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The Financial Implications of Telehealth Visits Within a Hand and Wrist Surgery Clinical Practice During the COVID-19 Pandemic

Published:April 06, 2021DOI:https://doi.org/10.1016/j.jhsa.2021.03.019

      Purpose

      Telehealth use is likely to increase as a result of practice changes during the COVID-19 pandemic, although the overall picture surrounding the billing, coding, and continued insurance coverage of these visits remains uncertain. The purpose of this study was to identify potential financial implications of continued telehealth use in hand and wrist surgery clinical practice.

      Methods

      Two hundred telehealth visits were randomly selected and matched 1:1 based on primary diagnosis code to in-person visits. Medical and billing records were reviewed to compare visit complexities, total visit charges, work relative value units (wRVUs), and approved insurance reimbursement. Postoperative visits and visits with radiographic evaluation were excluded.

      Results

      Level 4 visits were more common with in-person encounters compared to telehealth (11% vs 2%, respectively), and level 1 and 2 visits were more common with telehealth compared to in-person encounters (14% vs 6%, respectively). Twenty-seven in-person visits (13%) had at least 1 additional procedure code billed. The mean total visit charge was 26% less in telehealth compared to in-person. Based on the primary procedure code alone, the sum of wRVUs was 15.1 points less in the telehealth cohort compared to in-person (per visit average, 1.1 [telehealth] vs 1.2 [in-person]). The 28 additional services provided during in-person visits accounted for an added 20.7 wRVUs. Unpaid claims were more common among telehealth encounters (8% [telehealth] vs 3% [in-person]).

      Conclusions

      Higher complexity visits and visits with additional procedural codes billed were more common with in-person visits. This led to a lower number of total wRVUs and lower total visit charges among the included telehealth visits compared to the matched in-person controls.

      Clinical relevance

      It is important to understand and consider the long-term financial impact of telehealth implementation. Practices must develop strategies to incorporate radiographic evaluation into telehealth visits and effectively stratify those patients that may require procedural interventions for in-person visits. Understanding the economic implications of this changing care delivery paradigm, providers can continue to provide telehealth services while protecting the financial sustainability of hand surgery practices.

      Key words

      The landscape of surgery has changed as a result of the COVID-19 pandemic, with the cessation of most elective surgeries and in-person office visits and a concomitant shift to virtual medicine. With necessary social distancing and quarantine efforts limiting available services, the financial sustainability of surgical practices has become strained. To address this and ensure access to care, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth coverage for its beneficiaries, guaranteeing similar reimbursement to in-office visits.
      Centers for Medicare & Medicaid Services
      Medicare Telemedicine Health Care Provider Fact Sheet.
      Many private insurers also adopted such policies. With this novel reimbursement coverage continuing to support the rapid expansion of telehealth platforms, the potential financial implications for hand and upper extremity surgical practices are unknown.
      Before the pandemic, telehealth had already been used in hand surgical practice and creative solutions had been proposed to deliver appropriate care to patients through virtual platforms.
      • Grandizio L.C.
      • Foster B.K.
      • Klena J.C.
      Telemedicine in hand and upper-extremity surgery.
      • Zhao J.Z.
      • Blazar P.E.
      • Mora A.N.
      • Earp B.E.
      Range of motion measurements of the fingers via smartphone photography.
      • Wagner E.R.
      • Conti Mica M.
      • Shin A.Y.
      Smartphone photography utilized to measure wrist range of motion.
      • Tofte J.N.
      • Anthony C.A.
      • Polgreen P.M.
      • et al.
      Postoperative care via smartphone following carpal tunnel release.
      Given its proven efficacy, telehealth will likely remain commonplace even after the pandemic has resolved. However, it is unclear how these visits will be reimbursed by insurers on a long-term basis, particularly considering that CMS policies surrounding the coding, billing, and reimbursement schedules of in-office visits have changed with approved regulations taking effect in January 2021.
      Centers for Medicare & Medicaid Services
      CY 2019 Medicare Physician Fee Schedule Final Rule.
      Therefore, we sought to investigate the differences in rates of visit level of care—a marker of visit complexity and the associated billed amount—between telehealth and in-person visits, while secondarily assessing the total charges associated with these visits. We hypothesized that inherent limitations within telehealth platforms and visit coding policies would result in lower complexity visits and total visit charges with telehealth use.

      Materials and Methods

      Following institutional review board (Thomas Jefferson University) approval, with a waiver of informed consent per institutional protocol, a database search was conducted to identify all telehealth visits within the Hand and Wrist Surgery division of a single orthopedic practice between March and April of 2020, and 200 of these visits were selected using a random number generating sequence. During this time, nearly all the previously scheduled clinical visits within the practice were transitioned to telehealth platforms in accordance with local strategies implemented in response to the pandemic. Prior to this shift, a small minority of visits within the practice were conducted via telehealth. The selected visits were matched 1:1 to in-office visits occurring between January and February of 2020 by the primary diagnosis code assigned to the visit. Postoperative follow-up visits billed within an operative bundle were excluded because these visits do not incur any additional charge to the patient or insurer regardless of whether the patient is seen in-person or via telehealth. Visits including radiographic evaluation were excluded because these may not have been available for many of the telehealth visits during the COVID-19 pandemic but could likely be incorporated with appropriate planning moving forward. Electronic medical records were reviewed to collect basic patient demographics and visit procedure codes, and internal billing records were also reviewed to collect the associated charges, insurance type, and insurance reimbursement of each visit.
      The primary endpoint, visit level of care, is encoded within the procedure code for each visit. For each type of clinical visit—new patient examination (9920-), existing patient follow-up (9921-), and in-office consultation (9924-)—the final digit of the procedure code equals the level of care designated for that visit. Among the most commonly encountered upper extremity pathologies, the level of care ranges from level 1 (low complexity) to level 5 (high complexity). At the time of data collection, level of care determination was based on 3 principal domains of the visit: history, physical examination, and required medical decision making. The levels of care for each of these domains were calculated based on their depth and complexity, and the lowest level determined between the 3 domains was assigned for the total visit.
      Centers for Medicare & Medicaid Services
      CY 2019 Medicare Physician Fee Schedule Final Rule.
      For example, if a particular new patient visit involved a level 4 history, level 3 physical examination, and level 4 medical decision making, it would be designated as a level 3 visit and subsequently coded 99203. If this same patient was seen and a level 4 history and medical decision making were obtained but the physical examination was limited to the requirements of a level 2 examination, the visit would be designated a level 2 visit and coded 99202.
      Total visit charge (the amount billed to primary insurance for each visit) and total approved reimbursement (the percentage of total visit charge approved by primary insurance for each visit) were the secondary endpoints used to determine financial differences between telehealth and in-office visits. Finally, work relative value units (wRVUs)—a CMS measure of value assigned to each common procedural terminology (CPT) code based on the provider time and effort required and subsequently used for reimbursement purposes—were recorded for all visits and additional procedural CPT codes billed. Values of wRVUs were obtained from the October 2020 release of the CMS Physician Fee Schedule Relative Value Files.
      A power analysis indicated that a sample size of 400 was needed to detect an effect size of 0.15 with a χ2 test of visit level of care rate differences at a power of 0.85 and a significance level of 0.05. The level of significance was maintained at P < .05 for all statistical analyses. A chi-square test was used to compare differences between visit level of care rates, basic demographics, and insurance types. Mean differences in total visit charges, approved reimbursements, and wRVUs were assessed for normality using the Shapiro–Wilk test and compared using the Mann-Whitney U test.

      Results

      Four hundred clinical visits among 395 patients were included in the final study sample. The mean patient age was 56 years (range, 11–97 years) and did not differ between telehealth (54 years; range, 11–97 years) and in-person (57 years; range, 11–92 years) visits. The most common primary diagnoses (with associated International Statistical Classification of Diseases and Related Health Problems 10 codes and percentage of all visits) that matched between telehealth and in-person visits were carpal tunnel syndrome (G56.01/2/3, 10%), de Quervain’s tenosynovitis (M65.4, 8%), and wrist pain (M25.531/2, 6%). Sixty-eight percent (271) of all encounters were established patient visits (Table 1) and 82% of all encounters were level 3 visits (208) (Table 2). Level 4 visits were more common with in-person encounters compared to telehealth (11% vs 2%, respectively; P < .05), and level 1 and 2 visits were more common with telehealth compared to in-person encounters (14% vs 6%, respectively; P < .05). Twenty-seven in-person visits (13%) had at least 1 additional procedure code billed (Table 3). No telehealth visits had an additional procedure code billed. Upon review of clinical documentation for the 29 level 1 or 2 telehealth visits, 19 (65%) were found to explicitly lack the necessary components of a level 3 physical examination and would have otherwise been level 3 visits.
      Table 1Rates of Visit Types Among Telehealth and In-Person Encounters (P = .516)
      Visit TypeNew PatientEstablished PatientConsultationTotal
      Telehealth5213315200
      In-person5213810200
      Total10427125400
      Table 2Differences in Level of Care Frequencies Stratified by Visit Type Among Telehealth and In-Person Encounters (P = .006)
      Visit TypeNew PatientEstablished PatientConsultation
      Level of care123412341234
      Telehealth-349-1251015--16-
      In-person--466-1310817--10-
      Table 3Procedure Frequency During In-Person Visits With the wRVUs Assigned to Each Assigned CPT Code Based on 2020 Centers for Medicare and Medicaid Services Physician Fee Schedule Relative Value Files, October 2020 Release
      CPT CodeDescriptionFrequencywRVUs Per Service
      20550Injection, tendon sheath/ligament120.75
      20605Injection, without ultrasound50.68
      20526Therapeutic injection, carpal tunnel30.94
      20600Injection, without ultrasound20.66
      20551Injection, tendon origin/insertion20.75
      20552Injection, trigger point10.66
      20610Injection, without ultrasound10.79
      20612Aspiration/injection, ganglion cyst10.70
      29125Application of splint, short arm splint10.50
      The most common insurance coverages were Preferred Provider Organization (49% telehealth and 42% in-person), Medicare (21% telehealth and 27% in-person), and Worker’s Compensation claims (7% telehealth and 13% in-person). The mean total visit charge was 26% less in telehealth compared to in-person encounters (P < .05), whereas the mean approved reimbursement percentage of total visit charges was similar between telehealth (60%) and in-person (62%) encounters. At nearly 4 months from the most recent telehealth visit and 6 months from the most recent in-person visit, unpaid claims were more common among telehealth encounters compared to that among in-person encounters (8% vs 3%, respectively; P < .05).
      Based on the visit CPT code alone (ie, 99213), the sum of wRVUs was 15.1 points less in the telehealth cohort compared to in-person (per visit average, 1.1 [telehealth] vs 1.2 [in-person]; P = .051) (Table 4). The 28 additional services provided during in-person visits accounted for an added 20.7 wRVUs (Table 3).
      Table 4The CPT Codes for Visit Types Among the Study Population With Associated wRVUs Assigned to Each CPT Code Based on 2020 Centers for Medicare and Medicaid Services Physician Fee Schedule Relative Value Files, October 2020 Release
      CPT CodeTelehealth Visits (n = 200)In-Person Visits (n = 200)
      wRVUswRVUs
      992022.79-
      9920369.5865.32
      99204-14.58
      992110.18-
      9921212.006.24
      9921397.97104.76
      992147.525.50
      9924330.0818.80
      Total220.10235.20

      Discussion

      Telehealth use underwent an unprecedented expansion across the hand and wrist surgical practices during the COVID-19 pandemic, aided by expanded insurance coverage.
      • Parisien R.L.
      • Shin M.
      • Constant M.
      • et al.
      Telehealth utilization in response to the novel coronavirus (COVID-19) pandemic in orthopaedic surgery.
      Its use is likely to remain elevated beyond the pandemic because many patients will continue to expect its availability. With the unclear future of insurance reimbursement for these visits, and recently updated policies regarding office visit billing and coding, it is important to understand and consider the long-term financial impact that telehealth use may have on a hand surgical practice. In this study, telehealth visits were associated with lower complexity visits, lower total visit charges, and fewer wRVUs assigned per visit compared to in-person encounters for the same diagnoses.
      There were a significantly lower number of level 4 visits and a higher number of level 1 and 2 visits performed via telehealth compared to in-person visits within our study. The lack of physical examination is, perhaps, the most obvious limitation of virtual platforms, and we suspect it also contributed to the observed differences in the level of care rates. Although many studies have demonstrated that components of the physical examination can be done effectively via telehealth, fewer have considered the coding implications.
      • Zhao J.Z.
      • Blazar P.E.
      • Mora A.N.
      • Earp B.E.
      Range of motion measurements of the fingers via smartphone photography.
      • Wagner E.R.
      • Conti Mica M.
      • Shin A.Y.
      Smartphone photography utilized to measure wrist range of motion.
      • Tofte J.N.
      • Anthony C.A.
      • Polgreen P.M.
      • et al.
      Postoperative care via smartphone following carpal tunnel release.
      ,
      • Van Nest D.S.
      • Ilyas A.M.
      • Rivlin M.
      Telemedicine evaluation and techniques in hand surgery.
      • Tanaka M.J.
      • Oh L.S.
      • Martin S.D.
      • Berkson E.M.
      Telemedicine in the era of COVID-19: the virtual orthopaedic examination.
      • Meislin M.A.
      • Wagner E.R.
      • Shin A.Y.
      A comparison of elbow range of motion measurements: smartphone-based digital photography versus goniometric measurements.
      Under the previous coding framework, without a complete physical examination meeting all requirements for a level 4 new patient visit, it was impossible to code for a level 4 visit regardless of the overall complexity. Providers may have effectively cared for highly complex patients during telehealth visits but have been unable to bill for a level 3 or 4 visit because of limitations of their virtual physical examination. This not only highlights the importance of targeted physical examination strategies and detailed documentation for telehealth visits but also identifies an inherent financial barrier to long-term incorporation associated with prior coding policy. Fortunately, this protocol changed in January 2021 when CMS allowed providers the option to code the visit level of care based on either medical decision making alone or total encounter time.
      Centers for Medicare & Medicaid Services
      CY 2019 Medicare Physician Fee Schedule Final Rule.
      Although we anticipate this hurdle to be cleared, it assumes the policy will equally cover telehealth visits in the long-term and that insurance providers will continue to reimburse as they did throughout the pandemic. Our findings strongly support the need for these assumptions to be met and, importantly, for all providers to fully understand the national and regional policies regarding the billing and coding of telehealth visits.
      In addition to the identified differences in the level of care rates, telehealth total visit charges were 26% less than in-person charges, and providers lost 35.79 wRVUs across the 200 telehealth visits we reported. Reimbursement concerns have long hindered the adoption and expansion of telehealth by providers, and our findings suggest that equal insurance coverage is not the only assurance needed to overcome such concerns.
      • Scott Kruse C.
      • Karem P.
      • Shifflett K.
      • Vegi L.
      • Ravi K.
      • Brooks M.
      Evaluating barriers to adopting telemedicine worldwide: a systematic review.
      The differences in charges and wRVUs we observed were largely attributable to the coding differences previously discussed as well as the additional procedures performed during in-person visits. Again, as the coding differences should resolve with the enacted policy changes, which also normalized wRVU values across levels 2, 3, and 4 visits, it becomes incumbent upon the practice to appropriately screen for patients who may need procedural intervention.
      Centers for Medicare & Medicaid Services
      CY 2019 Medicare Physician Fee Schedule Final Rule.
      This will ensure not only optimal patient care but also financial viability for the provider and practice while eliminating redundant visits for patients first seen through telehealth who require an in-person procedure. Although such stratification is needed to sustain telehealth implementation, exactly how this can be accomplished remains to be seen. Potential strategies may ultimately include a stratification based on diagnosis and previous treatments tried for established patients, requiring in-person visits for all new patients, or previsit screening performed by a clinical staff member to determine eligibility for a telehealth visit. Postoperative and established patients requiring visits to assess a specific issue (eg, wound check or range of motion check) are likely to be ideal candidates for telehealth visits.
      As expected with the insurance coverage parity during the pandemic, we did not detect a difference in the approved reimbursement between telehealth and in-person visits, although unpaid claims were significantly higher among telehealth visits. In a study published by Lin et al
      • Lin J.C.
      • Kavousi Y.
      • Sullivan B.
      • Stevens C.
      Analysis of outpatient telemedicine reimbursement in an integrated healthcare system.
      prior to the COVID-19 pandemic, the investigators found that 15% of telehealth claims were denied at first billing; however, upon deeper analysis, they recognized the rate of true denials was only 4%. In our study, the unpaid telehealth claims rate was 8%; however, we were unable to similarly assess which of these were truly denied versus reimbursed under other services or still under process. As identified in the study by Lin et al,
      • Lin J.C.
      • Kavousi Y.
      • Sullivan B.
      • Stevens C.
      Analysis of outpatient telemedicine reimbursement in an integrated healthcare system.
      there is likely a learning curve to telehealth billing, and it will be important to incorporate adequate training and monitor how unpaid claim rates change over time.
      There are limitations to our study. First, the observed differences must be interpreted in the context of billing policy at the time and rapid implementation of telehealth during the COVID-19 pandemic. Visit coding may have been similar to in-person visits if the incorporation of telehealth occurred in more ideal conditions with prerequisite training, and the observed differences may not persist with the enacted CMS policy changes. However, these changes did not affect consultation visits (9924-), and without proper training, practices may risk discrepancies among treating providers regardless of policy. Second, the billing practices of individual surgeons before the start of the pandemic were not assessed and, as such, may have confounded our results to a small degree. In terms of the data we selected to analyze, total reimbursement received by the practice was not used as an endpoint primarily because CMS and many private insurers waived all patient co-pays for telehealth visits during the COVID-19 pandemic and this led to discrepancies between the approved reimbursement and reimbursement received for a small number of visits. It can be presumed that such discrepancies will ultimately be resolved; however, in order to avoid this potential confounder, we instead used the approved reimbursement amount to assess practice reimbursement. Also, it was not possible to distinguish between claims still in process and denied claims so, for the purposes of analysis, these were grouped together and considered unpaid claims. The significant difference between unpaid claim rates suggests additional factors contributing to the overall differences between telehealth and in-person visit billing that we were unable to fully assess. This difference may also be, at least in part, attributable to delayed processing of telehealth claims and a learning curve associated with the proper coding of telehealth visits. The guidelines establishing the appropriate coding of telehealth visits evolved rapidly at the start of the pandemic. It is therefore more pertinent to consider the value in training providers and developing a standardized approach to telehealth delivery and coding within a practice to avoid potential discrepancies rather than view the present findings as a deterrent to future implementation. Finally, we did not report the number of patients scheduled for in-person visits to undergo therapeutic or diagnostic procedures after being seen via telehealth. Although these cases may have offset the decrease in telehealth wRVUs to a degree, it is important to consider the effects of such a situation. Any time a patient is seen via telehealth and told their pathology requires an in-person intervention, it risks a loss to follow-up, the potential for additional co-pays to the patient, and multiple clinical visit charges to the insurer for what could have been a single visit. Therefore, dedicated attempts to stratify visit appropriateness for telehealth platforms are in the best interest of the practice, patient, and healthcare system as a whole.
      In these unprecedented and uncertain times, the hand and wrist surgery community must remain aware of rapidly changing regulations and their economic impact as they relate to telehealth implementation. Telehealth will continue to provide access to care for patients wishing to avoid potential viral exposures while also improving efficiency and reducing travel times, wait times, and overhead for orthopedic practice. However, in order to fully appreciate its potential benefits, practices must develop strategies to incorporate radiographic evaluation into telehealth visits and effectively stratify those patients that may require procedural interventions for in-person visits. Understanding the economic implications of this changing care delivery paradigm, providers can continue to provide telehealth services while protecting the financial sustainability of hand surgery practices.

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