Optimizing telehealth services

By Alexander Miller, MD, July 1, 2020

By now, many dermatologists have significantly integrated telehealth services into their practices. I have appreciated the benefits and some of the limitations of the telehealth system. Basic to our diagnostic and therapeutic decision-making are images, both video and photo.

Synchronous (live interactive) patient encounters, other than for the occasional audio difficulties that can be readily remedied, involve live video images. This is where the synchronous signal delivery system can sometimes challenge us to the point of precluding a diagnosis. Synchronous images can be blurry. This has been a bane in my office, particularly when the signal transmission has been carried through an encrypted HIPAA-compliant modality rather than through a direct (non-HIPAA compliant) video interaction with the patient, such as via FaceTime.

What factors can affect synchronous image quality?

• Patient’s camera resolution (on computer, tablet, phone)

  • Ask patient to use a device with a camera providing the highest pixel count, if available

• Lighting

  • Brighter light optimizes clarity

  • Ask the patient to preferably use a well-lit area, such as a brightly lit room or outdoors, in indirect sunlight

  • Faint light will produce grainy images

• Signal transmission bandwidth and strength

  • For the patient, plugged in cable or Wi-Fi will yield the strongest signal

  • Patient should locate where their Wi-Fi signal is strongest

  • Multiple people simultaneously using Wi-Fi may consume the bandwidth and slow transmission

  • Receiving end (office or physician location) should have a maximized signal

• HIPAA-compliant signal transmission and capture

  • May reduce image resolution

  • Resolution may be improved by changing the synchronous transmission to a direct patient-office interaction via patient’s tablet or smartphone (not HIPAA compliant, but may be used without penalty during the COVID-19 public health emergency period (PHE))

When all of the above synchronous transmission variables are optimized, it is still up to the patient/patient’s "videographer" to properly focus on the lesions in question. In the process of guiding a patient to reveal areas that I have wanted to evaluate, I have gained insight into a patient’s furniture, ceiling, windows, and outdoor landscaping, but not always the lesion(s) in question. For this reason, it is valuable to have staff evaluate and troubleshoot image and sound quality and the patient’s general ability to provide useful live images prior to the physician’s/qualified health care professional’s (QHP) entry.

• Position in good lighting: outdoors, but avoid direct sunlight; well-lit room

• Use the phone’s back camera, as it yields higher resolution than the front-facing, FaceTime camera

• Hold camera still

  • Cupping the phone in both hands so that it is being held at two opposing edges will better stabilize it than holding it by one edge

• Gently touch the portion of the image revealing the lesion in question, as this will lead the lens to focus upon that spot and generate an optimal color balance

  • There is a minimum distance below which a lens will not focus

  • If a closeup is out of focus, move phone back and take another photo

• Consider a solid monochrome background; Having a ‘busy’ background in the photo may cause the camera to focus upon the background

• Press gently on the shutter actuator, so as to avoid jiggling the phone

• Subject should stay still

• Take a large-area photo to reveal lesion distribution (whole back, face, etc.)

• Then, take a close-up of the lesion or rash; this photo should minimize background

• Avoid digital zoom, as it degrades image quality

• Ensure a clean lens: If all images are blurry, lens may need cleaning (sunglass cleaning cloths work great)

• Ask patient to check photo quality, particularly whether the lesion in question is in the photo and in focus, prior to sending it

• If images are blurry or landmarks are indistinct, ask patient to re-take and send

Now that telehealth is in focus, let’s check on recent related developments. The Centers for Medicare and Medicaid Services (CMS) has recognized that some Medicare patients may not have access to, or proficiency in, conducting a live interactive telehealth visit. Realizing these limitations, CMS has instructed that during the COVID-19 PHE, evaluation and management (E/M) services can be provided telephonically. These services should be reported with CPT codes 99441-99443. Physicians and QHPs are now further incentivized to provide such E/M services by way of reimbursement, which will parallel that of similar established office outpatient E/M visits. This will raise reimbursement from about $14-$41 to about $46-$110 per encounter and is retroactive to March 1, 2020.

Private payer coverage for telehealth

Private payer coverage for telehealth can vary from payer to payer and sometimes plan to plan. The AAD/A is proactively tracking payer guidance and has gathered a list of more than 65 updates from private payers. Please check this resource often, as it is updated frequently.

Sample CMS reimbursement for telephone codes effective 03/01/2020



Time clarified by CMS

CMS has further clarified that the office/outpatient E/M level selection for services, when furnished via telehealth can be based on medical decision making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter. The medical record documentation must also include a medically appropriate history and/or examination, even though these are not considered in determining the final level of service reported. This policy is similar to the policy that will apply to all office/outpatient E/M services beginning in 2021.

Time is counted based on the total time spent with the patient, including pre- and post-time on the date of service. The typical times for purposes of level selection for an office/outpatient E/M are the times listed in the CPT code descriptor.

I just spent seven minutes doing a telephone evaluation with a patient. Based upon the patient’s history of non-melanoma skin cancers and the report of a rapidly growing facial lesion, I suspected a squamous cell carcinoma and recommended a prompt in-office biopsy. The patient is scheduled to come in tomorrow. I reported the telephone E/M interaction with CPT 99441.

Example 1

I did a legitimate Mohs surgery on a scalp atypical fibroxanthoma, satisfied all qualification and documentation criteria, submitted a claim to Medicare with CPT 17311 and 17312 for two stages of Mohs surgery, and indexed it to ICD-10-CM code C44.40, “Unspecified malignant neoplasm of skin of scalp and neck,” as there is no ICD-10-CM code specifying an atypical fibroxanthoma. The claim was denied. Why?

Answer: Incorrect. Although an E/M service was done, the information gathered is a component of the service included in a biopsy code. Since this service led to a prompt appointment and biopsy done within 24 hours (or first available appointment), as defined by CPT, no separate charge for the telephone interaction is warranted.

Example 2

An established patient calls, worried about a potential flare of bullous pemphigoid, which was being controlled with topical ultrapotent steroid applications. A telephone evaluation confirms an exacerbation of bullous pemphigoid. Prednisone is prescribed to control the eruption and a telephone two-week follow-up is scheduled. The interaction with submission of prescription order to the pharmacy lasted 15 minutes, for which CPT 99442 is reported.

Answer: Correct. A full telephonic E/M service was done. Scheduling a follow-up telephonic interaction does not preclude billing a telephone E/M code for the present visit.

Example 3

An established Medicare patient’s synchronous telehealth visit lasts 25 minutes. Realizing that during the COVID-19 PHE you may report E/M service levels based on either MDM or time, you select time. Then, you note that the CPT stipulates that time may be used to report E/M services only when counseling/coordination of care constitute greater than 50% of the encounter’s time. You decide to select an E/M code based on time, anyway.

Answer: Correct. CMS has issued a waiver stipulating that during the COVID-19 PHE the entire time associated with the day’s patient encounter may be used to select a level of E/M service. This includes pre-service time, such as reviewing the chart, and/or viewing store-and-forward patient images, time spent synchronously interacting with the patient, and post-synchronous time, such as for sending a prescription. Counseling/coordination of care are not required for this time determination.

Example 4

Now that you have 25 minutes of time, you are a bit stumped. The CPT provides “typical” time breakdowns for codes 99201-99215 levels of care, but these times are defined as face-to-face times, and not total times. What code do you choose?

Answer: In its updated missive approving the use of time for reporting telehealth E/M interactions during the COVID-19 PHE, CMS has clarified that the times used for the purpose of determining time are those listed in the CPT code descriptors. The following are the CPT published total times, to be used for determining levels of synchronous telehealth service:

Based upon the above time breakdowns, 25 minutes of service would be reported with CPT 99214.

More information can be found in the recently updated CMS COVID-19 IFC 5531 (PDF download).

Additional DermWorld Resources