Urology in the Time of COVID19

Telemedicine and eConsults

for Hospitalized Patients During
COVID-19
Adam J. Gadzinski*, Juan J. Andino*, Anobel Y. Odisho, Kara L. Watts, John L. Gore, and
Chad Ellimoottil

T
he COVID-19 pandemic has rapidly changed how on patient location during video visits have been waived by
physicians assess and interact with patients. Many the Centers for Medicare and Medicaid Services as well as
providers have appropriately cancelled nonemer- by most state Medicaid programs and private insurers.2,3
gent surgical procedures and converted ambulatory in-per- Nearly all Americans can now participate in a video visit
son appointments to remote video visits or phone calls. with a healthcare provider from any location. As a result,
As hospitals throughout the United States begin to fill clinicians across the United States have rapidly adopted
with patients afflicted with COVID-19 and other acute the use of video visits to replace in-person outpatient visits
illnesses, the need to preserve personal protective equip- during the COVID-19 emergency.4
ment (PPE) and to reduce the risk of nosocomial Many of these regulatory changes are directly applicable
COVID-19 transmission to patients and providers is criti- to physician consultation in both the ED and inpatient
cal. Likewise, it is imperative to rapidly triage, diagnose, settings. Video visits can be used to evaluate patients
and provide disposition for nonCOVID-19-related urgent without a procedural need or for conditions where physi-
and emergent hospital visits. cal exam is not a major contributor to clinical decision
In order to support this objective, we developed a pro- making.5 During the COVID-19 emergency, this will
cess to utilize inpatient telemedicine video visits and elec- facilitate rapid assessment and disposition from the ED
tronic consultation (eConsults) to assess patients with and promote essential goals: preserving PPE, limiting
non-procedural urological needs presenting to the emer- potential exposures and the possible spread of disease in
gency department (ED) or admitted to the hospital. We the ED and inpatient settings. Although this method of
aim to describe these types of remote consultation, medi- consultation may be new for many providers, video visits
cal documentation and billing requirements, and demon- have been used for years to assess patients presenting with
strate a process for rapid implementation. Our hope is that stroke symptoms to facilitate rapid decisions on tissue plas-
other consulting specialists can implement similar pro- minogen activator use.6,7
grams, contribute to PPE preservation, and minimize The appropriate documentation and consenting process
unnecessary physical exposure without compromising for ED and inpatient video visit consultation are identical
medical care. to outpatient video visit requirements. In addition to stan-
dard evaluation and management components of a con-
sultation note, providers should document (1) consent of
VIDEO VISITS FOR HOSPITALIZED AND the patient to a video visit, (2) the location of the patient
EMERGENCY ROOM PATIENTS and the provider at time of the encounter, (3) the time
Video visits are a real-time, simultaneous audio and visual spent for the consultation. We also encourage providers
interaction with patients via a video conferencing plat- to document a statement that the visit was conducted via
form.1 During the COVID-19 emergency, prior restrictions video to preserve PPE and limit exposures during the
COVID-19 emergency. The specific CPT codes for initial
* Drs. Gadzinski and Andino contributed equally to this manuscript. and follow-up video visit consultations are provided for
Disclosures: Dr. Anobel Odisho had a prior consulting relationship with VSee, Inc. reference (Table 1).
From the Department of Urology, University of Washington, Seattle, WA; the
Department of Urology, University of Michigan, Ann Arbor, MI; the Department of
Urology and Center for Digital Health Innovation, University of California, San Fran-
cisco, CA; the Department of Urology, Montefiore Medical Center, Albert Einstein Col-
lege of Medicine, Bronx, NY; and the Institute for Healthcare Policy and Innovation, ECONSULTS
University of Michigan, Ann Arbor, MI An eConsult, or interprofessional consultation, is defined
Address correspondence to: Adam J. Gadzinski, M.D., M.S., University of Washing-
ton, 1959 NE Pacific St. Box 356510, Seattle, WA. E-mail: [email protected] as a diagnosis or management service provided by a con-
Submitted: April 15, 2020 sulting physician to a requesting physician or other
12 https://doi.org/10.1016/j.urology.2020.04.061 © 2020 Elsevier Inc.
0090-4295 All rights reserved.
Table 1. Video visit and eConsult codes
CPTÒ Code Description Time Spent CY2020 RVU
Video Visits
G0425-7 Telehealth consultation, emergency department or 30, 50, 70 min 1.92, 2.61, 3.86
initial inpatient
G0406-8 Telehealth consultation, follow-up 15, 25, 35 min 0.76, 1.39, 2.00
eConsults
99446-9 Interprofessional telephone/internet/electronic 5-10, 11-20, 0.35, 0.75,
health record assessment and management 31-30, >30 min 1.05, 1.40
service provided by a consultative physician,
including a verbal and written report to the
patient’s treating/requesting physician or other
qualified healthcare professional.
99451 Interprofessional telephone/internet/electronic 5+ min 0.70
health record assessment and management
service provided by a consultative physician,
including a written report to the patient’s treating/
requesting physician or other qualified healthcare
professional.

qualified healthcare professional via verbal and written that are frequently requesting consultation (eg, ED, inter-
report.8 This service takes place without face-to-face or nal medicine, and general surgery) will help to address
video evaluation of the patient by the consultant. This workflow impediments when recommending a video or
method of consultation allows for rapid, direct, and docu- eConsult during COVID-19.
mented communication of recommendations from the One of the greatest challenges for consultants is deter-
consultant to the treating provider.9,10 It is important to mining which patients are ideal candidates for video or
note that the consultant must be a physician. Like video eConsult. For consults requiring a procedure or assessment
visits, the use of eConsults has typically been reserved for for emergent surgery, an in-person evaluation is required.
outpatient care; however, there are no restrictions for its Otherwise, there are no clear guidelines for which clinical
application to inpatient and ED consultation.11 questions require in-person evaluation. The consultant
There are important billing and documentation and requesting provider should discuss patient acuity,
requirements for eConsults. First, the requesting provider physical exam needs, and provider comfort with remote
needs to briefly obtain and document verbal consent from assessment.
the patient for the use of eConsults. Second, the consult- Lastly, technological workflows for video visits should
ing physician should document (1) the reason for consul- be established. Not all patients, hospital rooms, or ED
tation, (2) findings from the medical records, (3) further units, have a device capable of video conferencing. Thus,
evaluation and/or treatment recommendations, and (4) inpatient wards and EDs may consider repurposing mobile
the time spent reviewing the record and speaking with the computers and/or tablets used for research or translator
requesting physician (if applicable). Lastly, if upon services to be used for video visits. The consultation work-
reviewing the clinical record, the consultant determines flow at our institutions is displayed in Figure 1. At present,
that a formal video or in-person consultation is recom- some institutions have implemented this for all patients.
mended (either immediately or as an outpatient), or if an Others are using this workflow only for patients admitted
in-person consultation occurs within 14 days, then the to COVID-19 wards. Each institution will need to deter-
eConsult is no longer a billable event. The appropriate mine its individualized workflow and its criteria for which
billing codes are listed in Table 1. One important nuance patients would benefit from remote evaluation. This will
is that code 99451 is used when there is no verbal report also depend on the state of each institution's technologi-
given to the requesting provider after the recommenda- cal capabilities, hospital PPE supplies, and the estimated
tions are documented in the eConsult note. This is more trajectory of patients with COVID-19.
often utilized in the outpatient setting but may also be Importantly, the use of remote ED and inpatient con-
appropriate for inpatient use. sultation could harness a centralized team of providers
that could manage remote consultations across multiple
hospitals. This may become particularly important at
CONSULTATION WORKFLOW institutions experiencing a surge of COVID-19 patients
Implementing video visits and/or eConsults in the ED and where specialists are being redeployed to provide care in
inpatient settings requires careful planning for safe and intensive care units, EDs, and inpatient wards. As fewer
effective implementation. These methods of consultation specialists are available to serve as consultants for their
will likely be new for many providers who request a con- trained specialty, more facilities will likely need to be ser-
sultation. Thus, engaging with the leadership of services viced by a smaller team of specialist providers.

UROLOGY 141, 2020 13

 Figure 1. Remote consultation workflow. (Color version available online.)

CONCLUSION 9. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consulta-

The COVID-19 pandemic has necessitated dramatic tions (e-consults) to improve access to specialty care: a systematic
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patients requiring specialist evaluation in the ED and review. World J Urol. 2019. https://doi.org/10.1007/s00345-019-
inpatient ward setting will help to conserve PPE, limit 02882-9.
exposures bidirectionally, could allow for a centralized 11. Tande AJ, Berbari EF, Ramar P, et al. Association of a remotely offered
infectious diseases eConsult service with improved clinical outcomes.
consult workforce to service multiple hospitals, and facili- Open Forum Infect Dis. 2020;7. https://doi.org/10.1093/ofid/ofaa003.
tate rapid triage and disposition of non-COVID-19 emer-
gencies during this crisis.

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PublishedAccessed 1 April 2020. UROLOGY 141: 14, 2020. © 2020 Elsevier Inc.

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