In-office and Teledermatology Appointments

As the U.S. remains under the threat of the COVID-19 public health emergency, health care providers across the country have been investigating new ways of caring for their patients amidst quarantines and social distancing protocols. Patients, especially if they are older or have other risk factors for adverse effects of COVID-19, may feel more comfortable with telehealth appointments, leaving providers to adapt their workflows to accommodate teledermatology and/or in-office visits.

Preparing Your Office and Staff for Teledermatology Appointments

Once a provider decides to offer teledermatology appointments, preparation is key. This can include choosing a teledermatology modality, as well as establishing procedures for scheduling patients, documenting and e-prescribing, and patient billing. Modalities of telehealth include direct to patient (i.e., live synchronous audio and video), store-and-forward photos, audio (telephone)-only, and e-consults.

When preparing for teledermatology appointments, providers should research what modality and platform works best for their clinic and patients, considering available devices and ease-of-use for patients, staff, and the provider. “When deciding if teledermatology is appropriate for your office, providers should also consider if their patients have access to computers or mobile devices, and if they are familiar with how to use the camera on their devices,” says Abby Van Voorhees, M.D., who is the Chair of Dermatology at the Eastern Virginia Medical School and previous chair of NPF’s Medical Board. 

Providers may also want to consider having patients send in photos of their area of concern before the appointment. While video calling may allow for better counseling and/or higher reimbursement, photos can provide more detail regarding the area being examined. Some HIPAA-compliant modalities even allow for secure chat/messaging prior to the appointment, benefitting both patients and provider.

However, not all appointments types are best suited for teledermatology. “In-person visits are a better option for patients who are new to the provider or are experiencing flares, or have involvement in sensitive areas such as genitals, scalp, or back,” says Dr. Van Voorhees. Discussing what types of appointments and whether blocks of time should be reserved for teledermatology appointments can help staff members adapt to this new workflow.

Incorporating a new workflow isn’t without challenges. When we spoke with George Han, M.D., Ph.D., System Medical Director for Dermatology and Chief of Teledermatology at the Icahn School of Medicine at Mount Sinai, he shared his thoughts on the challenges that accompany this practice evolution. “I think the biggest challenge is figuring out what platform(s) can work to help provide a seamless workflow integration into the practice's operations, including having an easy way for patients to send in photos of their condition and log in for the visit at the appointment time. The last thing we want to be doing is calling the patient to troubleshoot technical issues at the time of the visit, so finding a solution that is very straightforward from the patient perspective is critical. As with many things in life, communication is key!”

Changes in Teledermatology Billing during COVID-19

In general, most commercial carriers and Medicare are now covering telehealth during the COVID-19 pandemic, however, providers should still check with insurance carriers with which they participate individually. Additionally, HIPAA violations for telehealth platforms will not be enforced; however, using a HIPAA-compliant platform is still suggested (especially if providers might continue to offer the service in the future). The American Academy of Dermatology website offers a complete list of HIPAA-compliant modalities as well as a wealth of information regarding billing for telehealth in their Teledermatology Toolkit.

At the end of March 2020, the Centers for Medicare and Medicaid Services (CMS) released guidance regarding access to Medicare telehealth services. Some key changes included in this guidance include:

• New patients are eligible for telehealth appointments, with no prior in-person relationship necessary
• Dermatologists can provide teledermatology services for any patient in any location
• Healthcare providers can provide virtual encounters for beneficiaries who have audio phones only  
• Health care providers can provide virtual check-in services (HCPCS codes G2010, G2012) to both new and established patients
•   Virtual evaluation and management visits (CPT codes 99201-99215) are considered the same as in-person visits and paid at the same rate as regular, in-person visits. Providers must utilize modifier 95 and a place of service (POS) code of 11 to receive reimbursement at the non-facility rate for Medicare.
• Healthcare providers can provide telehealth services from their home while continuing to bill from their currently identified practice location without having to update this in their Medicare enrollment
• Medicare co-payments can be waived for Original Medicare Beneficiaries

Preparing and Managing In-Office Appointments

Not all appointments are ideal for teledermatology. “Teledermatology is convenient and for patients who are doing well on their current systemic treatments or for check-ins it can be an adequate substitution for in-office visits. However in some situations, it can be challenging for providers to examine skin, determine BSA or to fully appreciate the extent of disease burden,” says Dr. Van Voorhees.

For instances where a provider’s location is permitting in-office appointments, the CDC has issued guidance on preparing your office for these situations.

Safety is a primary concern. Prior to opening the office, providers should make sure clinical staff is educated about the right ways to put on, use, and remove PPE as well as recognize the symptoms of COVID-19 in themselves and patients. The CDC also recommends emphasizing good hand hygiene and cough etiquette and asking staff to stay home if they are sick.

Prior to the patient’s arrival, the CDC recommends that providers know which patients are at a higher risk of adverse outcomes from COVID-19 and to ask patients about symptoms during reminder calls. The waiting area and patient rooms can also be prepared with safety in mind by providing supplies such as tissues and hand sanitizer, placing chairs 6 feet apart, and removing toys or reading materials (or at least cleaning them regularly).

When patients arrive in the office for their in-person visit, providers can have staff assigned to ask patients about symptoms and conduct any necessary checks (e.g., temperature checks) at the office entrance. Providers may want to consider asking patients to wait outside or in their car, if possible. Patients can receive a call or text message when the practice is ready for them to be seen and they can go straight into the cleaned exam room, bypassing the waiting room.

At the conclusion of the appointment, providers may want to consider providing at-home care instructions and/or consider teledermatology for follow-up appointments. Once the patient has left, the surfaces frequently touched (e.g., counters, bed, seating) should be thoroughly cleaned using EPA-registered disinfectants.

Benefits of Teledermatology

Telemedicine and teledermatology can enable health care providers to continue caring for patients, including those who may be at a higher risk of adverse outcomes due to COVID-19. And while it may have challenges and requires adapting to new routines, teledermatology does have its benefits such as increased access and convenience for patients, reduced wait times for patients who need in-person visits, and improved scheduling[1]. Also, during these times, teledermatology can promote the CDC’s recommended social distancing.

“Teledermatology has allowed us to provide continuity of care to our patients while keeping the most vulnerable patients home, out of harm's way during the COVID pandemic but I think it's also opened a lot of peoples' eyes to the ability of teledermatology to provide triage for dermatologic conditions as well as follow-up visits in a way that's easy for the provider and for the patient,” says Dr. Han.

Disclaimer:

Please check with your local government if you are considering in-office based appointments. Please check with your Medicare Administrative Contractor (MAC) to learn more about how CMS is currently processing telemedicine claims.

 [1]https://aadmeetingnews.org/2018-summer-meeting-wrap-up/teledermatology-benefits-and-challenges/