Photo credit for featured image: Jeanine Smith

By Sarah A. Throop, CCS-P

I sit in a Telehealth Task Force conference call, rejoicing that this will be my last one before the long weekend. I am sure I am not alone. We have all worked long, intense hours since the early days of the pandemic.

The task force’s agenda changes from week to week, but the goal is always the same: Scale up a comprehensive virtual care program that ensures each patient receives the best care, minimizes impact on provider workflow, maximizes clean claims, and guarantees compliance with payer guidelines.

Task force members span multiple disciplines—informatics systems experts, revenue cycle leadership, coders, providers, and several professionals whose jobs I didn’t know existed three months ago.

And then there is me—the virtual care coding resource for Indiana University Health (IU Health). Ages ago, this was a small role in my portfolio of responsibilities, an interesting opportunity to expand my sphere of knowledge.

Today, I am part of the team charged with scaling a previously modest telehealth program to a primary driver of patient care at the state’s largest health system—with 16 hospitals, hundreds of multi-specialty clinics and 34,000 employees, including over 3,500 physicians and advanced practice providers.

Before COVID-19, IU Health averaged 600 virtual visits per month. By April 2020, we averaged 27,000 per month, in addition to more than 15,000 virtual coronavirus screenings.

A project that would normally take years and encompass an entire career had to be done, and done well, within a matter of weeks. Achieving this goal in the grip of the most significant public health emergency in a century, with a workforce scattered over hundreds of remote locations, and with ever-changing federal and state guidelines, felt impossible.

If someone told me when I took on this role that I would eat, breathe, and sleep virtual care in 2020, I would not have believed them.

Virtual Care Before COVID-19

In July 2019 a colleague and mentor retired and I assumed some of her responsibilities, including keeping up with the payer guidelines for virtual care.

I enjoy expanding my coding knowledge base, and looked forward to the challenge, so we scheduled a few sessions to get me up to speed.

It didn’t take long for her to notice the “deer in the headlights” expression on my face. There was no getting around it: virtual care was different than any other service I had supported.

I’m a professional services coder by trade and have held many positions, including account collections, insurance follow up, clinic-based professional coding, and my current role, physician coding auditor and educator. Serving as the virtual care coding expert for IU Health would become a small addition to my job, I thought. Ten hours a month, at most.

My mentor and I met a few more times and, after some repetition, my brain started to process the different components of virtual care. Provider location, patient location, and service rendered via virtual care became the mantra I would repeat to both providers and service-line leaders to properly fulfill documentation requirements.

Despite its atypical aspects, the opportunity for virtual care was there. I saw it. A handful of providers and colleagues also saw it.

I have worked for IU Health for nearly 10 years and have watched the system grow into a visionary and goal-oriented health system. “The best care, designed for you” is our promise to our patients. Our vision is to “lead the transformation of healthcare through quality, innovation and education, and make Indiana one of the nation’s healthiest states.”

Photo credit: Chris Bergin

When I first heard this vision, I was taken aback. Indiana is far from one of the healthiest states. When I asked a system leader how he felt about the goal, he responded with confidence: “If anyone can make Indiana one of the healthiest states, it’s IU Health.”

In a system as large as IU Health, many factors are involved in implementing new programs. The spread of virtual care to different service lines was steady, but slow, for a number of reasons. For example, the services that payers reimbursed varied across carriers. These variations, and the administrative headaches they caused, were often cited as a bottleneck to broader virtual care adoption. In addition, providers generally seemed skeptical that they could bill for such a wide range of services.

Still, I was excited by the prospect of helping to expand virtual care services throughout the IU Health system. Then, on March 7, 2020, we had our first confirmed case of COVID-19, and everything changed.

The Pandemic Blooms

The state declared a public health emergency (PHE) on March 13. Suddenly, my “10 hours, at most” of virtual care work turned on a dime. We were no longer trying to generally improve the overall health of a state, we were trying to save the state from the crippling effects of a global pandemic.

The system’s focus was on sparing personal protective equipment (PPE) and saving lives. The answer to both problems was clear—virtual care!

I saw colleagues on the nightly news, sharing the efforts being made by IU Health to allow access to healthcare professionals through free virtual screenings. I was on daily calls with top revenue cycle leadership, answering questions about what virtual care services could be billed and what could not.

We took that promise to innovate and jumped into virtual care with both feet, trusting that our teams across the state could deliver quality care in the safest way possible.

IU Health was fortunate enough to have an established platform integrated into our environment prior to COVID-19, but with the PHE declaration, everything we knew about virtual care changed.

That luxury of providing services within a clear system of guidelines was out the window. Our system leadership, as well as guidance from the Centers for Medicare and Medicaid Services (CMS), was clear: Treat patients as safely and effectively as you can.

Almost instantaneously, virtual care and virtual care services became the primary modality for care delivery, as we ceased in-person visits in the ambulatory setting. CMS changes poured in. Restrictions that clearly defined when, how, and to whom virtual care services could be provided were being lifted left and right.

By April 30, CMS released a second interim final rule giving providers freedom to access patients via phone and video with few restrictions. From March 6 to the middle of May, 1,890 providers were added to the IU Health virtual care platform, allowing then to perform virtual services.

Rollout

As we rolled out virtual care to the four corners of the state, providers embraced the transition, which allowed for ongoing care of our patients while minimizing the risk of exposure to COVID-19. This not only ensured patient safety, but the safety of our healthcare professionals and preservation of PPE.

I work with a small team of experts and together we cover all the bases of compliance, coding, charge management, and other areas to ensure the guidance we share does not lead to a ripple effect of erroneous billing at some point downstream in the system.

The first step in ensuring billing success of virtual care services is digesting the different payer guidelines. We started with CMS and Medicaid, then fanned out to the largest commercial payers. We visit payer websites, looking for up-to-date guidance on virtual care billing. We do not want to burden the providers with different payer guidelines.

The second step for the stakeholders is to meet—virtually, of course. We are not only implementing virtual care throughout the system, we are also operating virtually. We discuss the guidelines, looking for similarities among payers, trying to find the path of least resistance and identify opportunities to automate processes, such as adding modifiers and changing the place of service for virtual care services.

We typically meet three to four times to identify any setbacks or potential problems in our systems. Our instruction to providers is to bill all virtual care the same, with the GT modifier, which is used for virtual care claims. The GT modifier will trigger the system edits to recognize the service as virtual care. The system recognizes the payer and updates the modifier and place of service accordingly.

Getting Up to Speed

Once we found a clear path in the system, we turned to educating our providers on how to bill, what services can be provided via virtual care, and the associated restrictions. The virtual care team, which existed pre-COVID, also quickly ramped up to support providers, many still novices who needed assistance with logistical and technical issues.

To keep the providers up to date on changing guidelines and how to submit their charges to ensure accurate claim reporting, we create job aids that are distributed system wide. As the virtual care coding expert, I am responsible for creating the content. To complete these tasks, I lean heavily on my years of experience educating providers. I have experience outside of virtual care creating educational documents and presentations to aid our providers in digesting the complicated world of coding and billing guidelines.

Once I have the information in the Word document, I send to leaders in compliance and charge management, my director, and our revenue cycle medical director for review. Each has a role in ensuring that the complex coding and documentation content is presented in a manner that providers can easily digest and integrate into their clinical workflows.

Bumps in the Virtual Road

Although the people I work with excel at virtual care services billing across the system, we have had our challenges. I was especially surprised by the interest of virtual care adoption on the inpatient side, resulting in new workflows for providers. For example, providers may be on-site at the facility but unable to enter the exam room due to risk of exposure. The provider would connect with the patient via video or phone, in addition to chart review and consultation with other medical professionals. In some cases the patient would be intubated and unable to participate in a phone or video connection, adding an additional element of complexity. This led us to creating inpatient workflows for providers that were then distributed in a job aid, which our clinical IS team transformed into a one-page, easy-to-follow decision process.

IU Health virtual Screening for COVID-19, March 25, 2020.
Photo credit: Chris Bergin

I also aided in integrating quick-pick billing folders in our electronic health record (EHR), to support providers in coding for the virtual services rendered.

The task force of experts and leaders I have come to know so closely faced the same challenge that all healthcare systems (big and small) face: rapidly changing billing and coding guidance.

We all appreciate CMS and payers who recognize the need to rapidly redesign their billing systems for ease of use and grant waivers that allow providers to more efficiently provide care for patients.

Additional challenges include patient access to reliable technology. Since many patients still lack smartphones or the knowhow to engage in a virtual care service, our support staff must dedicate time to helping patients sign on to the virtual care platform to minimize delays from technical glitches and ensure patients have their full visit with the provider.

. Despite a phenomenal effort on the part of our virtual care team, accounts could not be created quickly enough, at times, to meet the needs of all patients.

With CMS allowing the use of other platforms, such as Microsoft Teams or Doxy, our leaders began vetting the security of the platforms. Remaining HIPAA compliant and maintaining patient privacy while also ensuring integration with our EHR remained high priorities.

Even with these challenges, providers and patients alike have taken to virtual care services like fish to water. Projects with a virtual care focus, intended to extend post-PHE, are popping up left and right, with a general buzz that virtual care will remain a part of the everyday practice of medicine well into the future.

Looking Ahead

I have always wondered how healthcare automation would impact the role of the health information management (HIM) professional. I’m seeing that far from eliminating the need for a qualified HIM professional, automation requires HIM professionals as the conduits to allow healthcare systems to swiftly and effectively implement rapidly changing healthcare guidance during the COVID-19 pandemic.

We are the interpreters of coding and billing systems that continue to grow more complicated with the addition of technological advancement in medicine and more integrated health system operations.

What I have learned from this rapid expansion of policy is that every automated process requires the input of multiple business analysts, compliance professionals, and coding experts to even have a shot at making sure it’s effective.

So where do we go from here? Isn’t that the million dollar question? As I write this, we are settling into an understanding that we do not know what the future holds, but we can tackle the awesome challenges this era presents.

Those heavily involved in helping launch this tremendous project are working many more hours and more intensely than pre-COVID. So, we lean on each other because we know there is not a true end in sight. We have accepted the uncertainty. We expect it and methodically dissect it within our appropriate roles. We no longer feel the panic and pressure of constant change, but we digest the new guidelines with efficiency.

We can rely on each other and be confident in our contributions, to the success of IU Health and the delivery of quality patient care.

Our health system, like many others, rapidly adapted in an uncertain environment. What will it look like to reinstate pre-pandemic virtual care restrictions to a system with over 8,000 physicians and advanced providers? What will the payers continue to allow in terms of virtual care services? The uncertainty remains, but the confidence in our teams holds true.

Today, we are shaping and witnessing change in the healthcare industry, and I’m confident that we have the most effective HIM professionals in place to lead the industry to highly efficient billing and coding systems that will serve our patient and provider communities as we enter the future of virtual health care.

 

AUTHOR’S NOTE: Insights on provider experience were provided by Wanita Kumar, MD, Indiana University Health Revenue Cycle Services Medical Director.

Insights on HIM leadership experience were provided by Angela Hite, MS, RHIA, CCS-P, Indiana University Health Director, Total Quality Management Physician Coding.

 

Sarah A. Throop, CCS-P, (sthroop1@iuhealth.org) is an Operational Performance Expert CC – Provider Reviewer/Educator & RCS Virtual Care Coding Expert

 

A View from the Top

By Angela Hite, MS, RHIA, CCS-P, Director, Total Quality Management Physician Coding

IU Health’s massive and urgent undertaking to educate ourselves, providers, other departments, business partners, and professional coders on virtual care coding, documentation, and payer guidelines was the most challenging project in my 20-year career in health information management (HIM).

The good news is that IU Health is brimming with the top experts in their fields, and this expertise was evident during the public health emergency.

We didn’t have all the answers, but interdepartmental clinical, financial, and administrative teams came together to get the job done. As Sarah wrote, guidance is always changing and our task was to determine how to incorporate those changes with minimal disruption to the providers’ workflows while ensuring appropriate coding and documentation.

As a leader operating during a crisis, it’s important to have people on your team who are subject-matter experts and truly dedicated to the organization’s mission and goals. I could not be prouder of Sarah, the rest of my team, and all other leaders and individuals we worked with across IU Health.

While this was a difficult time to go through professionally and personally, everyone came together and succeeded. We all work more closely together, to live the IU Health values of Purpose, Team, Excellence and Compassion, in order to have the best outcome for our patients.

 

Angela Hite, MS, RHIA, CCS-P, (ahite1@iuhealth.org) is the director of total quality management physician coding at Indiana University Health.

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