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Telemedicine rheumatology
The document discusses the increasing shortage of rheumatologists in the U.S., highlighting a demand of approximately 6000 rheumatologists against a workforce of around 4997, predicting a reduction to about 4700 by 2030. It emphasizes the adoption of telemedicine in rheumatology, which enhances patient access, facilitates timely diagnosis, and allows for effective communication while reducing exposure risks during the COVID-19 pandemic. Additionally, it details the coding, billing practices, and necessary consents for telehealth visits, alongside suitable patient conditions for remote evaluation.
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Telemedicine rheumatology
- 1. Telemedicine in Rheumatology DianaGirnita, MD, PhD
- 2. The law ofsupply and demand Shortage of rheumatologists in US Many arthritis patients Long waiting time to be seen by specialist (aprox. 4-6 months) States with highest population are the highest in need North and middle US – greatest need of rheumatologists
- 3. Rheumatologist shortage inUS 2015 – workforce study 4997 rheumatologists (the need was about 6000s in the US), most concentrated east/ west coast The same number of spots available for fellowships across US for aprox 20 years Shortage by 2030 - estimated to be will be aprox. 4700 rheumatologists 60% are females (PT schedule) 50% of rheumatologists plan to retire in the next 10 years https://www.medpagetoday.com/rheumatology/generalrheumatology/72333
- 4. 2015 US data-52 millions adults with arthritis (24 millions with limitations due to arthritis); will increase in 2040 to 78 millions patients with arthritis Barbour KE et al. Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation—United States, 2013–2015. Morb Mortal Wkly Rep 2017;66:246–253. Hootman JM et al Updated projected prevalence of self-reported doctor-diagnosed arthritis and arthritis-attributable activity limitation among US adults, 2015-2040. Arthritis Rheumatol. 2016;68(7):1582–1587.
- 5. Conditions that maybe evaluated ARHRITIS Osteoarthritis Gout/ pseudogout Rheumatoid arthritis Polymyalgia rheumatica Psoriatic arthritis Spondylarthropathy (Ankylosing spondylitis) Reactive arthritis (after viral/ bacterial infections) Autoimmune diseases/other Raynauds phenomenon Inflammatory myopathies (follow up) ANCA vasculitis (follow up, limited disease) Giant cell artheritis (follow up) Lupus and scleroderma patients (follow up) Fibromyalgia (counseling) Sjogren sdr Osteoporosis
- 6. Adopting telehealth inrheumatology
- 7. Appropriate NEW patients Osteoarthritis Gout/ pseudogout Rheumatoid arthritis Polymyalgia rheumatica Psoriatic arthritis Spondylarthropathy (Ankylosing spondylitis) Reactive arthritis (after viral/ bacterial infections) Raynauds phenomenon Fibromyalgia (counseling) Sjogren sdr Osteoporosis
- 8. Appropriate FOLLOW upspatients Osteoarthritis Gout/ pseudogout Rheumatoid arthritis Polymyalgia rheumatica Psoriatic arthritis Spondylarthropathy (Ankylosing spondylitis) Reactive arthritis (after viral/ bacterial infections) Raynauds phenomenon Fibromyalgia (counseling) Sjogren sdr Osteoporosis Inflammatory myopathies Lupus Scleroderma ANCA Vasculitis
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- 10. Patients taking immunosuppressive/biologics Very important to respect the social distancing rules Continue medication under tight medical control Avoid ER/ urgent care visits for flare ups (management by telemedicine)
- 11. Follow ups Labs(immunosuppressive safety labs every 3-4 months) Imaging Medication management (side efects) Education for administration of medication Refills of medication
- 12. NOT appropriate fortelemedicine ICU visit Procedures (injections)
- 13.
- 14. Consent Written/ verbal consentdocumented in the chart Evaluation Medical decision This is a billable visit This is not a video chat/ facetime
- 15. History is 50%of the evaluation Very important Review of the chart, signs and symptoms Review of previous labs Review of available imaging
- 16. ROS (1) document Constitutional: (+/-) chills, fever, malaise/fatigue, weight loss. HENT: (+/-) hearing loss; dry mouth, oral / nasal ulcers, hair loss, jaw pain/claudication, headaches, ear swelling, nasal polyps Eyes: (+/-) blurred vision, dry eyes, redness or pain; no history of scleritis/ uveitis Respirator: (+/-) cough/ shortness of breath, history of pleurisy Cardiovascular: (+/-) chest pain, palpitations, leg swelling, history pericarditis Gastrointestinal: (+/-) abdominal pain, constipation, diarrhea, heartburn, nausea and vomiting. Genitourinary: (+/-) dysuria and urgency.
- 17. ROS (2) Musculoskeletal:(+/-) back pain, joint pain and neck pain; myalgia Skin: (+/-) rash, photosensitivity, Raynauds, skin tightening, ulcers Neurological: (+/-) dizziness, tremors, speech change, foot/wrist drop Endo/Heme/Allergies: (+/-)environmental allergies; ecchymosis; history of DVTs/ Pes, miscarriages Psychiatric: (+/-) depression, brainfog, memory loss, insomnia.
- 18. Physical exam -general GEN: awake, alert, no acute distress HEENT :atraumatic, normocephalic, no rashes noted,+/- alopecia/ temporal thinning of hair Eyes: NO redness, discharge, swelling Nose: NO redness, swelling, discharge, deformity, or impetigo/crusting Skin: no lesions, wounds, erythema, or cyanosis noted on face or hands Cardiopulmonary: no increased respiratory effort, speaking in clear sentences, I:E ratio WNL Neuro: cranial nerves grossly normal, speech normal rate, orientation arrived to appointment on time with no prompting, no foot/ wrist drop noted Pysch: appearance, behavior, and attitude- well groomed, pleasant, cooperative
- 19. MSK examination ROM inthe neck, spine, upper/ lower extremities deformities, swelling of joints , fist formation Good ambulation in front of the camera; getting up from a chair Strength You may use a NP/ MA/PCP to conduct exam
- 20. Diagnosis Challenging, but notimpossible!
- 21. Telemedicine is appropriatefor Labs Imaging studies Medication Subspecialty consultation (dermatology, neurology, nephrology, GI)
- 22. Rheumatology telemedicine consultation ishelpful ER Hospitals remote PCPs Dermatology ( co-management with PsA management) Urgent cares (gout management?, reactive arthritis)
- 23.
- 24. COVID-19 pandemic March17th , 2020: CMS expanded access to telehealth 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act waived telemedicine restrictions for Medicare beneficiaries, reimbursement rates at the same fee for-service rate as regular, face-to-face evaluation and management (E/M) visits. Office of Civil Rights (OCR) will not impose penalties on rheumatologists who use everyday communications technologies (FaceTime; Skype- HIPAA noncompliant)
- 25. Licensing 1135 Waiver:"waiver of provider licensure" Different US states create their own licensure waivers Check with the medical board states https://www.fsmb.org https://www.imlcc.org
- 26. CODING video vstelephone visits SYNCHRONOUS audio/ video E/M codes Telephone visits E/M codes 99201-99205 new patients 99212-99215 established POS 02/11 (office) Patient Consent Telemedicine platform used Modifier 95 (private payers) 99441- 5-10 min 99442 -11-20 min 99443 -21-30 min
- 27. Payment adjustment fortelephone encounters Retroactive policy to March 1st, 2020 to increase payments for telephone visits to match reimbursement for similar office and outpatient visits.
- 28.
- 29. Private payers March17, UnitedHealthcare announced they will largely follow CMS’s lead for billing and reimbursement for telehealth services (waive originating site restriction. allowing providers to bill for telehealth services performed while a patient is at home; policy change is effective until June 18th, 2020) https://www.rheumatology.org/Portals/0/Files/Commercial- Payer-Telehealth-Tracking-COVID-19-Public-Health- Emergency.pdf
- 30. Telemedicine in rheumatology •Improves access to specialized care • Facilitate the timely diagnosis and treatment to rheumatic patients, while limiting exposure • Allow providers to communicate with patients effectively, convenient and track their health status • Provide timely interventions • Saving time, money on transportation • Not having to take significant time off of work • Not having to arrange child care
- 31.
- 32. Additional information Websiterecourses CMS billinghttps://www.cms.gov/Medicare/Medicare-General- Information/Telehealth/Telehealth-Codes Coding/ billing E/M https://emuniversity.com/Definitions.html Consent statement video/ telephone visits Telemedicine platforms
- 33. Telephone Consent statement Patientwas informed of the risks, benefits, and alternatives of the services being provided via telephone and consented to receiving care in this manner. Reason Telephone Visit service requested: Covid-19 Physical Location of patient: {Telehealth Patient Location:21383} Physical Location of Telephone Visit Provider: {Telemed Provider Location:17451} Telephone Visit time spent: {Telephone time spent with patient:21385} Discussed with {gen discussed with:310081} and nursing
- 34. Video Consent statement Patientwas informed of the risks, benefits, and alternatives of the services being provided via telehealth (video and audio) and consented to receiving care in this manner. Patient verbally consented to this service. The telemedicine platform used is doxy.me (HIPAA compliant) Reason Telehealth Visit service requested: Covid-19 Physical Location of patient: home Physical Location of Telehealth Visit Provider: POS 02 /11 (office) Discussed with patient and nursing
- 35. Platforms used DOXY.me Vsee.com ZOOM Google duo/ Facetime/ Whats app (not HIPAA compliant)
Editor's Notes
- #25 Centers for Medicare & Medicaid Services (CMS) expanded telehealth services as part of the government-wide effort to ease the growing COVID-19 pandemic.
- #27 CMS previously required telehealth services to have both audio and visual elements; the ACR along with the AMA and other medical groups pushed the Agency to remove that requirement, arguing that some sessions can easily be conducted over the phone. •