helping us, uh, get, uh, get better interactive with our patients and make our patients better. So, uh, with that, uh, I think that, uh, we will thank everybody. Lisa, I can't thank you enough. And Meredith is going to field some questions for both Lisa and myself. Uh, and then we'll conclude tonight's, uh, webinar. Sure. I have, uh, there's a few questions that have come through. The first one is, will a telehealth visit count in place of the minimum one standard in-person global 90 day post-operative visit? We've been using it that way. Yeah, that's very common in my practice. The majority of my patients, uh, uh, I'm doing within the global period. Uh, again, I'll have to ask Lisa, we don't get paid for that global visit. Uh, but the ability for you to be able to communicate with your post-operative patient is extraordinarily important. And the patients are extremely appreciative that they don't have to drive to the hospital, uh, and that they can manage everything within their safe environment. And one thing we've done, even historically before we implemented Doxy.Me is we'll have patients, and I'm sure you've seen this too, where patients take pictures of their, um, of their incisions and they'll email it to us, which is not HIPAA compliant on their side. And as long as we don't respond back, it is not a HIPAA violation on us. So this has been going on a long time for post-operative care. One thing we've also done from a social distancing perspective is if it is a post-operative visit that requires an x-ray, what we'll do is we'll schedule x-rays and spread those patients out a little bit. Um, and then the doctor can still do a telemedicine post-op because he's got the x-ray in front of them and able to call the patient. The next question that we have received is, is there any concern that telehealth visits can be brought into potential legal matters through subpoena? There's always a concern that people are going to bring things into legal matters. Um, what we have is the documentation. So that's back around to what we've been harping on this whole time. A telehealth consult is not an opportunity to halfway document the encounter. Um, so if you document the encounter appropriately, it's in the medical record. That's what's going to be subpoenaed. Yeah. And again, uh, Meredith, we begin our, we have our pre-visits getting consents. We begin my visit getting a consent, and then we end with thank you for, uh, being part of the telehealth, uh, evaluation. Again, um, you know, legal things are going to pop up regardless of how good of a job you do, but the key to legal matters are going to be documentation. So not only do you need to make sure that you're seeing your patients, right? Because that is one level of reason why patients can be mad at you. Uh, but also that you're documenting what happened during that conversation. That becomes a very important part of the documentation. Well, that in telemedicine is not appropriate for every patient. And I think that's an important thing to realize too, that if it's not an appropriate to see them remotely, bring them in. I mean, we still see patients in the office. Yeah. That's how I end every one of my conversations is, you know, listen, if we're having problems, you know, I need you to come in, you know, we need to escalate this more than just by telehealth. So we give them that option at the end of every discussion. Great. Uh, relating to documentation. This is the last question that we received for license purposes. How do you make sure about the patient location in a telehealth visit? How do you document that? Okay. Well, we talked about, you document where the patient is. So if they're at home and their home address is in Alabama, then we are fine. And so I think it's important to ask them, where are you? And then document where they are and then have reason to say, we've got their home address on file. Yeah. And as Lisa indicated, that website, maybe you can reiterate that website, Lisa, that allows physicians to be able to get licensures outside their home state to be able to have a discussion with patients. So that's very important. And you have to recognize your license may not exist outside the boundaries of your state. As well as malpractice. All right. So that covers, we just had a few questions that came through. Thank you so much, Dr. Busconi and Lisa for dedicating time to this webinar and the education towards the fellows. Next Tuesday's webinar is featured here. UCL repair versus reconstruction and non-operative treatment point counterpoint with Drs. Sukati and Dugas. Thank you all for your participation. This goes to the presenters as well as the attendees. Thank you so much. Thank you. Thank you. Good night. Night.

Understanding and Implementing Telehealth

Dr. Brian Piscone

Lisa Warren

AOSSM Fellows webinar series

orthopedic sports medicine fellows

telehealth during COVID-19 pandemic

clinical and administrative processes

coding and billing guidelines

reimbursement processes