Telemedicine in rheumatology can help the shortage of physicians across US. Covid-19 crisis showed us that telemedicine in rheumatology is highly effective, cost efficient, convenient and can provide excellent care for patients in a safe environment without the unnecessary exposure to coronavirus.

1. Telemedicine in Rheumatology
Diana Girnita, MD, PhD

2. The law of supply 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 in US
 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 may be 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 in rheumatology

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 ups 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
 Inflammatory myopathies
 Lupus
 Scleroderma
 ANCA Vasculitis

9. Positive ANA
Autoimmune
Malignancy
Infection
Drugs
Radiation

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 for telemedicine
 ICU visit
 Procedures (injections)

13. The rheumatology telehealth visit

14. Consent
Written/ verbal consent documented 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 in the 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 not impossible!

21. Telemedicine is appropriate for
 Labs
 Imaging studies
 Medication
 Subspecialty consultation
(dermatology, neurology,
nephrology, GI)

22. Rheumatology telemedicine consultation
is helpful
 ER
 Hospitals remote
 PCPs
 Dermatology ( co-management with PsA management)
 Urgent cares (gout management?, reactive arthritis)

23. CODING, BILLING

24. COVID-19 pandemic
 March 17th , 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 vs telephone 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 for telephone
encounters
Retroactive policy to March 1st, 2020 to increase payments for telephone
visits to match reimbursement for similar office and outpatient visits.

28. Interprofessional telephone/ ERH
assessment

29. Private payers
 March 17, 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. Thank you

32. Additional information
 Website recourses
 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
Patient was 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
Patient was 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)