Mary K. Pratt

Many doctors complain that electronic health records (EHRs) drain their time, rather than create efficiencies. Results of Deloitte’s 2018 Survey of U.S. Physicians indicate that respondents “[perceived] themselves as mere passive participants in HER optimization efforts and, at worst, feel ignored.”

Implement these six tips to boost your productivity:

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Tips for creating efficiencies in your systems.

Six ways to boost EHR productivity 

However, despite the growing use of and demand for telehealth, experts say physicians still struggle to be adequately compensated for their services.

The Centers for Medicare & Medicaid Services (CMS) is addressing that concern by offering better reimbursement rates for telemedicine in its proposed 2019 

. Yet physicians say getting reimbursed for virtual visits and digitally-enabled patient care remains a top challenge.

These reimbursement challenges stem, in part, from issues with medical coding: whether there’s a recognized alphanumeric code associated with a particular telehealth service; and if there is, whether a payer will accept it; and if there’s not, whether an alternative option for payment is available to the physician.

“There are all sorts of technology opportunities to interact in a non-face-to-face manner, but the payment and coding system has not kept up with that,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians (AAFP).

Technological advances over the past decade have created new ways of treating patients over the phone and via video outside of the traditional in-office visit. Patients also want to connect with their physicians via email and text and through patient portals. And some patients want to digitally share medical data, such as readings from their own personal medical devices, for evaluation.

But physicians aren’t always compensated for these visits. Medicare, Medicaid, and private payers vary in what virtual services they’ll cover. 

 for virtual visits where the physician and patient connect together in real time (synchronous visits). 

, on the other hand, will pay in some states for visits where the physician and patient do not interact together at the same time (asynchronous visits), such as a patient sending a photo of a concerning rash that the physician later reviews and then prescribes a course of treatment.

As a result, physicians must educate themselves on how to code for telehealth to ensure the fiscal viability of their practices as medicine moves further into the Digital Age.

“If you don’t have a code, it’s harder to get paid-and it’s harder for the insurance company to know how to process the bill,” Moore explains.

Most physicians already realize there are various medical coding sets with the American Medical Association’s Current Procedure Terminology (CPT) codes being the most prevalent. CMS uses CPT codes, too, but also uses Healthcare Common Procedure Coding System (HCPCS) codes to reimburse physicians for Medicare services.

But beyond the different code sets, there can be different codes for same procedures performed in the physician’s office and in outpatient settings. In other words, the code essentially describes not only what services were provided but where they were provided.

Experts say physicians should realize that using the appropriate codes isn’t always a guarantee to be reimbursed, however.

“There have been codes for telemedicine for years, but just because there’s a code doesn’t mean a health plan will pay. Coverage varies,” says Robert Tennant, director of health IT policy for the Medical Group Management Association (MGMA), headquartered in Englewood, Colo.

And that coverage can vary dramatically among payers, he and others note.

The nonprofit Center for Connected Health Policy (CCHP), which aims to increase the availability of telehealth services, explains in its 2018 report 

 that, “Telehealth restrictions in the Medicare program include limitations on where telehealth services may take place, both geographically and facility-wise, the limited number of providers who may bill for services delivered via telehealth, a limited list of services that can be billed, and restricting, for the most part, to only allowing live video to be reimbursed.”

The CCHP says that although state Medicaid policies “have been more progressive, each state dictates what their policies are, which creates a patchwork quilt of telehealth laws and regulations across the nation.”

Beverly Gibson, MBA, CPC-I, a senior industry adviser at MGMA, says there are codes that should be used in certain cases, along with the restrictions on them. For example, she says telephone services and online medical evaluation (non-face-to-face services) codes are 99441 – 99444; however, she notes that the codes for these services when performed by a nonphysician are 98966 – 98969.

To better understand coding for telehealth, experts say physicians should:

Practices should review the agreements they have with their patients’ payers, particularly the ones they bill most frequently, to understand what specific virtual services will be covered under what circumstances, what conditions must be documented for reimbursement, and how the payer wants those services coded. “The physician should also ask whether phone calls are separately reimbursable services or not, and the same with online FaceTime-type visits,” Moore says. If they are reimbursable, practices should understand what conditions must apply.
 

Confirm with payers that won’t cover telehealth services whether physicians can charge patients directly for specific virtual visits or if payers consider such visits as part of a bundled service they’re already covering. “The key takeaway is to make sure you know what your contract says, how the payers view the services, and whether you can collect from the patient if [payers are] not going to pay for certain services,” Moore says.

Consider how to implement and offer telehealth services based on reimbursement. Tennant notes physicians can offer virtual services in a few different ways. They can implement technology to enable secure online visits or to enable secure text exchanges. Or they can work with established telehealth companies that provide telehealth services but brand their services as part of the physicians’ own practice. Tennant says these companies are generally well-versed in coding for telehealth.

Regularly revisit what Medicare, Medicaid, and private payers are covering for telehealth on a regular basis. “The rules of the road can shift, which is why it’s important for the practice staff to keep up on top of these changes,” Tennant adds.

Tennant says physicians who can integrate telehealth services into their overall practices and master medical coding for such services will be most successful moving forward. “Ultimately, this is all coming down to reimbursements,” he says. “It doesn’t matter how great the technology is. If practices aren’t being paid for the services, they can’t afford to do it.”

CMS has defined rules around what it considers telehealth and what virtual services it will pay for. However, proposed new rules could expand Medicare telehealth options.

As it stands, federal law defines Medicare telehealth services as exactly equivalent substitutes for in-person services, CMS spokeswoman Maria LoPiccolo said in an email to 

. The law currently restricts Medicare payment for telehealth services under certain conditions. Under Medicare, virtual services that are not paid for through Medicare telehealth policies are considered part of other bundled services, such as evaluation and management visits.

However, CMS’s proposed 2019 rule for the Medicare Quality Payment Program (QPP) includes changes to the Physician Fee Schedule (PFS) that will expand telehealth coverage.

“CMS is seeking to recognize changes in healthcare practice that incorporate innovation and technology to manage patient care,” LoPiccolo said. “We aim to modernize Medicare and increase beneficiaries’ access to physician services that are routinely furnished via communications technology.”

Among other provisions in the pending 2019 PFS/QPP proposed rule, CMS seeks to:

Pay clinicians for virtual check-ins, defined as brief, non-face-to-face assessments via communications technology such as phone or video chat.

Pay Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services furnished by an RHC or FQHC practitioner when there is no associated billable visit.

Pay clinicians for evaluation of patient-submitted photos or recorded video, such as those texted to a clinician.

Expand Medicare-covered telehealth services to include prolonged preventive services and longer visits for complex patients.

CMS expects to release the final rule in November 2018 that will take effect Jan. 1, 2019.

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How to meet patients wherever they are-and ensure you can get paid for telehealth and virtual check-ins.

Coding for patient care outside the office

Electronic health records (EHRs) have been adopted and implemented by physicians across the country. Unfortunately, physicians often find themselves working after hours due to both technology shortcomings and strenuous charting regulations. 

What are some of the features physicians believe would help them work more efficiently with their EHR? We asked, and this is what they had to say.

Physicians sound off on features they wish the EHR had in order to make their jobs and the patient experience better.

8 EHR Improvements That Need to Be Made

Federal lawmakers have been wrestling with what to do about the Affordable Care Act (ACA) since its passage in 2010. However, healthcare policy experts say Congress would do well to put other health-related issues on the docket.Â Many of these items are just as important to the current and future of the country's healthcare system. Experts note Congress has shown a willingness to address some of these issues and thereby enact legislation that can help support better health policy and help ensure better healthcare for the country.Â "Congress is really interested in working on non-ACA stuff as much as we're interested in having them do that," says Jennifer McLaughlin, JD, senior associate director of government affairs for the Medical Group Management Association (MGMA).

Health policy experts say there are numerous concerns, issues, and programs that need Congressional attention besides the Affordable Care Act.

ACA Aside: 10 Other Health Policy Items to Consider

At Family Doctors LLC, a family medicine practice in Swampscott, Mass., some patients are happy to share data they've collected from their personal trackers. Jeff W. Phillips, MD, a family physician with the practice, is happy to have it.

So much so, Phillips reaches out to other patients to see if they have data to share and counsels on how wearable technology could be beneficial to their healthcare. If he sees a patient using such a device, he'll ask them about it and how many daily steps they walk. "It gives us a common frame of reference which is helpful in counseling patients in lifestyle changes," he says.

Phillips sometimes advises patients suffering obesity, back pain and other common chronic diseases reliant on exercise and healthy habits to consider using trackers, too. He'll have them follow up with him in two to four weeks to review the information. "At the very least, the tracker serves as an educational tool, showing the patient just how little (or how much) they move," he says.

The trackers, he says, gives him and the patient the kind of accurate view of activity that can really be helpful.

"We spend time counseling patients about these things, but this is based entirely on what patients tell us. Studies have shown that patients tend to over-report exercise, and under-report calories consumed, alcohol use, etc.," he says. "On the other hand, wearable activity data is objective, and gives us valuable information as to what people are 

 doing. Assuming that the accuracy is reasonable (and studies have shown that it is, at least for step counts), this is valuable information that we can use in our counseling." Demand for wearables is huge among consumers. According to the International Data Corporation (

Worldwide Quarterly Wearable Device Tracker

, 102.4 million devices shipped by vendors in 2016. That represented 25 percent growth from the prior year's figures. Meanwhile, market research firm eMarketer calculates that nearly 40 million U.S. adults use an Internet-connected wearable device at least once a month.

Physicians are less enthusiastic about the technology than their patients. According to the 2017 

 Technology Survey, only 5 percent of respondents say they use technology that monitors aspects of their patients' health status.

Despite the medical community's low adoption rate, researchers say wearables can help physicians and their patients improve outcomes by generating reliable information that can be used to better address  myriad health concerns. This includes tracking measures around chronic conditions to disruptive sleep habits.

Contrarily, health IT experts also say the medical community and patients themselves are asking for better technology tools in order to make wearables more useful in clinical settings. As it stands now, experts report that some patients say they find wearables either too expensive or sharing data with clinicians too cumbersome. Meanwhile, physicians say they, too, struggle with sharing data and making sense of it.

"As a result, a lot of the consumer wearables are living outside the sphere of healthcare," says Dan Ledger, founder of Path Collaborative, a Boston-based advisory, research and consulting firm whose work includes connected health and wearable technology. "Doctors might say, 'You should get a Fitbit,' and that's where the conversations end. They don't say, 'Bring me the data.'"

Ledger, like others, says doctors today - even though they say wearables can support good health habits -generally find the data feeds coming off of them too cumbersome to weed through for useful insights. Other physicians still question the accuracy of some devices. Such worries, Ledger says, prevent physicians from asking for such information.

Joseph C. Kvedar, MD, vice president of Connected Health at Partners HealthCare in Boston, divides healthcare wearables into several different use cases.

First are medical-grade devices which many medical institutions incorporate into their procedures. In these cases, patients receive a wearable, such as a heart monitor, that  gather and transmit to their care teams needed information for a diagnosis or monitoring after a hospital stay to help prevent re-admission.

Then there are patients who use a connected device at home to collect information requested by their doctors. These cases, Kvedar says, generally involve patients using blood pressure cuffs, continuous glucose monitors, or even digital scales to monitor their conditions. Although many patients 

 record and share the data with their physicians, some are beginning to electronically transfer the data instead.

The third use case involves the consumer wearables, where patients use trackers, smartwatches and similar devices to electronically monitor and record various health data, from sleep patterns to daily exercise levels to biometrics.

Kvedar says researchers have found value in the first two use cases, with wearables helping to cut readmission rates and improve patient conditions. The value of the third use case, however, isn't clear cut. He points out that many of the patients who use wearables tend to be those who are already active and don't need as much guidance from their physicians. They're not usually the patients whose sedentary lifestyles and poor health habits have them contending with chronic diseases like diabetes and high blood pressure.

That in itself is a lost opportunity, health IT experts say. "It's a shame that these devices are marketed towards fit, wealthy Millennials, because the people who stand to benefit most are, in my opinion, those with chronic health conditions," says Phillips, who is also the wellness director at Boston-based RecycleHealth, a nonprofit that provides refurbished wearables to underserved populations to help improve their health and fitness.

Lisa Gualtieri, PhD, an assistant professor at Tufts University School of Medicine's 

Department of Public Health and Community Medicine

 and founder of RecycleHealth, led a study examining whether trackers could help adults with chronic conditions improve their health. In a paper published on the study in 2016 in 

, she reported that researchers saw improvements in clinical outcomes, attitudes toward trackers and physical activity among participants over a 12- to 14-week period.

Health IT experts say wearables give a more accurate account of the patient's daily activity vs. self-reporting. They also can provide useful biometric information, allowing the physician and patient to have a more targeted discussion about goals, accomplishments and improvements.

"If you have Type 2 diabetes, for example, you should be more active – walk more and track it. It used to be the doctor asks if the patient walked more, and the patient said yes; now we can say walk 10,000 steps a day, and we can see whether than happened and it's a much more meaningful conversation," says Kvedar.

Although health IT experts say wearables can help improve patient outcomes, there are stumbling blocks to that success. The ability to take in and make sense of the data produced by wearables is the biggest obstacle.

"Say it's been three months since your last visit or a year since your last checkup, what can be done with this incredible volume of data? What can be done to provide some meaningful data points that a physician can quickly look at, absorb and figure out how to integrate them into the session through, say, tailored counseling to a patient?" Gualtieri asks.

Patients can't easily send the data to their physicians. And even if they can send the data, for example, via one of the few apps that allow for such sharing, physicians can't easily import the data to their EHR systems nor easily produce reports from the information to gleam useful insights from it, she says.

"The part no one has solved yet is the analyses of those data and the presentation for some sort of insight," Kvedar says. "That is the biggest barrier: the normalization of data and decision support being applied to these streams and streams of data."

Economics are also a barrier to more widespread adoption of wearables in healthcare, Kvedar says. Traditional fee-for-service insurance plans don't cover the time a physician would spend reviewing data from a patient's wearable, even if that helps improve patient care. Nor does insurance usually cover the actual cost of wearables for those that can't afford them.

Ledger says liability questions have surfaced, too, further tempering physician enthusiasm for wearables. He says some physicians wonder if they could be held liable if they miss something problematic in a patient's wearable data stream.

Gualtieri says she believes data from wearables have real value in a medical setting, particularly when compared to information provided by patients (who tend to be more positive in their own self-reports than reality warrants).

"Trackers are providing the potential for objective data that shows patterns over time," says Gualtieri. For example, wearables can show physicians when a patient has a sudden decline in physical activity, perhaps after reaching retirement. The data presents both the information indicating a problem and an opportunity for the physician to probe further to identify problems and then suggest solutions.

"With the more accurate information, the counseling that the physician provides goes beyond 'You need to exercise more' to 'I see you are exercising in the warm weather but you need to exercise year-round' or 'I see you exercise during on weekdays but you need to exercise on the weekend, too. Here's a suggestion on what you might try to do,'" Gualtieri says.

Kvedar says physicians will have an economic incentive to incorporate wearables into their practices as healthcare moves further toward value-based reimbursements. As reimbursement models shift toward paying doctors for keeping patients well versus providing a specific service or test, physicians may find incorporating wearables to boost healthy habits outside of the office more fiscally viable., Ledger says he's seeing wearables gain more traction as part of employer-sponsored wellness programs, with many now distributing them as a way to inspire workers to stay healthy. "What's quietly happening now is this conversation about prevention seems to be happening outside healthcare, or at least it's happening more quickly outside healthcare," he says.

Health IT experts expect the medical community to catch up to consumer interest. As wearables become more popular as a healthcare tool, Kvedar predicts health IT vendors will see more demand from physicians for software that will allow them to take in and analyze data coming from patients' wearables. That demand will prompt vendors to invest more in developing the technology that physicians and patients need to easily allow for data exchange.

Gualtieri says it's important for physicians to be part of that process, so they can express what data points they'd find most useful, how they want that information presented, and what patient populations they believe could benefit the most from wearables.

As a physician, Phillips is optimistic for the future of wearables, but says his fellow doctors must be open to the opportunities they offer.

"Big obstacles for adopting wearables into healthcare include security and privacy concerns, data overload, lack of time, and lack of EHR interoperability. These challenges are all surmountable and many innovative groups are working on these problems," he says. "However, the biggest obstacle is us. Changing something about how we practice isn't easy, and doctors tend to be creatures of habit. To make wearables a routine part of the medical experiences, patients will need to continue to advocate for it, and we should keep an open mind when they do."

Only 5 percent of practices are using technology that monitors their patients' health status. Why haven't wearables made an impact in clinical care?