In light of recent events related to COVID-19 (i.e. the coronavirus), the U.S. healthcare system finds itself at a difficult crossroads.1 With the number of infected individuals continuing to climb and the death toll surpassing 82,000 globally, both fear and anxiety are crippling physical therapy clinics.2,3 Many outpatient orthopedic clinics, private practices, and hospital-based systems are shutting down in the U.S. by order of the government.4 Bank reserves for therapy clinics are also quickly depleting in states such as Nevada, California, New York, Ohio, and Kentucky.4,5,6,7,8 In an effort to mitigate financial losses, the American Physical Therapy Association (APTA) is pushing for legislative action supporting the immediate implementation of telemedicine.9,10 While the Centers for Medicare and Medicaid Services (CMS) has swiftly responded with new G-codes that can be used for “e-visits,” they have made no related changes to allow PTs to actually provide telehealth services.11 As such, reimbursement rates continue to be inconsistent, underwhelming, and heavily regulated.12-15
Whether private insurance companies will reimburse for telemedicine services is also unknown.16-17 Aetna, United Healthcare, and Anthem have recently announced that they will reimburse for telehealth for CPT codes 97161, 97162, 97163, 97164, 97110, 97112, 97116, 97535, 97755, 97760, and 97761 at the same rate as in-person services.18-20 Providers are expected to use the same CPT codes with modifier 95 or GT and place of service code 02.18-20 While Cigna has also decided to cover telehealth services through May 31, 2020 with a GQ modifier and service code 02, it will only reimburse for codes 97161 (i.e. evaluation – low complex, 20 min), 97162 (PT evaluation – moderate complex, 30 min), and 97110 (i.e. therapeutic exercise, maximum of two units).21 Thus, while many states are lobbying for telehealth to be written into their state practice acts, thereby ensuring that the traditional CPT codes can be used, reimbursement may be inconsistent across states, limited, and not guaranteed.22
Importantly, while physical therapists have the capability to virtually evaluate and treat patients, the clinical outcomes of telehealth physical therapy vs. in-person physical therapy is presently unknown.23 While a number of recent studies suggest that telehealth may be cost efficient24 and effective,24-25 the assertion that telehealth physical therapy is as successful as in-person physical therapy is dangerous and misleading, particularly for patients with subacute and chronic pain conditions. Although the VERITAS Trial found that telehealth PT led to similar outcomes compared to traditional in-person PT for pain, ROM, walking speed, and rehospitalization in patients with a recent total knee arthroplasty,24 it is perhaps worth noting that another recent trial also concluded that supervised physical therapy did not improve function and patient satisfaction better than unsupervised NMES and ROM exercises.26
Furthermore, a recent systematic review of 11 studies and 2,280 patients with nonspecific low back pain and found that telehealth was not able to improve pain and disability more than minimal care.27 While telehealth may be more convenient for many patients, a recent study reported that telehealth patients had concerns about medical errors due to the difficulty of not being able to complete a physical exam.28 Patients additionally noted issues with the quality of care they received via telehealth along with difficulty communicating and establishing a provider-patient relationship.29
Nevertheless, telemedicine may provide a lifeline to help physical therapists navigate through the COVID-19 crisis.29 However, if telemedicine becomes the “new normal,” the physical therapy profession may ultimately jeopardize the “art” of physical therapy. That is, if convenience of telemedicine exceeds the value of “hands-on” manual therapy, the profession risks backtracking to strategies overly reliant on exercise.30-31 While “therapeutic exercise” continues to provide the foundation of the physical therapy profession and is supported as part of the management program in many neuromusculoskeletal conditions, the literature supports an approach that combines exercise (typically in-person, supervised exercise often with equipment or tactile cues and feedback, rather than exercise at home over the phone or video) with manual therapy to achieve optimal outcomes.32 While the short-term goal is to survive the COVID-19 crisis, physical therapists should focus on the “long-game.” As the crisis comes to an end, the physical therapy profession must establish value in a continually changing healthcare system, where treatment efficiency and effectiveness will likely win the day. As such, perhaps legislation should focus on the use of telehealth by PTs for virtual consultation, screening, and patient education while distinguishing the unique mission of in-person, hands-on clinical treatment.
TELEHEALTH IN PHYSICAL THERAPY PRACTICE
Notably, many medical practices have offered telemedicine consultations prior to the COVID-19 crisis.33-34 To some of the more seasoned healthcare providers, telemedicine may seem daunting. However, there are a few advantages to telemedicine that traditional healthcare has yet to demonstrate. Telemedicine increases access to patients that live in remote locations or are too old and/or sickly to travel for medical appointments. In the case of the COVID-19 crisis, telemedicine also makes it possible to receive medical attention without risking exposure to the virus or putting others at risk.25-36 Telemedicine also facilitates proper screening so as to reduce unneeded and/or unnecessary visits to urgent care facilities and emergency rooms.37-39 Given that physical therapists are well-trained to evaluate neuromusculoskeletal conditions, PTs may play a key role in telehealth consultations.
Telehealth platforms have been well established in the physical therapy profession and the general medical community.40 Companies such as Physitrack© have provided telehealth video calling and home exercise program access at a reasonable rate since 2012.41 Other electronic medical record platforms such as TheraOffice and WebPT are working to integrate telehealth into their existing software in a more reactive way.42-43 However, the goal of such platforms is to expand and perhaps supplement care, not to replace it. Thus, while many clinics are investing time and money to quickly move to telehealth PT in the short-term, the outcomes of telehealth physical therapy are still unknown, and the transition to virtual care may ultimately hurt the physical therapy brand in the long-term. While it may finally facilitate accomplishing APTA’s 2020 vision, “Transforming society by optimizing movement to improve the human experience,” it will likely create more confusion about what physical therapists “do” and what they can successfully treat by using “manual therapy” (i.e. CPT code 97140) and/or dry needling.44 If the physical therapy profession can use telehealth during the COVID-19 crisis to expand scope of practice and demonstrate value as first-line clinicians, they will almost certainly be stronger in the post COVID-19 world. The danger, however, for brick and mortar private practice PTs, would be lobbying that what physical therapists can do in-person can be equally achieved over the phone or on live video, and for much less cost.
SCREENING AND DIRECT ACCESS
As aforementioned, physical therapists are experts in evaluating and treating neuromusculoskeletal (NMS) conditions. In the military, for example, many physical therapists are already practicing as general care practitioners with an NMS specialty.45 Given that military physical therapists also have the ability to order and interpret diagnostic images and prescribe medications, they are well equipped to provide first-line treatment during a national crisis or military conflict.46,47 In some instances, the physical therapists are the preferred NMS specialist over the physicians in the military.45-46 Doctors of Physical Therapy are trained to be expert screeners at entry-level practice, making it quite feasible for them to act as primary care providers to the general public for all NMS conditions, both in-person and in telemedicine.47 It follows that physical therapists can and should use telemedicine to help the U.S. move through the COVID-19 pandemic and beyond.
THE ACTUAL COSTS OF TELEHEALTH FOR PTs
A two-month loss of revenue can be devastating for independently-owned PT clinics, but telehealth may provide a useful crutch in the short-term and a means to expand business in the long-term. While many EMR companies are up-charging telehealth capabilities to compensate for lost revenue during the COVID-19 crisis, telehealth does not have to be expensive.41-44 Physitrack© costs around $10.99/month for each practitioner plus a per-minute telecommunication charge.41 Certainly, this small investment could allow physical therapists to consult a new patient inquiry within the same day. Physical therapists could then provide valuable patient education, prescribe exercises, and schedule an office visit. With the proper foresight and strategy, reasonably priced, telemedicine software could facilitate survival during the COVID-19 crisis and significant growth afterward.
The recent COVID-19 crisis has thrown many outpatient physical therapy clinics into full crisis mode. A recent survey of 1,935 physical therapists in California found that 73.3% (i.e., 1419 of 1935) of PTs in that state have experienced a reduction in work hours due to the COVID-19 crisis. Clinics are figuring out how to keep the lights on, while clinicians are questioning whether they will continue to receive a paycheck. Small businesses, hospital systems, and the APTA are working hard to implement telehealth legislation in the current climate to help off-set the financial impact of the coronavirus.
While in-person physical therapy is restricted or limited in the short-term, telehealth may help the profession weather the storm. Nevertheless, physical therapists must not lose site of the “long game.” Beyond consultations or screenings, widespread use of telehealth by PTs for ongoing and extended treatment sessions, should be discouraged or only considered a temporary fix within the framework of unusual circumstances (such as the COVID-19 crisis).
Telehealth by physical therapists in private practice should not become the new normal for the rehabilitation and management of neuromusculoskeletal conditions. In truth, we are “PHYSICAL therapists” and this often involves physical interventions that require physical contact with our patients. That is, it doesn’t seem possible for physical therapists to properly or comprehensively treat conditions such as plantar fasciitis, knee osteoarthritis, cervicogenic headache, or mechanical neck pain over the phone or by a video call.
Dr. Benjamin S. England, PT, DPT, Dip. Osteopractic
Physical Therapist, Mallers & Swoverland Orthopaedic Physical Therapy
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Fort Wayne, IN
Dr. Raymond Butts, PhD, DPT, MSc (NeuroSci), Dip. Osteopractic
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical therapy
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Dr. Clint Serafino, DPT, FAAOMPT, Dip. Osteopractic
Senior Physical Therapist, Fight Back Physical Therapy
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Dr. James Dunning, PhD, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Owner, Montgomery Osteopractic Physiotherapy & Acupuncture Clinic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
- Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-nCoV/index.html. Published March 13, 2020. Accessed March 23, 2020.
- Bellamy J. Letter From President Dunn on COVID-19 Impact. APTA. http://www.apta.org/Coronavirus/PresidentLetter/. Published March 20, 2020. Accessed March 23, 2020.
- Bellamy J. APTA Statement on Patient Care and Practice Management During COVID-19 Outbreak. APTA. http://www.apta.org/Coronavirus/Statement/. Published March 17, 2020. Accessed March 23, 2020.
- Kentucky Orders Theaters, Gyms, Salons Closed Amid Outbreak. U.S. News & World Report. https://www.usnews.com/news/best-states/kentucky/articles/2020-03-17/university-of-kentucky-extends-shift-to-online-instruction. Published March 17, 2020. Accessed March 23, 2020.
- Rothman J. Telehealth in Physical Therapy in Light of COVID-19. https://www.apta.org/PTinMotion/News/2020/3/16/TelehealthCOVID19/. Published March 16, 2020. Accessed March 23, 2020.
- Shayna Jacobs DB. New York governor orders shutdown of all nonessential businesses. The Washington Post. https://www.washingtonpost.com/national-security/coronavirus-new-york-shutdown-cuomo/2020/03/20/ce124798-6aca-11ea-abef-020f086a3fab_story.html. Published March 20, 2020. Accessed March 23, 2020.
- Washington Post: Breaking News, World, US, DC News & Analysis. The Washington Post. https://www.washingtonpost.com/. Accessed March 23, 2020.
- Cowan J. Newsom Orders All Californians to Stay Home. The New York Times. https://www.nytimes.com/2020/03/20/us/coronavirus-california-stay-at-home-order.html. Published March 20, 2020. Accessed March 23, 2020.
- Keselman I. National Health Emergency Triggers CMS Waivers for Medicare, Medicaid, CHIP. APTA. http://www.apta.org/PTinMotion/News/2020/03/16/CMSWaivers1135/. Published March 16, 2020. Accessed March 23, 2020.
- Gagnon MA. CMS Moves to Allow Digital Communications by PTs. APTA. http://www.apta.org/PTinMotion/News/2020/03/17/E-VisitsCMSCoronavirus/. Published March 17, 2020. Accessed March 23, 2020.
- CMR Rule Stops Short of Allowing PTs to Conduct Telehealth Services. PT in Motion. https://www.apta.org/PTinMotion/News/2020/03/33/CMSInterimRuleCOVID/. Accessed April 6, 2020.
- Vredeveld K. Furnishing and Billing E-Visits: Addressing Your Questions. APTA. http://www.apta.org/PTinMotion/News/2020/03/18/E-VisitFAQs/. Published March 18, 2020. Accessed March 23, 2020.
- Use of E-Visit Codes for Medicare Part B Services During Coronavirus. Use of E-Visit Codes for Medicare Part B Services During Coronavirus. https://www.asha.org/Practice/reimbursement/medicare/Use-of-E-Visit-Codes-for-Medicare-Part-B-Services-During-Coronavirus/. Accessed March 23, 2020.
- Fact sheet MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET. CMS. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Published March 17, 2020. Accessed March 23, 2020.
- Medicare & Coronavirus. https://www.medicare.gov/medicare-coronavirus. Accessed March 23, 2020.
- McClain M. Coronavirus Update: March 19, 2020. APTA. http://www.apta.org/PTinMotion/News/2020/03/18/CoronavirusUpdateMarch19/. Published March 19, 2020. Accessed March 23, 2020.
- Aetna Expands Telehealth and Remote Visit Coverage, Allows PTs to Bill for E-Visits. In The News. https://www.coloradophysicaltherapists.org/in-the-news. Published March 20, 2020. Accessed March 23, 2020.
- Aetna Now Covers Telehealth Delivered by PTs. PT in Motion. https://www.apta.org/PTinMotion/News/2020/04/02/AetnaTelehealthCOVID/. Accessed April 6, 2020.
- United Healthcare Allows Telehealth for Physical Therapists. PT in Motion. http://www.apta.org/PTinMotion/News/2020/03/27/UHCTelehealth/. Accessed April 6, 2020.
- Information from Anthem for Care Providers about COVID-19 (updated April 1, 2020). https://providernews.anthem.com/kentucky/article/information-from-anthem-for-care-providers-about-covid-19-7. Accessed April 7, 2020.
- Cigna Announces Telehealth Coverage. https://www.ccapta.org/page/CignaTelehealth. Accessed April 6, 2020.
- Senior R. COVID-19 Impacts Physical Therapy. Elite Learning. https://www.elitecme.com/resource-center/rehabilitation-therapy/covid-19-impacts-physical-therapy/. Published March 20, 2020. Accessed March 23, 2020.
- Connect LH. LDH Novel Coronavirus Disease (COVID-19) Provider Update. LDH Novel Coronavirus Disease (COVID-19) Provider Update | Louisiana Healthcare Connections. https://www.louisianahealthconnect.com/newsroom/ldh-novel-coronavirus-disease–covid-19–provider-update–3-14-2.html. Published March 17, 2020. Accessed March 23, 2020.
- Study Shows Effectiveness of Telehealth Platform. https://www.hcinnovationgroup.com/clinical-it/news/13030823/study-shows-effectiveness-of-telerehabilitation-platform. Accessed April 7, 2020.
- Kane LT, Thakar O, Jamgochian G, Lazarus MD, Abboud JA, Namdari S, Horneff JG 2020 The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial. J Shoulder Elbow Surg 29, 775-783.
- Levine M, McElroy K, Stakich V, Cicco J 2013 Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA. Orthopedics 36, e319-324.
- Dario AB, Moreti Cabral A, Almeida L, Ferreira ML, Refshauge K, Simic M, Pappas E, Ferreira PH 2017 Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis. Spine J 17, 1342-1351.
- Gordon HS, Solanki P, Bokhour BG, Gopal RK 2020 “I’m Not Feeling Like I’m Part of the Conversation” Patients’ Perspectives on Communicating in Clinical Video Telehealth Visits. J Gen Intern Med.
- Staff PTT. Challenges and Opportunities in Telehealth: A Q&A With the Experts. APTA. http://www.apta.org/Blogs/PTTransforms/2020/1/8/Telehealth/. Published January 8, 2020. Accessed March 23, 2020.
- Shaw DK. Overview of Telehealth and Its Application to Cardiopulmonary Physical Therapy. Cardiopulmonary Physical Therapy Journal. 2009;20(2):13-18. doi:10.1097/01823246-200920020-00003.
- Telehealth Physical Therapy. Physical Therapy Services – Fall Prevention. https://www.fyzical.com/oklahoma-city/Telehealth-Physical-Therapy. Accessed March 23, 2020.
- Chimenti RL, Frey-Law, LA, Sluka KA. A Mechanism-based Approach to Physical Therapist Management of Pain. Physical Therapy Journal. 2018 Apr 16. doi: 10.1093/ptj/pzy030: 10.1093/ptj/pzy030.
- Young J, Badowski M. Telehealth: Increasing Access to High Quality Care by Expanding the Role of Technology in Correctional Medicine. Journal of Clinical Medicine. 2017;6(2):20. doi:10.3390/jcm6020020.
- The Use of Telemedicine to Address Access and Physician Workforce Shortages. Pediatrics. 2015;136(1):202-209. doi:10.1542/peds.2015-1253.
- Broffman L, Xaviour AF, Roche S. Telemedicine can blunt the cost of unnecessary Covid-19 visits. STAT. https://www.statnews.com/2020/03/19/telemedicine-blunt-cost-unnecessary-covid-19-visits/. Published March 19, 2020. Accessed March 23, 2020.
- Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. New England Journal of Medicine. November 2020. doi:10.1056/nejmp2003539.
- Rademacher NJ, Cole G, Psoter KJ, et al. Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine. JMIR Medical Informatics. 2019;7(2). doi:10.2196/11233.
- Papanagnou D, Stone D, Chandra S, Watts P, Chang AM, Hollander JE. Integrating Telehealth Emergency Department Follow-up Visits into Residency Training. Cureus. May 2018. doi:10.7759/cureus.2433.
- Fairchild RM, Ferng-Kuo S-F, Laws S, Rahmouni H, Hardesty D. Telehealth Decreases Rural Emergency Department Wait Times for Behavioral Health Patients in a Group of Critical Access Hospitals. Telemedicine and e-Health. 2019;25(12):1154-1164. doi:10.1089/tmj.2018.0227.
- Lee ACW, Harada N. Telehealth as a Means of Health Care Delivery for Physical Therapist Practice. Physical Therapy. 2012;92(3):463-468. doi:10.2522/ptj.20110100.
- Physitrack® – The world leader in remote patient engagement and Telehealth. https://www.physitrack.com/. Accessed March 23, 2020.
- Telerehab Bumps Elbows with COVID-19. TheraOffice. https://www.theraoffice.com/telerehab-bumps-elbows-with-covid-19/. Published March 13, 2020. Accessed March 23, 2020.
- Founder Letter: Emergency Preparedness and Business Continuity for Rehab Therapists During the COVID-19 Pandemic. WebPT. https://www.webpt.com/blog/post/founder-letter-emergency-preparedness-and-business-continuity-for-rehab-therapists-during-the-covid-19-pandemic/. Published March 19, 2020. Accessed March 23, 2020.
- Gardner K. Vision Statement for the Physical Therapy Profession and Guiding Principles to Achieve the Vision. APTA. https://www.apta.org/Vision/. Published 2013. Accessed March 23, 2020.
- Garner G. PTs Are Effective Primary Care Providers in Military Settings. https://www.apta.org/PTinMotion/NewsNow/2013/10/7/MilitarySettings/. Published 2013. Accessed March 23, 2020.
- Mcgill T. Effectiveness of Physical Therapists Serving as Primary Care Musculoskeletal Providers as Compared to Family Practice Providers in a Deployed Combat Location: A Retrospective Medical Chart Review. Military Medicine. 2013;178(10):1115-1120. doi:10.7205/milmed-d-13-00066.
- Murphy BP, Greathouse D, Matsui I. Primary Care Physical Therapy Practice Models. Journal of Orthopaedic & Sports Physical Therapy. 2005;35(11):699-707. doi:10.2519/jospt.2005.35.11.699.