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Medical Coding News Archives

Quality of Care Lags Behind Growth of Telemedicine

February 27, 2017:

As more health care providers, payers, and consumers turn towards telemedicine services, questions arise concerning the accuracy of diagnoses, quality of care, and professional ethics.

Recent Harris Poll studies commissioned by the telehealth company American Well indicate that 64 percent of consumers would be interested in seeing their primary care provider over video. The majority of respondents indicated that they would consider using telemedicine for chronic conditions, birth control consultation, post-surgery or inpatient care, and to fill prescriptions.

Consumer interest in telehealth is tied not only to advances in technology, but also to increasing payer coverage of such services. For example, Medicare recently began paying for remote care related to end-stage renal dialysis, critical care consultations, and advanced care services if they meet certain criteria. Part of payers’ interest in this developing technology is due to the relatively low cost of remote care as compared with in-person care—a 2014 analysis estimated that the average face-to-face encounter for an acute condition cost at least $136, while a remote visit cost between $40 and $50.

According to an article in The Wall Street Journal from June 2016, among the fastest-growing telehealth services are phone, video, or email “visits” for nonemergency issues such as mild viruses, earaches, and rashes. The number of large employers offering benefits for remote doctor visits also grew, shooting up 50 percent from 2015 to 2016 to now nearly 75 percent of these employers.

Providers are stepping up to fill the increased demand for remote care. For example, Kaiser Permanente CEO Bernard Tyson reported in October 2016 that more of their patients access care virtually by phone, online, or through the health system’s apps than through in-person visits. Teledoc, a telehealth services company, and Analyte, which provides lab services, recently announced a partnership that will offer in-home lab services in more than 1,000 locations throughout all 50 states. Starting in April, Teledoc will be able to connect patients with an Analyte lab technician in their area who can come to their homes to collect blood or samples. A Teledoc physician will then review the results in one to three days to use in diagnosis and treatment.

Coding systems have tried to keep pace with these developments in telemedicine and its coverage. The American Medical Association added new CPT® modifier 95 this year to indicate such services provided in real time using interactive audio and video (replacing Medicare’s modifier GT). The Centers for Medicare and Medicaid Services (CMS) also beefed up its telemedicine coding options for 2017: It added two HCPCS Level II codes for critical care telehealth services (G0509 and G0508).

For telemedicine services reported on or after January 1, 2017, CMS has also created a new place-of-service (POS) code 02 Telehealth: The location where health services and health related services are provided or received, through telehealth telecommunication technology, that should be used to indicate that the service furnished is a telehealth service.

Quality of Care May Suffer

Some worry that the technology and eagerness to take advantage of convenient, low-cost telehealth services are outstripping health care providers’ ability to ensure the quality of care delivered remotely. They point to a study published in the Dermatology Journal of the American Medical Association in July 2016 that unveiled some troubling trends. The authors found in a study lasting five weeks in 2016 that not one of 16 direct-to-consumer telemedicine websites asked for patient identification or questioned pseudonyms or falsified photos in 62 clinical encounters related to skin disease. A minority, 26 percent, relayed information about the provider’s license, only 23 percent asked for the name of the patient’s primary care physician, and 10 percent offered to send medical records.

The study found that the websites rarely probed beyond photos to ask about critical history elements, such as fever and excessive hair growth, only a third mentioned relevant adverse effects of prescription medications, and slightly more than 40 percent noted pregnancy risks. These services also failed to impress in terms of diagnostic accuracy—they regularly missed major diagnoses, such as secondary syphilis and polycystic ovarian syndrome. When a diagnosis was reached, the study found that the treatments recommended sometimes conflicted with existing treatment guidelines.

Overall, this analysis concluded that, while telemedicine holds out great promise to expand access to care without inflating health care costs, this growth should wait until quality of care can be ensured. Without improvement, we will end up with expanded access to “fragmented, low-quality care.”

Some steps have been taken to address quality issues. For example, in June 2016, the American Medical Association released ethical guidelines for physicians providing telemedicine services. The guidance aims to ensure that physicians put the patient’s welfare first, provide competent care, give patients sufficient information for them to make decisions about their care, safeguard patient privacy and confidentiality, and keep the continuity of care in mind. The key focus is to give clinicians access to the relevant information that will allow them to make the best medical decisions for the well-being of the patient. The AMA guidelines stress the need for the telemedicine community to come together collaboratively, such as in the case of Teledoc and Analyte, to ensure high-quality care while encouraging continued enhancement of telemedicine technologies and applicable standards and campaigns to make this type of service available to any patients who wish to use it.

Trends indicate continued growth in the telemedicine industry due to three key reasons: patient demand for convenient and affordable virtual health care, government commitment to move towards controlling expenditures, and a focus on improving care quality through legislation like the Medicare Authorization and CHIP Reauthorization Act of 2015, which has opened the door for tremendous system improvements.

CPT is a registered trademark of the American Medical Association.


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