How Cleveland Clinic created a telehealth team and new documentation to tackle coding, billing changes

When CMS issued sweeping regulatory changes on March 30 to address COVID-19 patient surge, Cleveland Clinic assembled a team of IT, coding and billing experts to help translate the new telehealth policies and waivers into clinician-friendly electronic workflows. 

While the health system already adopted telehealth pre-COVID-19 in ambulatory settings and select emergency and inpatient uses such as stroke and intensive care, the widespread use of inpatient virtual visits was new for Cleveland Clinic, according to the June 25 news release. 

"With everything that our providers were going through, we knew we couldn’t expect them to also become instant experts on CMS waivers and other regulatory changes," said Allison Weathers, MD, associate CMIO. "We had to think through how the EHR could be leveraged to allow our providers to put their time and attention on what mattered most — caring for their patients, not knowing the intricacies of documenting and coding of providing virtual care." 

Here are three things to know about Cleveland Clinic's telehealth strategy:  

1. The health system created an inpatient distant health multidisciplinary team with members representing physicians, nurses, coding, IT and administration. The group used its collective coding and clinical informatics expertise to create new telehealth documentation that helped streamline new billing guidelines and support remote care for hospitalized patients.

2. Dr. Weathers, Katina Nicolacakis, MD, medical compliance, billing and reimbursement director, and Leslie Wong, MD, assistant director of Cleveland Clinic's Medical ACO, teamed up during daily meetings with IT and coding colleagues to analyze the new CMS telehealth waivers and help create new inpatient telehealth documentation and billing templates.

3. The IT and coding teams modified existing electronic workflows for physician documentation and billing designed for in-person care to meet the new requirements for telehealth. The teams also created user-friendly documentation templates in the EHR that can be easily adapted across the different specialty services at Cleveland Clinic. 

"What we learned was how invaluable it was for physicians to be involved in how a telehealth strategy is deployed, and to use an interdisciplinary approach to ensure proper documentation and reimbursement, but also good communication between caregivers," Dr. Wong said. 

More articles on telehealth: 
UC Davis Health expands pediatric telemedicine offering to 14 California counties
M Health Fairview expands telemedicine pilot to local homeless shelter 
Idaho makes COVID-19 telehealth expansions permanent

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