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Adopting Telemedicine in Wound Care: Interprofessional Internet Consultations

Consulting with other medical professionals online may improve patient care and increase revenue for the wound clinic. These authors provide a guideline to consultations using telemedicine software, and detail how clinics can receive the appropriate reimbursement.

The healthcare landscape has been moving from a fee-for-service to a value-based era. Payers have been implementing new reimbursement models that encourage providers to be cost effective. Many clinicians still face a myriad of constraints that may pose an obstacle to better outcomes or increased access to wound care. Telemedicine can be a plausible option for clinicians to do more with less in wound care. 

Throughout the world, the use of telemedicine in chronic wound management has been associated with lower cost of care, shorter healing time, fewer foot amputations and fewer office visits.1–6

Telemedicine modalities are usually classified as:7,8  

• Store and forward (asynchronous): e.g., digital photographs and clinical data sent over the internet to a wound care specialist, who analyzes the data and sends back written recommendations

• Real-time tele-video conferencing (synchronous): e.g., live interaction/communication with a wound care specialist via a webcam 

• Remote monitoring: e.g., provider continually monitors vital signs, glucose, etc. of a patient who is at home or a remote care facility  

• Mobile health (mHealth): health care and public health information provided through mobile devices

Getting Reimbursed for Interprofessional Internet Consultations 

As wound care moves toward more comprehensive patient-centered care management, frequent consultation with multiple specialists is necessary. For patients, this often means separate visits, which become costly and inconvenient. Interprofessional internet consultations among treating practitioners and consulting specialists provide a convenient and cost-effective alternative.9 

Interprofessional consultations are not new. Providers of different specialties consult each other routinely for patient assessment and management, but often do not receive reimbursement. Consultations are usually informal, via impromptu text messages, phone calls, or on other platforms that are not particularly compliant with the Health Insurance Portability and Accountability Act (HIPAA) or that may not allow for adequate documentation. 

Even without direct payer reimbursement for interprofessional internet consultations, teaching hospitals affiliated with the Association of American Medical Colleges (AAMC) have been able to demonstrate a positive impact on utilization of services, access to care, costs, and patient and provider experience.10 Since 2014, some AAMC academic services have been utilizing interprofessional internet consultations through HIPAA-compliant tools to optimize referral experiences—that is, to reduce low value referrals, improve timely access to specialty input and enhance patient experience through more effective communication and coordination between providers. In their model, interprofessional internet consultations are initiated by a primary care provider to a specialist for a low acuity condition with a specific question that can be answered without an in-person visit.10 

In 2019, the Centers for Medicare and Medicaid Services (CMS) approved payments for 6 interprofessional internet consultation CPT codes (see details on CPT codes in Table 1).9 However, to benefit from billable interprofessional internet consultations, most wound clinics still need to overcome reimbursement complexities and/or burdensome technological requirements.11 

Notes on billing requirements for the CPT® codes above: 

• Consultants and requestors are physicians or qualified healthcare professionals.

• Prior to interprofessional internet consultations, patient verbal consent needs to be obtained and documented in the patient’s chart.

• Those are time-based CPT® codes, thus tracking service time for both consultants and requestors is essential. 

•Applicable to new or established patients with a new problem or an exacerbation of an existing problem. The consultant should not have seen the patient in a face-to-face encounter within the last 14 days. When the consultation leads to a transfer of care or other face-to-face service (e.g., surgery, a hospital visit, or a scheduled office evaluation of the patient) within the next 14 days or next available appointment date of the consultant, these codes are not reported.  

Implementing Wound Care-Specific Telemedicine Software

A hospital-based wound and hyperbaric clinic in the Midwest saw great benefits in incorporating billable interprofessional internet consultations into their daily workflow. As with most wound centers, the clinic receives multiple requests for wound consultations from other departments within the hospital network. The clinic also requests consults from other professionals, such as infectious disease specialists. 

The adoption of a wound care-specific telemedicine software (WoundReference TeleVisit Module, Wound Reference Inc., San Francisco, California) provided an opportunity to formalize interprofessional internet consultations, optimize patient care and generate the documentation required for reimbursement from the Centers for Medicare and Medicaid Services (CMS). The module is a cloud-based, mobile-responsive, HIPAA-compliant solution that allows wound care providers to meet clinical needs and CMS reimbursement requirements for internet interprofessional consultation through built-in features/documentation templates.  

Implementation of the Module was conducted according to the framework below (see Figure 1), adapted from the American Medical Association (AMA) Digital Health Implementation Playbook.12,13 

Part 1 (Pre-Game): Exploring Telemedicine as a Solution

• Step 1: Identifying a need for telemedicine solutions

• Step 2: Forming the team

• Step 3: Defining success

• Step 4: Evaluating the vendor

• Step 5: Making the case

• Step 6: Contracting

Part 2 (Game): Telemedicine Implementation 

• Step 7: Designing the workflow

• Step 8: Preparing the care team

• Step 9: Partnering with the end-user/customer

• Step 10: Implementing the solution

• Step 11: Evaluating success

• Step 12: Scaling

Key Takeaways From the Implementation Process

Identifying the initial use case. Implementation of the Module was guided by prioritization of the use cases. To find out which use case would bring the most value more quickly, main clinical scenarios were identified and compared. Potential scenarios included: 

• Wound care providers requesting consultations to in-network infectious disease specialists and vice-versa

• In-network primary care providers requesting consultations to wound care providers

• Out-of-network home health clinicians requesting consultations to wound care providers

• Out-of-network skilled nursing facility clinicians requesting consultations to wound care providers

Interprofessional internet consultations between the wound clinic and the infectious disease department were initially implemented to document and bill for interdepartmental consultations that already occurred on an informal basis. Interprofessional internet consultations in this case allow wound clinicians to accurately diagnose infectious conditions/comorbidities and initiate prompt treatment. Furthermore, this use case served as an ideal pilot case before expanding to other use cases, as wound care providers act as requesting providers or consultants, thus allowing the implementation team to experience both roles.

After identifying the use case, each step of the workflow was mapped out and presented to the team, so that each team member could understand his or her role in the workflow.

Integrating the telemedicine software into the EHR workflow. Throughout implementation, wound clinic providers tested the TeleVisit Module several times. As a result of their feedback, the wound care-specific documentation templates of the Module were substantially enhanced, and time to generate documentation was significantly shortened. Then, documentation templates of the Module were reproduced within the facility’s electronic health records (EHR) to ensure workflow integration. The EHR-agnostic Module allowed for seamless integration with the facility’s EHR workflow.  

Billing. Early involvement of coding and billing specialists in the implementation process is essential. The new codes were added to the charge master of the facility, and the steps for payers billing were mapped out. Special attention was given to the requirements of each CPT code (see Table 1) and to understanding the information to be entered in each field of the CMS/HCFA 1500 Claim Form.

In Summary

The implementation of billable interprofessional internet consultations can be streamlined with the framework provided in this article and with wound care-specific telemedicine software. 

In addition to improving patient care/satisfaction and fulfilling medico-legal documentation needs, interprofessional internet consultations utilizing proper telemedicine software may increase revenue through additional reimbursable services and more accurate ICD-CM coding. While CMS payment for telemedicine CPT® codes may not be as high as that for in-person Evaluation and Management CPT® codes, costs to furnish telemedicine services can be lower than those of in-person visits. Thus, providers and facilities may benefit from higher margins and more flexibility in their schedule. Telemedicine will continue to expand and is ripe for adoption by wound care services willing to save time, money and improve patient outcomes. 

Other resources on interprofessional internet consultations: 

• The Federation of State Medical Boards Telemedicine Policies by State

• The Center for Connected Health Policy

Elaine H. Song is a plastic surgeon, and Co-Founder and CEO of WoundReference, Inc.

Kye Evans is an emergency medicine physician, Medical Director for the Lawrence Memorial Hospital Wound Healing Center, and an Advisory Editorial Board Member of WoundReference, Inc

Scott Robinson is an emergency medicine physician, Medical Director of Hyperbaric Medicine for the Lawrence Memorial Hospital Wound Healing Center, and an Advisory Editorial Board Member of WoundReference, Inc.

Tiffany Hamm is an Advanced Certified Hyperbaric Registered Nurse, Certified Wound Specialist, and Co-Founder and Chief Nursing Officer of WoundReference, Inc. 

Jeff Mize is a Registered Respiratory Therapist, Certified Hyperbaric Technologist, Certified Wound Care Associate, and Co-Founder and Chief Clinical Officer of WoundReference, Inc. 

Catherine T. Milne is an advanced practice Wound, Ostomy Continence Nurse at Connecticut Clinical Nursing Associates, and an Advisory Editorial Board Member of WoundReference, Inc. 

Samantha Kuplicki is an Advanced Practice Registered Nurse, board certified as an Adult-Gerontology Clinical Nurse Specialist and Certified Wound Specialist with Utica Park General Surgery at Hillcrest Healthcare System, and an Advisory Editorial Board Member of WoundReference, Inc.

Kathryn Whiston-Lemm is an Acute Care Nurse Practitioner and Certified Wound Ostomy Nurse with Queen of the Valley Medical Center, and an Advisory Editorial Board Member of WoundReference, Inc. 

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Elaine H. Song, MD, PhD, MBA; Kye Evans, DO, FACEP; Scott Robinson, MD, Tiffany Hamm, BSN, RN, ACHRN, CWS; Jeff Mize, RRT, CHT, CWC; Catherine T. Milne, APRN, MSN, CWOCN-AP; Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA; and Kathryn Whiston-Lemm, ACNP, CWCN, COCN-AP
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References

1. Chanussot-Deprez C, Contreras-Ruiz J. Telemedicine in wound care: a review. Adv Skin Wound Care. 2013 Feb;26(2):78–82.

2. Gaydos J. The audio-visual connection: a brief history of telemedicine. Today’s Wound Clinic. 2019 Apr;13(4):16–19.

3. Sood A, Granick MS, Trial C, Lano J, Palmier S, Ribal E, et al. The role of telemedicine in wound care: a review and analysis of a database of 5,795 patients from a mobile wound-healing center in Languedoc-Roussillon, France. Plast Reconstr Surg. 2016 Sep;138(3 Suppl):248S-56S.

4. Wickström HL, Öien RF, Fagerström C, Anderberg P, Jakobsson U, Midlöv PJ. Comparing video consultation with in person assessment for Swedish patients with hard-to-heal ulcers: registry-based studies of healing time and of waiting time. BMJ Open. 2018 Feb 15;8(2):e017623.

5. Smith-Strøm H, Igland J, Østbye T, Tell GS, Hausken MF, Graue M, et al. The effect of telemedicine follow-up care on diabetes-related foot ulcers: a cluster-randomized controlled noninferiority trial. Diabetes Care. 2018;41(1):96–103.

6. Gamus A, Kaufman H, Chodick G. Remote care of lower extremity ulcers: an observational pilot study. Isr Med Assoc J. 2019 Apr;21(4):265–8.

7. Song E. What is new in 2019 for Telehealth and Telemedicine? WoundReference. Available at https://woundreference.com/blog?id=what-is-new-in-2019-for-telehealth-and-telemedicine . Published 2019. 

8. About Telehealth. CCHP Website Available at https://www.cchpca.org/about/about-telehealth .

9. Federal Register.  Available at https://www.federalregister.gov/documents/ 2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other .

10. Association of American Medical Colleges. Association of American Medical Colleges Medicaid Managed Care Letter to CMS Administrator Verma. September 27, 2019.

11. Mazuz R. Four ways to integrate digital health into the wound center today. Today’s Wound Clinic. 2019 Apr 9;13(4)9–10.

12. Telemedicine. Televisit Implementation Playbook - Part 1. WoundReference. Available at https://woundreference.com/app/topic?id=telemedicine-televisit-implementation-playbook .

13. American Medical Association. American Medical Association Digital Health Implementation Playbook. 2018. 

Additional References

14. American Telemedicine Society. Available at https://www.americantelemed.org/policy/

15. American Telemedicine Society. Available at https://www.americantelemed.org/initiatives/2019-state-of-the-states-report-coverage-and-reimbursement/ 

The authors thank Amy Miller and Kaitlin McAleese from Lawrence Memorial Hospital Physicians Central Billing Office for sharing information on the billing process described in this article. 

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