481: Telehealth Now

This episode of the Healthy, Wealthy and Smart Podcast features a Private Practice Section Webinar, “Telehealth NOW” to address ongoing concerns for physical therapy practices during the COVID-19 pandemic.

In this webinar, we cover:

-How to navigate telehealth terminology and different vendors

-State and federal telehealth regulations to frequently check

-How to effectively bill for telehealth services

-An example of a telehealth physical therapy visit

-And so much more!

 

Resources:

Lynn Steffes Twitter

Mark Milligan Twitter

Ali Schoos Twitter

PPS Covid19 Resources

ZOOM Recording of Telehealth Now Presentation 

Telehealth NOW Presentation slides

PPS Promoting Telehealth to Patients

PPS Tips and Tricks to Starting Telehealth

PPS COVID19 FAQ

PPS Telehealth Coverage Policies during COVID19  

 

For more information on Lynn:

Lynn Steffes, PT, DPT is President/Coach/Consultant of Steffes & Associates, a rehabilitation consulting service based in Wisconsin. Providing consulting services to rehab providers nation-wide working.

She has enabled providers to achieve optimum success in the delivery of high quality, cost-effective care to their patients/clients.

 

Coaching/consulting in:

Marketing, program development Selection, training & support of Practice Marketing Specialists Customer Service initiatives, patient alumni programs Lifestyle Medicine Programs Negotiating managed care contracts, payer relations

 

Dr. Steffes is a 1981 graduate of Northwestern University and Transitional DPT in December of 2010 Evidence in Motion's Executive Management Program.

 

For more information on Mark:

Dr. Mark Milligan, PT, DPT, OCS, FAAOMPT earned his DPT at the University of the Colorado. He is a full-time clinician and owner of Revolution Human Physical Therapy and Education, a concierge PT practice and micro-education company. He is adjunct faculty for 3 Doctor of Physical Therapy Programs. Mark has presented at numerous state and national conferences about telehealth, pain science, dry needling and has been published in peer reviewed journals. He is the founder and CEO of Anywhere Healthcare, a telehealth platform for all healthcare disciplines. He is an active member of the TPTA, APTA, and AAOMPT.

 

For more information on Ali:

Ali Schoos received her degree in physical therapy in 1982 from the University of Puget Sound. She is a co-founder of Peak Sports and Spine Physical Therapy, practicing in Bellevue, WA. 

 

Ali has been active in numerous roles in the Physical Therapy Association of Washington (PTWA) and APTA.  She  has chaired her state private practice Special Interest Group (SIG) and Orthopedic SIG, and  currently serves on the APTA Private Practice Board of Directors. She is also currently serving on the PPS COVID19 advisory task force. She is a past board member of the Bellevue YMCA and on the King County Regional Advisory Group for the Alzheimer's Association

 

Read the full transcript below:

Carrie Stankiewicz (00:00:05):

Hello everyone. Welcome and thank you for joining us for this special webinar tele-health NOW. I'm Carrie Stankiewicz with education and program manager for the private practice section. Before we get started, I'd like to review a few procedural items to submit your questions. Please enter them into the Q and a box which you can access from the zoom menu. We'll collect your questions there and the speakers will respond to them. As we go through the presentation, we expect to have a large number of questions so we need to manage them carefully in a moment. Ali Schoos will give you some parameters around entering your questions. If you have a technical question, you can type that into the Q and a box and I will respond to you in text. Please note that with the extremely high volume of companies and individuals that are now using online platforms for conferencing, there is a strain placed upon the technology and the infrastructure. Our vendors have done their best to provide a high quality experience, but neither we nor they can control internet slow downs resulting from unusually high volume. In the chat box, we posted a number of resources for you to refer to. Please feel free to copy these links and save them for future reference. This webinar is being recorded and will be posted on the PPS website for everyone to view. And with that I'll turn this over to PPS board member Ali Schoos to get us started.

Ali Schoos (00:01:26):

Thanks Carrie. Hi everybody. I’m Ali. I am a private practice physical therapist from Bellevue, Washington. And thank you for that musical introduction. I am the cofounder of Peak Sport and spine physical therapy in the Pacific Northwest. And I do have the honor to serve you on the board of PPS. I'm also on the advisory task force around all things COVID-19 and this webinar is a result of that task force. Our goal is to bring you business owners relevant information right now to help you manage your practice through this crisis and come out whole on the other end. But the end a couple things about our question process. There are 500 of you on this webinar. So we do expect to have probably more questions that we can answer. So we would ask that when you post a question look and see if anyone else has posted a similar question so that we don't get bombarded with the same saying.

Ali Schoos (00:02:28):

Don't ask state specific questions that's relevant to the laws in your state and mandates in your state. So we're not going to be able to answer a state specific questions, although we will keep a copy of all the questions that come in and try to deal with them later. We will stop intermittently to answer as many questions as we can and I'm going to apologize in advance. I don't think we're going to be able to answer every single thing that you asked, but we'll do our best. I would like to introduce our main presenters. Dr. Lynn Steffes is a graduate of Northwestern university and earned her transitional DPT in 2010 from evidence in motion's executive management program. Lynn is the president, coach and consultant with Steffes and associates. It's a rehabilitation consulting service based in Wisconsin. Lynn provides consulting services to rehab providers among a wide range of services including marketing and program development selection and training and support of practice management specialists lifestyle medicine programs, negotiating contracts.

Ali Schoos (00:03:34):

And Lynn's also been a frequent provider of content, the educational webinars that KPS puts out. Our second presenter is Dr Mark Milligan who earned his DPT from the university of Colorado. Mark is a full time clinician and owner of revolution human physical therapy and education, a concierge, PT practice and micro education company. That was a new term for me, Mark as an adjunct faculty for three PT programs. He has presented at numerous state and national conferences on tele-health, pain science and dry needling. And he's also been published by peer review journals. Mark is the founder and CEO of anywhere healthcare, a TeleForm platform for all health care disciplines. And with that, I would like to let Lynn take it away.

Lynn Steffes (00:04:32):

Okay. So welcome to this webinar. And before I get started, the first thing I wanted to say to all of you is really we're here honoring you for the good work that you're trying to do in serving consumers in your marketplaces. So we know that all of you are incredibly dedicated, compassionate, amazing clinicians and business owners that are looking at this COVID crisis today. And then also looking forward and seeing how can we best serve our patients. And, many of you may be continuing to serve some people in your clinics or you may not be, but we certainly wanted to talk about this really important option. And to give you a little bit of background on some details with it. So with that, I'll jump into more of the content information. So the objectives that I'm in a primarily deal with are just looking at the position, talking a little bit about the statutes and rules that will govern your ability to deliver and access these services. And also some information about payment policy, whether it's federal, state, commercial, work comp. And then I'm going to turn it over to the real expert who is Mark Milligan. And so I kind of get stuck with the fun stuff, the payment and policy things. So next slide.

Lynn Steffes (00:05:58):

So APTA has long had a position that tele-health is an appropriate model of service delivery and as long as it's delivered with the same essence really that we deliver care. And so this isn't new to APTA to be looking at telehealth as a way of delivering care. At a state level. Different States have different rules or excuse me, statutes and rules that govern your ability to deliver telehealth care. So rather than us focusing on any one state today, what I'm recommending to you is that you reach out to your state level associations. APTA has a site that looks at state statutes and rules and determine what your current level of coverage is regarding tele-health. So there are two different aspects of telehealth that you would need to look at that are legal at a state level, which is obviously governs what you can do within your scope of practice. And the one is your statutes and rules that govern your scope. And the second one really is, are there specific tele-health laws in your state that would in any way limit you from delivering those services?

Lynn Steffes (00:07:17):

Keep in mind that if you've looked before or downloaded those policies before they may have been updated or there may be some emergency provisions in place. So I encourage you to begin there. So that’s an important first step. Certainly anytime you deliver outside your scope of services, your malpractice insurance is no longer required to cover you. So it's important to do. So one of the things that we want you to think about is as your considering telehealth we want you to first check your state practice act to verify just as I had mentioned, and then also find out if there are emergency provisions. It's possible that your state practice act is silent on tele-health and as long as there isn't a prohibition that I would turn to your chapter for guidance and they're examining boards need look further, you certainly are going to document legal and ethical reasons.

Lynn Steffes (00:08:14):

You're converting patients to telehealth visit, so if you've never done tele-health before or eVisits and you're going to start doing so, I think it would be important for your practice setting to document that transition and the decisions that were involved. You're going to also have to make sure that you are securing consent for each of your patients along with the right to refuse. I've been most of you know that your individual States have consent laws that govern what type of consent you have to get and it'll be important for you to get consent for telehealth or evisits and the format from your patients. Most of the time it will be fine to secure that consent verbally and to document when you received it carefully in the medical record. It's also a good idea to look at what types of emergency policy procedures you might need to put in place.

Lynn Steffes (00:09:10):

For example, if you were to be teaching a patient exercises and they're working on them in their home through a telehealth visit and they fell, what would you do to address the emergency? Are there other folks that their family members, caregivers there and then how that might be handled. And that's something you may even want to look at with your legal team. Keep in mind also if you're going to start using telehealth, that a secured portal is ideal and if you have a secure portal or something that is designed to share information over the internet or phone, you're going to need a business associate agreement in place that ensures HIPAA compliance. I think Mark's gonna deal a little bit later with some of the other HIPAA things that give us a little bit of wiggle room right now and then finally make sure and review your malpractice insurance policy to make sure you're covered.

Lynn Steffes (00:10:03):

I know HPSO provided guidance that we have a link on. And I also know PT1 PGM provided guidance on that saying you're covered. So, real quickly, I want to just start off by saying there are different types of visits. I think when this was first announced that Hey, Medicare is gonna cover a PT as a tele-health service. Everyone got very excited and what they didn't realize is that Medicare actually is not covering telehealth. Instead, we're going to talk about the distinction between the eVisits and then telehealth. We also have third party payers, commercial payers that are covering assessment and management visits and not tele-health, and then the actual telehealth visits. So we're going to kind of explore those three areas, but we want you to really listen for which area might fit your practice in your regulatory environment.

Lynn Steffes (00:11:03):

So true tele-health. Let's start with the good news. If we could do true telehealth and we can often, we're going to bill our 9700 codes. We're going to continue to apply the GPP PT modifier, but we're going to also use the OTU place of service code, which is going to communicate that we're doing tele-health. Now, some payers may actually be looking for either a different modifier or an additional modifier. So we're going to talk a little bit later about how you get that information from your payers, but it certainly is important.

Lynn Steffes (00:11:47):

I wanted to start off by saying that a lot of codes are out which are often used in telemedicine, which is physician covered telehealth 99421, 22 and 23. These are actually evaluation and management or ENM codes and those codes are really reserved for physicians or other qualified non physician providers such as PAs or NPs in general. These codes exclude therapist's ability to bill. However, we have been hearing occasionally that there are third party payers that want us to use that code. So I'm just going to say if someone suggests that you use those codes to bill those services, make sure that they provide a URL or a link for you so that you can see the policy that ensures that you will be covered for those codes. Because those are traditionally not therapy codes. Payment from Medicare. So we were super excited and we heard tele-health is covered. And really that was a misconception at the beginning. Medicare doesn't consider physical therapists as an approved telehealth provider. The list is in the bullet below. But Medicare advantage plans can actually make their own decisions and may choose to cover tele-health itself. A lot of times policies are carrier specific.

Lynn Steffes (00:13:20):

This slide is really pretty important and it's just to give you the sense that take a look at the date of this press release, CMS finalizes policies to bring innovative tele-health benefit to Medicare advantage. That was April of 2019, which seems like a hundred years ago right now. A very different time. And so Medicare advantage plans definitely had plans to expand telehealth services, but those plans also did not include PT, OT and speech. So this is not a new idea or a new fight that we're trying to leverage. However we may be in a unique position and I'm kind of a silver lining person and I'm hoping that this opportunity might actually give us a window to get in next. Your Medicaid programs. As you know, Medicare is more federal and Medicaid is state driven. So some Medicaid programs have tele-health policies.

Lynn Steffes (00:14:24):

The telehealth reimbursement policies vary state to state. Those are very fluid. We just have had multiple updates being published in the last three days in Wisconsin. So I know for a fact that you're going to have to kind of stay on top of that to determine if you're trying to serve the Medicaid beneficiaries in your state. How that policy might change in response to the COVID crisis. So keep looking and you're going to have to, this is a moving target. So keep in touch, keep going. So what type of virtual visit again and we talked about there's an evisit, there's assessment and management or tele-health. Let's look at what the actual definition for an evisit is in the 2020 physician fee schedule. Final rule, CMS described eVisits as non face to face, patient initiated. So I want you to really pay attention.

Lynn Steffes (00:15:21):

This has to be initiated. So the contact has to be initiated by the patient. Digital communications that require a clinical decision. So again, clinical decision, that's really important. So you are going to have to document that clinical decision making was made during the contact of a visit that might otherwise typically been provided in your office. So this is the definition of an e-visit and the code descriptors that Medicare is using. Our hick picks codes are related to the eVisits and they're really designed as a short term, kind of like a, I always think of it as like a bridge loan when you're building. They're designed to cover short term up to seven days of assessments and management activities that are conducted online or through a digital platform. And then again include clinical decision making. So what's an online patient portal? HHS has described a patient portal as a secure online website that gives patients convenient 24 hour access to personal health information.

Lynn Steffes (00:16:29):

Patient portal requires a secure username and a password in the absence of broadband access online accounts or smart phones or other means. CMS has indicated they want the service to the furnace, so they're giving us more flexibility. Mark's going to talk more about the technology a little later, but I just wanted you to know the Evisit has, you know, variety of opportunities including something like doing FaceTime with your patients. Go ahead. The billing and coding is what I think you're all waiting for. So physical therapists are eligible to use the Hicks picks codes and these codes require a CR modifier and the CR modifier really indicates that they're related to the COVID crisis. So we have G two Oh six one six two and six, three again, the definitions qualified, non physician healthcare, professional online assessment management. It has to be for an established patient.

Lynn Steffes (00:17:27):

And lots of questions come up. What is an established patient? It is a patient who you're currently seeing under a plan of care. And so what would happen is if you were seeing the patient, you'd have the next seven days to provide some type of E interaction with that patient that provided clinical decision making in input with them. That would be much like what you do in the office. And so the different code levels are really time-related. So imagine that you saw someone today's Wednesday. So imagine that you saw them in person on Monday. There would be a seven day consecutive day window at which time you could have one contact with them or you could have a couple contacts. Each time you had a contact you would have to document the contact information. But really when you actually go to bill the code, it would be a summary of the seven days and the documentation at that point in time would summarize what type of clinical decision making assessment and management occurred over those contacts. As you can see nobody's retiring with this funding. We've got the five to 10 minutes at 1227, 11 to 20 2165 and 21 or more minutes at 33 92 so pretty limited. The place of service is the location of the billing practitioner, which Medicare is suggesting that we would do places service 11 and you can deliver these services via the phone.

Lynn Steffes (00:19:10):

Assessment and management are comparable codes. Non hick picks but they're CPT. So nine, eight, nine, six, six, six, seven and six, eight and those are actually used for telephone assessment and management services, again by a non qualified physician health care professional to once again an established client. But this one further expands and says a parent or guardian. So these are again established patients and they have to be initiated by the patient. That doesn't mean that you can't contact the patient and offer them this service. It doesn't mean that you can't help them set up et cetera. It just means that the call itself that you're doing, the assessment and management code has to be initiated by the patient. The assessment and management codes have a little bit more parameters put around them. And one is that the call can't or it can't originate from the provider and it can't be within the previous seven days.

Lynn Steffes (00:20:13):

So the case I gave earlier for the visits, it would have to be seven days prior. And then it would be the assessment and management calls and then you couldn't see them again within the next 24 hours. So there are these windows of time, seven days prior you couldn't have had a physical one-on-one visit with them and 24 hours after. So as of right now, if you're going to be doing these assessment and management codes they would have those limitations. These are codes by the way that I'm starting to see emerging from some of the commercial pairs as covered in lieu of the hick picks codes.

Lynn Steffes (00:20:59):

These again are telephone discussion times thereby to 10 minutes, 11 to 20 and 21 to 30. And of course, because these are other payer codes, you'd have to look to the payer for coverage of the codes and payment. So true tele-health, we're back to that. There really isn't a specific CPT code for true tele-health. You would be using the therapy codes, the 9700 series paired with the OTU place of service code, which would indicate that it was provided remotely. Because if you're going to be providing these CPT codes, face these what are called face to face codes, which I would argue if you're doing telemedicine or telehealth, excuse me, they're face to face, you're going to have to verify that the payer allows you to use these codes when they're tele-health. So you can't just build these codes leading the pair to believe that they were provided in our office X. I wanted to say payer policy is fluid and that is followed by multiple exclamation points.

Lynn Steffes (00:22:07):

This is changing so fast. I literally just got off the phone before I stepped on this call saying we've got legislation coming in our state that's going to do some mandates. So you may have to check regularly. For example, in the state of Wisconsin, our governor just issued a stay at home order. So peers are going to have to reevaluate their policies if they want to continue to have their enrollees get services. So when you are, whether you hear from one another provider or whoever that someone covers telehealth or someone covers assessment and management or EAD visits, I would suggest that each time you call, you verify benefits and you're going to ask several questions, are you or the physical therapist eligible for telehealth payment? If so, which CPT codes would be completed via telehealth, so which CPT codes will be approved and then what modifiers are required.

Lynn Steffes (00:23:07):

So the modifier GT or 95 is often used in facility billing and the place of service OTU in independent practice billing. And then you're going to want to also find out what their payment rate is. So if they allow you to build nine seven one one zero will there be parity in what they pay you or equivalency and what they pay you based on telehealth versus in office. Are there any restrictions on the location of the PT or the patient? Because of course, right now if your PTs are practicing from home, that would have to be okay or your patient may actually live in a CBRF or other facility. Then what devices or applications do they have any restrictions on that and what if any consents are required and then any special documentation requirements. So those are some of the good questions to ask.

Lynn Steffes (00:24:00):

The other thing I will say is regardless of what they tell you, if you can get a link to their peer policy or anything in writing from them, I would highly recommend that you do that. And then don't assume that what is not covered today will not be covered tomorrow. And what someone tells you is covered may not be covered. I've already had providers that said, they called and asked about telehealth. They said it was covered and when they called back in a second patient, they said, well that's not what we meant. So be careful. And finally both Mark and I have been using this a lot. The center for connected health policy has a ton of great resources, but one of the best that I think you're going to want to download that will give you far more details than I'm able to give you in this brief discussion is their billing fact sheet. So the link to the billing fact sheet is here and I wish you the best. I think we can provide amazing services in person and also via these wonderful technologies. So thank you.

Ali Schoos (00:25:10):

Thanks Lynn. So a number of questions, they've come in and I answered a few of them. So if those of you who received the answer, if that wasn't enough clarity, ask it again. But then I'm just going to let you know what some of the questions are more clever. We can answer them. One, yes, you'll have access to the presentation after it's over. This is being recorded and it will be posted on the website, the next question, will we have access? Why need an option to refuse consent? Wouldn't the person just declined to sign consent? It said in the consent form that we have to give them the option to refuse.

Lynn Steffes (00:25:49):

Well, part of the option to review is, and that's a really good question, is if someone gives consent once, they still have an opportunity to withdraw consent or refuse it in the future. So someone tells you, you know, I'm happy to do telehealth or I'm happy to do evisits and they give you consent and the next time that you're in contact with them, they call and they say, I don't want this anymore. They always have that opportunity to review. So that's typically what that's for. I will say that each state practice act and sometimes an overriding practice act over healthcare professionals tell you what's required for consent.

Ali Schoos (00:26:28):

And then another person asked about the secure patient portal being ideal, but it didn't CMS make a, the HIPAA compliance issue more lax and the pre-cancers yes.

Ali Schoos (00:26:43):

Mark, he's got that later in the presentation. Can you build the e-visit code every seven days or just once and done?

Lynn Steffes (00:27:01):

As far as we don't, I don't know. We've been asking that question if it can be billed repeatedly. We've heard yes. And we've heard no. So I'm not sure. I don't know Ali or Mark, if you know anything more.

Ali Schoos (00:27:14):

It's the same thing. And I apologize, we cannot get a straight answer on that. I think some people are saying, I'm just going to do it more than once and see what happens. Again, it's not a big charge. You're not going to get rich or go broke. So if you want to try it, the worst that'll happen is that a bit tonight.

Lynn Steffes (00:27:30):

Right. And we haven't had to seven day periods to try it yet. They've been released. So it hasn't even been an opportunity.

Ali Schoos (00:27:36):

Right, right. And then does the evisit have to occur within seven days of the last in-person visit or could it be 10 days or 14 days after the last in-person visit?

Lynn Steffes (00:27:53):

I don't think there's a restriction that says it has to be within seven days. I just think it can't be sooner than seven days.

Ali Schoos (00:28:00):

Yeah, I understand. Okay. and then someone wanted an example on it, an example regarding the verbage to justify the clinical decision making to use an evisit

Lynn Steffes (00:28:16):

For an individual patient or the practice.

Ali Schoos (00:28:18):

So when you're documenting, you know, political decision making. Yeah.

Lynn Steffes (00:28:23):

Okay. So you could document that either the facility or the patient or the clinician made a decision that it was safer to do an evisit versus the in person visit. And that there was a good, a good reason to do that in your clinical decision making would reflect that you advise the patient or gave the patient it's specific instruction. The patient asks you questions, you update an exercise program, you perhaps revisited how they're doing on something and gave them feedback. So again, it's kind of like you're documenting a regular visit but the clinical, so I would decide that you did the visit you know, virtually for a fairly simple, straightforward reason that that was what was appropriate at the time due to the crisis or for the patient. Now, Mark, you may address this later when you're talking about tele-health on an ongoing basis because there's lots of good reasons to do it. But right now I think we're talking COVID.

Ali Schoos (00:29:29):

Right? And then Mark you want to address now or later what you might be documenting when COVID is over.

Lynn Steffes (00:29:38):

Right.

Mark Milligan (00:29:42):

So this is a new space to navigate. And so when this crisis is over, I think that this will be a normal part of a plan of care. Right? So it will be an expected plan of care that you will put forth in a patient that they will have a combination of both digital and in person visits. If you line it out from the beginning and set it up that way, then there no deviation or there a deviation from your initial plan of care. That's how I would handle it.

Ali Schoos (00:30:10):

And then one person did ask if you have, if the patient, if you do a second seven day visit, yes. The patient would have to initiate that phone call the second time as well or that contact the second time as well. Yeah. Can you see a Medicare patient per tele-health per cache? Some many visits are covered and I did answer earlier. Yes. You can see Medicare patients for past, since telehealth is not actually covered.

Lynn Steffes (00:30:39):

Absolutely. Any patient where it's not a covered service unless you have, for example, say you had a contract with a certain commercial payer that had a prohibition to doing any services, which rarely do they for a non-covered service. You would inform the patient that this is not a covered service and you could go ahead and bill cash for it. For your Medicare patients. And ABN is not required, it's optional, but some folks will use the optional ABN kind of as a backup to ensure that they feel that their Medicare patients were well informed that this was not a covered service.

Ali Schoos (00:31:17):

That's a great question. Wanting to know if your PTA can provide the telehealth service if the supervising PT is not online with them because it's virtual

Lynn Steffes (00:31:30):

Currently for Medicare. The answer I believe is no, but I don't know with other payers. And that would be a question. If you were anticipating a PTA providing the services telehealth services that you would ask. I would think that the visits because they involve clinical decision making and the assessment and management would likely not be covered. But I can't, I think telehealth would be flexible. What do you think Mark?

Mark Milligan (00:31:59):

Right, so Texas just, I think we also have to default to the rules and regs of the state level as well. Texas just eliminated the verbiage that eliminate, that took PTs away from delivering tele-health. So state rags may have a prohibition written that physical therapist assistants can't provide that care. I need, I'll pull up the Texas specific language that I believe there's a caveat that says that it cannot be used for supervision, but no one has defined whether or not a PTA can perform it being unsupervised. Does that make sense? PTs are not physically being supervised in all scopes practice, right? Like in home health settings. PTs are not digitally covered or supervised by or physically supervised by PT immediately. It's by phone contact. Right.

Ali Schoos (00:32:48):

Well I get in state law. Yeah. And obviously in a private practice for Medicare there has to be onsite supervision.

Mark Milligan (00:32:58):

Right. So state law and then I'll, yes, I can check with the Texas regs too, but it's a state regulated issue.

Ali Schoos (00:33:06):

Yeah. Very good question. And there they are pouring in now guys. So lots and lots of questions here. I'm trying to go through them. Should we keep going and let Mark deliver and then we'll go back and ask more answers. And some of these make an answer with Mark's presentations. We'll come back to these. Yup.

Mark Milligan (00:33:23):

All right. So thank you for allowing me to be here and being with you guys in this presentation. Lynn, I know that you said earlier that that's not the exciting stuff, but that's what everybody wants to hear. So regardless if it's exciting, it's definitely information that is necessary for all of us to continue to keep our doors open and see patients. Right? So again, I'm Mark Milligan, I'm out of Austin, Texas and we're going to cover, basically we're going to cover just what tele-health is. We're going to get some baseline terminology, technology who players in the game evidence and then kind of how to implement it in a practice. Then is going to actually talk to us how to implement it into practice, right. Ali is has implemented this into her clinic. She's delivered care.

Mark Milligan (00:34:09):

She's also as a clinic owner has implemented as a clinic owner. So she's going to give us the nitty gritty on how this actually looks for a private practice owner. So we're going to start with basic terminology because again, terms, words have meaning and terminology can be misleading. And there's been a lot of misleading terminology that's been spread around the physical therapy world since tele-health and eVisits have all been introduced. So tele-health really is just a very large, broad term that describes any type of health, education or delivery of care using telecommunications technologies. And as you'll see that it applies to almost every profession other than medicine. Telemedicine is specifically owned and basically utilized only and exclusively with physician deliver care and their extended providers. Right. So I think one of the bigger issues that came across our country earlier or late last week was when tell them when I think the president said that telemedicine is going to be available for everybody and that you know, that there's these broad sweeping terms where it doesn't really change if you hear the term telemedicine, it doesn't shift anything for physical therapists necessarily.

Mark Milligan (00:35:21):

So you have to do your due diligence when it comes to looking at the information about telemedicine and who that applies to. Right? And so also when you look at your insurance policies and, and other types of documents, make sure that you're referring to telehealth or telerehab for physical therapy services. If you ask about telemedicine benefits, you will not be considered a provider for telemedicine. So make sure that you make those two distinctions. So tele-health again is we help manage our patients through their own their own illnesses to improve self care and access to education support systems and treatment. Telerehab is more of our specific a tele term, if you will. So really it's about delivery of rehabilitation service over a communication that works and the internet. So you can do assessment and functional abilities in their environment and clinical therapy.

Mark Milligan (00:36:12):

So when you're looking at benefits, you can also check to see if they have tele rehab benefits. Telerehab benefits also shows up more in clinical research, right? If you do research and look into the efficacy and effectiveness of digitally delivered care, tele rehab will be a much more used, utilized term than tele-health for physical therapy specific. Tele-Health again really accomplishes and encompasses all types of providers, dentists, counseling disaster management, consumer and professional education. So really tele-health is one of those terms that is not a very good descriptor of exactly what we do. But during these times, it's the most accepted term of what we do. So out of the all those things, just make sure that telemedicine, you understand that does not apply to us as physical therapists. And to make sure that if you hear something about telemedicine that you clarify that or that you clarify that those rules apply or may or may not apply to us.

Mark Milligan (00:37:13):

Some other terms that are coming up across the country are models of telehealth, right? So some terms of delivery so right now currently, what you're watching and how we're interacting would be a live video or synchronous technology. So this is a live two way interaction between the person and the patient and the caregiver or the patient, a caregiver or provider using the auto visual [inaudible] communications technology. So this can be used for both diagnostic and treatment services. And it's just like anything you've done on a video call with your family. So as long as you're live face to face talking to the patient, you're good. Second term is asynchronous. You'll hear this term floated around a circle. The asynchronous modes of communication are basically or otherwise known as store and forward. This is non live communication, right? So this could be emails of HEPs.

Mark Milligan (00:38:05):

This could be a recorded video of exercises that you send the patient. This could be a recorded exercise where the patient demonstrates their exercises and sends it to you. It could be lab results, it could be any type of electronic communication that happens on non-life, a synchronous video. So that's the important differentiator in those two modes of delivering telehealth. So those in some States, these get specific, I in Texas, I'll just give Texas, I'm here in Austin and Texas, you can't initiate tele-health via asynchronous mode of delivery. You have to have a live synchronous session before you can actually utilize asynchronous care. So depending on the state that you're in, that may impact the mode and model of how you deliver telehealth. So please be mindful of these types of definitions.

Mark Milligan (00:38:59):

Also there's remote patient monitoring is another term that's used. This is really about data health data that's collected from an individual at one location and delivered electronically to another. So when this comes to a lot of patients that have chronic diseases that they need to be monitored or something needs to be checked on them regularly, like wait for patients that have CHF they have a digital scale, they can weigh themselves daily and then that data is uploaded into the physicians portal or cloud and then they're monitored on a daily basis remotely for any progression of weight gain. That could be a contraindication or a need to necessitate a medicine change due to CHF. Typically right now, not a lot of physical therapists are in this space. They may be monitoring some of those patients, but they're not too many PTs are actually delivering this model of care.

Mark Milligan (00:39:50):

Typically this is a physician or hospital base. And then mobile health really depends on or is determined by apps and different mobile devices and things that appear that can be very portable, including tele-health. So I would, I would umbrella tele rehab and M health together because you can deliver it via a PDA, cell phone or tablet. Right. So this is more just to the, the more mobile you are as a provider, you can do telehealth with someone on the beach. And depending on your place of service code, you could deliver telehealth while you're on the beach. So just think about that as, as we talk about more app based functions of some platforms that could be applicable to that. So some of the technology that's really out there that we'll pretend I'll briefly brushed these just so you're aware of them, but know that right now in this time of the COVID 19 crisis, some of these may not be the best thing to implement into your practice right now, but know that the virtual reality and tele rehab is an extremely that's a very quickly developing technology where patients put on goggles and they can meet and go into augmented reality and meet their therapist in different spaces to perform exercises or to see exercises demonstrated.

Mark Milligan (00:41:03):

So it's a really cool technology. There's motion technology where patients can see themselves on the computer. And so they were they were able to look through and see themselves moving or get the movement collected from their body and pushed into a system. So sensors and body body monitoring have been they're an interesting technology where you can actually wear a piece of clothing or have a different sensor that will sense your body positioning and space and alert you and change your posture. Haptic technology as really interesting to me. It's cloth and clothing that you can actually generate sensations through distantly. So I could, a patient could have on a haptic cloth and then I can manipulate something a hundred miles away and they could feel the sensation on their skin. So I know if anybody has a new car and they're, and they've, you know, kind of diverted out of their lane and their seat has vibrated on there.

Mark Milligan (00:42:00):

But think about that as haptic technology and how that can be utilized in physical therapy for tactile queuing and for input AI, artificial intelligence that will come into play when we look at a larger type of systems and startup companies that are leveraging AI in order to deliver a digital physical therapy PDAs, electronical medical records, wireless technology, mobile apps are all just different ways that people can connect and also get data and information that can be a really important for medical monitoring. Right? So I think we all notice the explosion with the Apple watch that started to take a heart rate and other sensors and other vitals. And so that would be an idea of wireless technology and then that would also tap into the Apple medical records. So it all kind of is encompassed and in those, in that realm as well.

Mark Milligan (00:42:55):

So just terms that you should be aware of, not necessarily in the immediacy for the deployment of telehealth into your practice, but just to be aware of. So for your business really to get down and dirty and tele-health, typically it takes some time to implement telehealth into a practice. So do due diligence. You need to come up with your business plan, your patient demographics, right? Some people will not want to tele-health or they wouldn't choose telehealth at a given rate. But now with the current situation, many people are seeing this as a really viable option to dilute, to get care delivered to them. But you also have to make sure and take into consideration general cultural and generational issues. And also there's a tremendous bias amongst the long low income patients because they don't have access to high broadband wifi or they may not have a tablet to get care or they may not have access to a safe space to exercise.

Mark Milligan (00:43:46):

So please take into consideration patient demographics and the ability to deliver care because that may be impacted greatly depending on the patient population that you serve. So you also need to have relevant current healthcare delivery systems to how you deliver care. If you you need to make sure it blends with your current type of care and the delivery method that you deliver to your patients, you need to have skills and responsibilities as a PT providing tele-health. I'll touch on this briefly. Ali's going to cover some of this is that you've got to have good video, adequate etiquette. You have to make sure that you have, you know, appropriate lighting room to move and you need to be able to communicate nicely over video. And so that's a different wait, I know some of you have always had been on a tele on some type of teleconference when there's 48 people talking.

Mark Milligan (00:44:35):

Understanding the rules and kind of engagement by a telehealth is important to know as well. You also need HIPAA compliance scripts for patient communication and the protection of PI, right? If you're delivering care in a busy area where other people can hear you, you're transmitting their PI. So making sure that you take precautions and steps in order to and to protect your patients who you're treating digitally and on the other end, patient needs to be protected as well. And you also need to make sure you have appropriate policies and procedures in place for consent for medical emergencies. What Lynn covered earlier to protect PI, I know there's talk about people recording visits, right? Some payers I know in Texas are requiring recording visits to get paid for a telehealth. And so that video becomes a part of the patient's PI.

Mark Milligan (00:45:21):

So how are you going to store that? Who, where are you going to store it? How long? I mean, you store it from the normal five years. Right? So making sure that you have all of your business practices and policies in place for procedures is really important. And then your IT development and installation. Every system is different. Right now across the board you could have a list of a hundred different ways to deploy tele-health in your business. Just depends on how that model fits into your business and your patient flow. And to your workflow. So right now because of this rapid adoption, there's a lot of trying to navigate in plug and play systems, which is pretty normal. But it's even become more apparent that the need for some centralized systems for delivering this digital care.

Mark Milligan (00:46:08):

So you need it. That's my second question. You need a strong IT department to make sure you have secure system set up in place with your policies and procedures and protocol, right? So your equipment, I really want to make sure you're HIPAA compliant because as lens that earlier there has been a lowering of the shield of HIPAA during this COVID crisis. I'm going to sit here and tell you that you should always choose a HIPAA compliant, secure platform to deliver care if it's available. If it is not, then you may in that circumstance use a non HIPPA compliant platform, which we'll talk about later. But you need to do your due diligence in documenting why you chose that. And you need to document the time, the approximate length of time that that patient's PI was could have been compromised and the patient needs to be able to consent to this non HIPPA delivered care.

Mark Milligan (00:47:00):

Right? So I think that's an important part that a patient, like Lynn said about denial of their consent. You need to inform the patient, Hey, you know what? This isn't a secure platform. This is not a HIPAA compliant encrypted platform. Are you okay with continuing to go through with this? And they may or may not say yes, right? So you need to make sure that your connectivity reliable, you need to have bandwidth, audio and video interface quality. You need to make sure that the staff can use and learn the equipment both easily and onsite and remotely when needed. So can this function when you can't get to the clinic? Right. That's a great question. And is the system compatible with your current hardware software? Most tele-health systems right now can integrate. It just takes time. There's a process, typically integration of a telehealth system, depending on how you deploy, it can take a couple of weeks and maybe two to three weeks depending on branding and depending on how you want it to look.

Mark Milligan (00:47:55):

And so the scope of how you can deploy it into your clinical practice, the timeframes can vary anywhere from 12 hours, six hours to two, two to four weeks to six weeks, depending on the level of integration and the level of branding and the level of system that you want to deploy in your practice. All right, so some simple, the beautiful thing about this is most systems operate with very simple hardware, right? So you have some wifi up and download speeds that need to be a minimum. The minimum requirements, they need a laptop microphone or a headset. I prefer a good old wired headphones, right? I know this seems antiquated, but most people are switching to battery power to rechargeable headphones and they're lasting for an hour or two and then they're dying. So if you're in the middle of a healthcare day, if you're treating and training and triaging patients, I highly recommend either having a couple of sets of rechargeable earbuds or headphones or just go old school with cables and you don't have to worry about that at all, right?

Mark Milligan (00:48:56):

The mobility may be a little bit limited, but it depends on how you function in that telehealth visit that this may be restraining or not. It just depends on how you're set up. But again, it's hard. It's very challenging. Once your headphones die to do a visit through just the speakers on your computer, the qualities, it goes down pretty quickly. And then you need to think about what you're surrounding yourself with. You need to create a neutral background. We need to have a quiet room. You need a room to move as Ali will show you soon. That movement and room for both the therapist and the patient are super important because this isn't a normal, this isn't a normal treatment in a clinic where you have a table and you have a confined space and you do everything within that space, right?

Mark Milligan (00:49:44):

This is an opportunity where you have to help the patient move and show them. So Ali was going to be an amazing demonstrator of how you need to have the space both for the provider and the patient and similar on the other side, the patient needs that wifi service or cell service in order to get those uploads and download speeds. And there's simple tools that you can send to your patient but they can check it's just you can, there's probably 20 free links that they could just click a speed test and it can check the speed of their wifi. So that's an easy way to make sure patients have the capability. So there are other technology out there like VR and all these fancy systems. But look, when the rubber meets the road right now we're trying to get everybody on and adopting telehealth as quickly as possible.

Ali Schoos (00:50:28):

And these are the bare requirements, the essentials that you need. So practice models of telehealth. Actually, I was just a good time to stop or is it for questions? Yeah. All right. Well let's pause. Well, you're muted though. There we go. That's smart. Thank you. I've been madly typing away, so I'm really trying to answer the questions that I can just to simplify things and if there are questions that I think the whole group has to hear, I'm trying to save them. So we've been doing a little bit of both Mark. You've got some really good questions and land these yeah. Either one of you. If a patient has authorized visits, do the telehealth visits count towards those authorized visits? So if they'd been given six authorized visits, would Pella and I have a telehealth visit? Would that be one of them?

Lynn Steffes (00:51:21):

I guess if you're authorizing the visits and you're autho