Triaging Telehealth in Wound Care: Embracing the Regulations within Your Workflows
By Cathy Thomas Hess | Advances in Skin & Wound Care
Staying abreast of the regulatory changes related to the 2019 novel coronavirus (COVID-19) and navigating its impact on your wound care practice can be a daunting task given the sheer number of announcements that have amassed. The regulatory changes during this pandemic, coupled with the need to socially distance, may provide the impetus for your implementation of telehealth. One of the first things to consider is how you triage your patients and build your workflows to accurately reflect documentation for your virtual visits. Aligning your processes and practice to incorporate the changes is the key to your clinical and operational success.
As clinicians, we like direction and process. We like algorithmic thinking that leads to interventions, such as wound-healing pathways. We are comfortable knowing that if the characteristics of the wound change, we can review the pathway for alternate care options in real time when seeing our patients. However, in light of the pandemic, what services are provided to patients and when they are provided have changed,1 and telehealth has become a viable option for ensuring continuity of care for patients with wounds.
Over the last few months, telehealth regulations have been released that build upon each other and affect your site of service and your documentation. Starting on March 6, 2020,2 the CMS broadened access to Medicare telehealth services, allowing beneficiaries to receive a wider range of services from their providers without having to travel to a healthcare facility. On March 13, 2020,3 the President declared a national emergency under the National Emergencies Act and made an emergency determination under the Stafford Act. Shortly after this declaration, the CMS announced a set of waivers specific to the pandemic (COVID-19 waivers).4 Although each waiver is important to how we practice care, let’s review one of the waivers, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19,5 issued March 30, 2020, because it affects providers in all settings during this pandemic.
This temporary regulatory waiver provides new rules to equip the American healthcare system with maximum flexibility to respond to the pandemic. A few of the areas that directly impact the wound care business include the opportunity to broaden how patients are seen via telehealth and the impact on the Merit-based Incentive Payment System (MIPS). At the time of writing, there are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries that are clearly summarized in the regulations. These visit types included Medicare telehealth visits, virtual check-ins, and e-visits. Each new service is succinctly defined including who provides the service, what codes can be used for the service, and if the service can be applied when seeing new or established patients. (For more information, review the May Practice Points column, Expanded Telehealth Services Offer Smart Wound Care Workflows.) It is important to work directly with your registration, coding, billing, and medical records departments to determine how telehealth provides you with opportunities to expand your practice and connect with your patients in a virtual setting.
When you dig deeper into the regulations and cross-reference the interim final rule,6 you will find that one of the relaxed areas is documentation of the history and/or physical examination. The regulations state:
On an interim basis, CMS is revising our policy to specify that the office/outpatient E/M [evaluation and management] level selection for these services when furnished via telehealth can be based on Medical Decision Making (MDM) or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record.
To tie process into practice, a key question you may ask yourself is “Does this shift the documentation within my workflow or the cadence of questions asked to patients?” In addition, as you create your virtual visit workflows for new and established patients, remember to create the attestations needed to confirm verbal or written consent specific to participation in telehealth, total time for the virtual visit, and identification of the secure technology used during the visit.
Next, let’s take a look at how MIPS is highlighted in the regulation. The CMS has made two updates within the Quality Payment Program. First, the CMS modified the MIPS Extreme and Uncontrollable Circumstances policy to allow clinicians who have been adversely affected by the COVID-19 public health emergency to submit an application and request reweighting of the MIPS performance categories for the 2019 performance year. Second, CMS is adding one new Improvement Activity for the 2020 performance year that promotes participation in COVID-19 clinical trials and reporting COVID-19-related care data to a clinical data repository or clinical data registry. Last, there is an Improvement Activity related to telehealth. It is entitled Use of Telehealth Services That Expand Practice Access. Take a look to see if these measures apply to your practice for your 2020 quality reporting.7
With a clear understanding that it remains your responsibility to review the sweeping regulations, let’s begin to think through triaging patients and building your processes to map to your clinic or telehealth workflows. Here are seven takeaways that bridge wound care process into practice for telehealth:
Describe your wound care patient triage system to map the patient’s condition to site of service (in-person visit vs telehealth vs other).
Define the type of telehealth services provided within your practice.
Establish your virtual workflow/documentation sequencing based on your visit types.
Build your attestation statements to support the type of telehealth visit based on your regulations.
Enable your billing codes to support the telehealth services provided.
Configure your patient portal for your portal message, consent management, secure communications, online photo management, and so on. Enable your videoconferencing platform.
Connect with your patients to provide continuity of care.
Given the opportunity to expand services based on the newly updated telehealth regulations, you must ensure your workflows are structured to support the work performed in a smart, efficient manner based on your site of service. If your workflows are set up correctly, they detail your practice’s key processes and the proper steps to eliminate redundancies, all in an effort to provide optimization.
1. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck—the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes [published online March 25, 2020]. J Am Podiatr Med Assoc.
2. Centers for Medicare & Medicaid Services. COVID-19 Response News Alert: CMS Issues Frequently Asked Questions to Assist Medicare Providers. March 6, 2020. www.cms.gov/newsroom/press-releases/covid-19-response-news-alert-cms-issues-frequently-asked-questions-assist-medicare-providers. Last accessed April 21, 2020.
3. Centers for Medicare & Medicaid Services. CMS Snapshot March 13-19, 2020. www.cms.gov/files/document/snapshotupdate03192020.pdf. Last accessed April 21, 2020.
4. Centers for Medicare & Medicaid Services. CMS Takes Action Nationwide to Aggressively Respond to Coronavirus National Emergency. March 13, 2020. www.cms.gov/newsroom/press-releases/cms-takes-action-nationwide-aggressively-respond-coronavirus-national-emergency. Last accessed April 21, 2020.
5. Centers for Medicare & Medicaid Services. Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19. March 30, 2020. www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf. Last accessed April 21, 2020.
6. Centers for Medicare & Medicaid Services. Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. March 26, 2020. www.cms.gov/files/document/covid-final-ifc.pdf. Last accessed April 21, 2020. Last accessed April 21, 2020.
7. Quality Payment Program. Centers for Medicare & Medicaid Services. https://qpp.cms.gov. Last accessed April 21, 2020.