What's a service orthopaedic practices can offer that is popular with patients, reimbursed by most payers, not too expensive to implement, and deliverable in all 50 states?

Telehealth: Although it's obviously not suitable for every type of patient encounter, the value telehealth confers to patients, practices, and payers has pushed adoption to the tipping point. These services also allow practices to differentiate themselves.

Why consider telehealth?
According to the American Telemedicine Association (ATA), telehealth has four primary benefits, as follows:

1. Improved access
2. Reduced costs
3. Improved quality/safety
4. Improved patient satisfaction

Indeed, a 2015 Harris Poll found that 64 percent of patients were willing to participate in telehealth visits because of convenience. The ATA says more than 15 million Americans received at least some medical care remotely in 2015, and it expects those numbers to grow by 30 percent in 2017.

Although telehealth has been adopted faster in primary and urgent care environments, orthopaedists are seeing its benefits in pre- and postoperative care. With bundled payments and other value-based contracts looming, telehealth offers efficiencies that can improve profits and deliver conveniences that delight both patients and caregivers.

Even the Centers for Medicare & Medicaid Services (CMS) recognizes this opportunity and has been reducing adoption barriers. In the 2016 Final Rule for Comprehensive Care for Joint Replacement, CMS eliminated originating site and geographic area restrictions when telehealth is used to deliver follow-up care to patients who have undergone hip or knee replacements. That means orthopaedists can now deliver bundled payment postoperative care to patients who connect via a telehealth platform from their home (or hospital or skilled nursing facility) on a smartphone or tablet.

In addition, capital markets are bullish on telehealth. In 2016, the telehealth market had a value of $2.78 billion, with an expected compounded annual growth rate of 27.5 percent. So, by 2021, the telehealth market could be worth almost $9.5 billion.

Convenience and access can drive patient satisfaction and potentially reduce the cost of care.
For instance, patients who may otherwise cancel or not show up for their postop appointments because of a long drive can now be "seen" through a telehealth platform. That reduces the chance of a missed postoperative infection or other issues.

Telehealth in orthopaedics
Although it's true that the fastest-growing telehealth services are for simple conditions, orthopaedics is ripe for leveraging the technology to improve patient convenience. Imagine if patients who are in pain or wearing a cast didn't need to drive (or have someone drive them) to the office for what is often a 10-minute visit. The incision check or mobility assessment could be done on a tablet or mobile device in the comfort of the patient's home or workplace.

The orthopaedic department of a large multispecialty group has been offering telehealth via live video-conferencing. In less than 12 months, it's already become a huge hit with patients. (See "Delivery Options for Telehealth" for a list of the various methods for delivering telehealth.) In this practice, the physician assistants see scheduled, postoperative patients "on screen," freeing physicians to see new patients or administer injections. Patients log in using their iPhones or iPads for the visit. The telehealth visits are scheduled in the computer system just as live visits are and are conducted using the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant telehealth module in the group's electronic health record (EHR). Patients are offered the option of follow-up care in person or online when their surgeries are scheduled.

Another way orthopaedic practices can use telehealth technology is by providing specialty consultations for primary care physicians. These physician-to-physician conversations can eliminate the need for an actual patient visit with an orthopaedic surgeon or expedite scheduling an appointment for an acute problem.

Regulations and reimbursement: Who pays?
At the federal level, CMS covers telehealth services if specific conditions are met. These conditions include specified types of practitioners, sites of service, and types of service provided. A list of covered codes and requirements can be found on the Medicare Learning Network. CMS reimburses covered telehealth services at the same rate it reimburses for face-to-face visits.

Similarly, more than 30 states have "payment parity" regulations that require commercial payers to reimburse telehealth services at the same rate as face-to-face visits. These laws do not legislate which types of services must be reimbursed, however, or under what conditions. Some follow CMS guidelines; some have their own. A commercial plan may cover more services than Medicare. Research is essential to determine the rules for contracted plans.

State medical boards across the country are modifying existing regulations so that more patients can participate in remote care options. State policy typically determines what constitutes telehealth; the types of technologies, services, and providers that are eligible for reimbursement; where telehealth is covered and how; and other guidelines. States' definitions of telehealth are important because they can determine whether and which services are covered and reimbursed under public and private insurance. Medicaid programs in nearly every state cover telehealth for at least some services.

Many commercial payers cover telehealth. According to one Midwest payer, covering telehealth has improved access to high-level specialty services in rural areas. Cigna Healthcare has encouraged "virtual house calls" since 2007. As David E. Mino, MD, MBA, national medical director, orthopaedic surgery and spinal disorders for Cigna Healthcare, explained, "Cigna covers medical and surgical telehealth services at this time in states that mandate coverage of this service. This only applies to fully insured customers and is based on the customer's specific benefit plan. Providers submit claims as they would for a traditional service using the same CPT codes, with a GT or 95 modifier."

For CMS, telehealth services are billed using a modifier that indicates covered telehealth services. (See "How to Code a Telehealth Visit for a Medicare Patient" for details.) According to Dr. Mino, Cigna Healthcare "covers telemedicine mainly through American Well or MDLIVE, which are contracted vendors that treat minor medical conditions and have a standard process for submitting claims."

Diligence is required when it comes to reimbursement. Because payer coverage policies and billing guidelines vary by plan, state, and federal law, understanding the rules may involve some research. According to one payer, practices can reduce claim denials for telehealth by taking the time to understand each payer's telehealth policy, along with CMS' federal policy, before preparing and submitting the claim.

Conclusion
Orthopaedic surgeons have an opportunity to differentiate themselves by using telehealth to deliver physician-to-physician consults, pre- and postoperative care, and virtual visits. Regulations are relaxing; reimbursement is expanding; and Medicare, Medicaid, and most commercial payers reimburse for at least some services. Research payer rules and coverage policies; develop a process for offering, scheduling, and delivering telehealth visits; contact the practice's EHR vendor to see if an integrated module is available; and choose a HIPAA-compliant technology platform that's right for the practice's patients and culture.

Links to the studies and references cited can be found in the online version of this article, available at www.aaosnow.org.

Betty A. Hovey is a consultant, coding educator, and auditor with KarenZupko & Associates, Inc. (KZA). A former KZA consultant and technology executive, Cheryl Toth is the firm's director of marketing.

Next Steps in Telehealth Adoption

1. Thinking about offering telehealth? Here are five steps you can take now.
2. Understand federal guidelines first. Download and review CMS' telehealth reimbursement guidelines from the Medicare Learning Network.
3. Contact your EHR vendor about the availability and cost of telehealth features or modules. If the company doesn't offer any, evaluate HIPAA-compliant solutions, such as American Well or MDLIVE.
4. Research the rules and reimbursement details of commercial payers. Download coverage policies. Develop a chart indicating which services plans will reimburse, as well as the documentation and claim filing rules.
5. Contact your state medical board and ask for the state's policies on telehealth. Policies can vary widely, so it's important to know your state's thoroughly. Ask about any upcoming telehealth legislation.
6. Meet with your team to discuss logistics. Telehealth visits require a process. There are many questions to answer: Which patients or conditions are eligible? Who will deliver the care? How/where will it be documented? How do the telehealth patients get scheduled? Who will help patients if they have technical difficulties? Don't rush this process. Make sure you are organized before you schedule the first e-visit.

Delivery Options for Telehealth
A 2016 study by the Center for Connected Health found that states vary in their use of the terms "telehealth" and "telemedicine." Further, no two states are alike in how they define or regulate it. The following four options show how telehealth can be delivered:

1. Live video-conferencing. Also called "synchronous video," this is a live, two-way interaction between a patient and a healthcare provider. Simply put, it is like a HIPAA-compliant Skype session. Patients typically participate using a smartphone or tablet.
2. Store-and-forward/asynchronous video. Patient information is transmitted through an electronic communications system to a provider who uses it to treat the patient but does not treat the patient "live."
3. Remote patient monitoring. The collection of patient information that's transferred electronically to a provider or caregiver in a different location, who reviews, monitors, and/or acts on the information.
4. Mobile health (mHealth). The use of a mobile device, such as a smartphone or tablet, to collect, track, or monitor patient data or facilitate patient-provider communication.

Contributing sources: Center for Connected Health (cchpca.org), KeystoneTechnologies.com

How to Code a Telehealth Visit for a Medicare Patient

1. Choose the evaluation and management (E/M) visit code that corresponds to the visit. The covered E/M codes include 9920x, 9921x, 9923x. Refer to the CMS website under "Telehealth" for a complete list of covered services.
2. Append the proper modifier. Modifier GT appended to a service indicates that the service was performed by synchronous (live) method. Modifier GQ appended to a service indicates that the service was performed by asynchronous (store and forward) method. Note: Currently CMS only covers asynchronous services in a federal demonstration project being conducted in Alaska and Hawaii.
3. Submit the claim as you normally would. These are CMS rules. Other payers may have different requirements for submitting claims. Research the specific guidelines for your contracted plans.

Source: www.cms.gov/Medicare/Medicare-General-Information/Telehealth

Online References:

1. http://www.americantelemed.org/main/about/about-telemedicine/telemedicine-benefits
2. http://www.mobihealthnews.com/39833/survey-64-percent-of-patients-willing-to-have-video-visits-with-docs/
3. How Telemedicine is transforming healthcare, Melinda Beck, Wall Street Journal, June 26, 2016, https://www.wsj.com/articles/how-telemedicine-is-transforming-health-care-1466993402
4. http://www.marketsandmarkets.com/PressReleases/telehealth.asp
5. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
6. State Telehealth Laws and Medicaid Program Policies, a report by the Center for Connected Health Policy, March 2016, http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf