The “New” New Normal: Changes in Telemedicine Utilization Since COVID-19

ABSTRACT

Objective: To evaluate trends in telemedicine utilization overall and across clinical specialties, providing insights into its evolving role in health care delivery.

Study Design: This retrospective cross-sectional study analyzed 1.9 million telemedicine video visits from a large academic health care system in New York City between 2020 and 2023. The data, collected from the health care system’s electronic health records, included telemedicine encounters across more than 500 ambulatory locations.

Methods: We used descriptive statistics to outline telemedicine usage trends and compared telemedicine utilization rates and evaluation and management characteristics across clinical specialties.

Results: Telemedicine utilization peaked during the COVID-19 pandemic, then declined and stabilized. Despite an overall decline, 2 non–primary care specialties (behavioral health and psychiatry) experienced continued growth in telemedicine visits. Primary care and urgent care visits were mainly characterized by low-complexity visits, whereas non–primary care specialties witnessed a rise in moderate- and high-complexity visits, with the number of moderate-level visits surpassing those of low complexity.

Conclusions: The findings highlight a dynamic shift in telemedicine utilization, with non–primary care settings witnessing an increase in the complexity of cases. To address future demands from increasingly complex medical cases managed through telemedicine in non–primary care, appropriate resource allocation is essential.

Am J Manag Care. 2025;31(3):In Press

Takeaway Points

There is a shift in how telemedicine is utilized by patients with varying clinical needs.

• In primary care, telemedicine is mainly being used for routine, low-complexity consultations.
• Patients with moderate- to high-complexity cases in non–primary care specialties are increasingly using telemedicine, even after the COVID-19 pandemic.
• Organizations should prioritize resource allocation and policy adjustments to manage growing telemedicine demand for complex cases in non–primary care specialties and mitigate any telemedicine-induced burnout concerns among providers.

Telemedicine, broadly defined as the delivery of health care services via telecommunications and computer technologies, enables providers to offer care without direct, in-person interaction with patients.¹ Telemedicine can expand patients’ access to health care providers, particularly for low-acuity medical services, at lower costs.² Given its transformative impact on care delivery, understanding telemedicine’s utilization patterns and the complexity of services it supports is essential for guiding future policy and resource allocation.

The COVID-19 pandemic triggered a rapid uptake of telemedicine in the US,³ aided by policy changes allowing reimbursement for telemedicine services at parity with in-person services.⁴ Analysis of telemedicine utilization reveals its evolving role in health care delivery, from substituting for in-person services during the pandemic to coexistence with office visits in the postpandemic era.⁵ Although telemedicine offers significant benefits in health care delivery, it also brings new challenges for clinicians,⁶ including increased patient messaging and increased time spent working with electronic health records (EHRs) both during and outside scheduled work hours (work-outside-work); this especially affects physicians,^7,8 which has raised burnout concerns. Preliminary data show varied impact on work-outside-work based on physicians’ practice settings: Primary care physicians report less, whereas specialists report more work-outside-work with increased telemedicine use.⁹

A great deal of research predicting future telemedicine utilization has investigated adoption among patient demographics, socioeconomic statuses, regions, and clinical conditions,^10-12 but little is known about the types and complexity of services delivered through telemedicine visits. The Current Procedural Terminology (CPT) system by the American Medical Association (AMA) is a standardized coding system that health care professionals use to accurately report and track health care utilization and to identify services for payment.¹³ CPT codes associated with telemedicine visits can offer insight into what types of services are provided via telemedicine, but data on their usage with telemedicine are scarce. This analysis aims to address this gap by leveraging CPT code usage to characterize telemedicine service level trends.

METHODS

The New York University Langone Health (NYULH) institutional review board reviewed this study and awarded an exemption (S21-01207). The study conforms to Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.¹⁴

Design and Setting

This cross-sectional study leveraged EHR use metadata from NYULH, a large academic health system based in New York City. Data included all video-based telemedicine visits documented in the EHR over 4 years (January 1, 2020, to December 31, 2023), including visit type, location, department information, and evaluation and management (E/M) codes used for billing. E/M coding utilizes AMA-recommended CPT codes to denote services provided by qualified health care providers (QHCPs) for evaluating and managing a patient’s health.¹⁵ Notably, CMS approved a revision to CPT codes, effective January 1, 2021, allowing QHCPs to code telemedicine visits based on either the total time spent on E/M services (including non–face-to-face tasks) or the level of complexity in medical decision-making (MDM). This expansion recognizes time spent on non–face-to-face tasks, such as chart review and care coordination,¹⁶ while aiming to reduce burdensome documentation requirements.¹⁷

Measurements

Telemedicine visits by individuals other than physicians and advanced practice providers (APPs) (eg, physical therapists and social workers) were excluded because they were unlikely to conduct high-complexity visits independently. The remaining visits were then classified into 3 categories based on the department and location of the visit: primary care (internal medicine, family medicine), urgent care (managed by emergency medicine providers), and non–primary or specialty care (all other departments).^5,9 Longitudinal trends were assessed across 5 MDM levels using the 10 most frequently used E/M codes (99201-99205, 99211-99215). The first 2 levels (99201-99202, 99211-99212), comprising visits with no or straightforward MDM, were combined into a single category (eAppendix Table [eAppendix available at ajmc.com]) because such visits predominantly involved registered nurses (RNs) and typically lacked physician involvement. Additionally, trends in E/M levels were analyzed separately for new and existing patients, as prior studies highlighted differences in providers’ E/M practices between these groups.¹⁸ Per established guidelines, a new patient is defined as one who has not received professional services from the same physician or another physician of the same specialty and subspecialty within the same group practice in the past 3 years; those who do not meet these criteria are considered existing patients.¹⁹

RESULTS

Telemedicine Volume

Over the 4-year period, 1,901,142 telemedicine visits were recorded, with 1,853,365 (97.49%) conducted by physicians or APPs and included in the subsequent analysis. Telemedicine visits peaked in 2020 at 564,191 during the pandemic, then declined annually by more than 10% in the next 2 years to reach 411,925 visits in 2022 before stabilizing at 413,676 in 2023. Internal medicine accounted for more than 17% of all telemedicine visits each year, the highest by a single department (Table). Notably, although telemedicine visits declined overall during the 4-year period, 2 non–primary care departments saw a steady increase in telemedicine visits: behavioral health (from 16,926 in 2020 to 21,978 in 2023) and psychiatry (from 9122 in 2020 to 21,285 in 2023). The Table further highlights that within-year variation in telemedicine utilization peaked in 2020 during the acute phase of the pandemic, reflected by the highest SD in monthly visit volumes across the health system and within each specialty. In the subsequent 3 years, telemedicine utilization exhibited greater stability, as evidenced by a declining SD over time.

E/M Code Volume

Among the 112 unique E/M codes present in the data, the 10 considered for analysis of the trends (eAppendix Table) covered 1,767,480 visits (95.37%). In terms of E/M levels, 53.62% (993,608 visits) involved low MDM, 32.73% (606,583) were moderate, and only 3.57% (66,244 visits) involved high service levels. Visits typically covered by RNs (with service levels classified as straightforward or not applicable) accounted for 5.45% of all telemedicine visits. The majority of visits (75.80%) were by existing patients, whose visit volumes for all 5 MDM classifications ranged from about 3 to 10 times higher than for new patients (see eAppendix Table for further details).

E/M Code Volume by Clinician Specialty

E/M codes with low complexity dominated primary care and urgent care visits (eAppendix Figure 1 [A and C]). Specifically, in primary care, the proportion of telemedicine visits categorized as low E/M increased steadily from 13.23% in 2020 to a peak of 15.23% in 2022, followed by a decline to 12.97% in 2023. Visits categorized as moderate E/M also showed an increase from 4.53% in 2020 to 5.44% in 2022, before decreasing to 4.94% in 2023.

In contrast, in non–primary care, low-level E/M visits decreased from 27.38% in 2020 to 22.56% in 2023. Notably, moderate-level E/M visits in non–primary care surpassed low-level E/M visits, rising from 19.34% in 2020 to 32.30% in 2023 (eAppendix Figure 1 [B]). High-complexity visits associated with high E/M level followed a similar upward trend, increasing from 2.27% in 2020 to 4.46% in 2023. In urgent care, E/M levels associated with telemedicine remained mostly unchanged, except for a steady decline in low-level E/M visits (eAppendix Figure 1 [C]).

Comparison of E/M Code Volume by Patient Type and Provider Specialty

Further analysis of the divergent trends between primary care and non–primary care settings, stratified by patient types (existing or new), revealed distinct patterns in E/M levels for each patient type over the years (Figure). For new patients, telemedicine utilization in primary care peaked in 2020 during the COVID-19 pandemic across all E/M service levels and has steadily declined since (Figure [A]). In non–primary care, moderate-complexity visits increased from a monthly average of 14.44% in 2020 to 16.61% in 2021, then decreased to 13.88% in 2023. High-level E/M visits followed a similar trend, rising from 4% in 2020 to 4.91% in 2021, before declining to 4.19% in 2023. Both straightforward and low-complexity visits showed similar downward trends from 2020 to 2023 (Figure [B]).

In contrast to the decline in telemedicine utilization among new patients in primary care, there was a small but steady increase in telemedicine utilization among existing patients in primary care visits, particularly for moderate E/M levels (Figure [C]). For existing patients, moderate E/M visits increased from a monthly average of 5.73% in 2020 to 6.28% in 2023. Low-level E/M visits also increased from 17.39% in 2020 to 19.08% in 2022, before decreasing to 16.61% in 2023. In non–primary care, telemedicine visits by existing patients were dominated by low and moderate E/M levels; however, these 2 visit levels showed opposite trends (Figure [D]). Low E/M visits peaked at 44.04% in 2020, then continuously declined and reached 27.25% in 2023. Conversely, moderate-level E/M visits increased from 26.05% in 2020 to 38.59% in 2023, surpassing low-level E/M by 2021. High-complexity visits also saw an increase, doubling from 2.22% in 2020 to 4.75% in 2023. Overall, the trends suggest a shift in telemedicine practices from providing access to new patients to serving existing patients, particularly in non–primary care specialties, in which moderate- and high-complexity visits are on the rise (eAppendix Figure 2).

DISCUSSION

The study highlights evolving telemedicine utilization patterns across clinical specialties over 4 years, spanning the periods before, during, and after COVID-19. Telemedicine utilization surged during the peak pandemic period across all clinical specialties³ but declined thereafter.⁵ However, the non–primary care specialties of behavioral health and psychiatry showed a sustained increase, reflecting growing acceptance of telemedicine for mental health care, consistent with existing research.²⁰

Telemedicine utilization also varied by patient type and visit complexity, suggesting different levels of comfort with its use. Analysis of E/M codes from completed telemedicine visits shows that most visits involved existing patients requiring low to moderate MDM. In primary care, the proportion of low-complexity visits with low MDM or total time increased steadily in the first 3 years before declining in 2023. The trends suggest that telemedicine in primary care is shifting from new diagnoses to routine follow-ups and chronic condition management,²¹ consistent with evidence that telemedicine supports conveniently addressing primary care needs within an ongoing patient-physician relationship, without substantially increasing follow-up visits or health events.^22,23

Analysis of E/M code utilization by patient type (new or existing) revealed contrasting telemedicine use trends between primary care and non–primary care settings. In primary care, low-complexity visits consistently outnumbered all other telemedicine visit types, regardless of patient type. In contrast, in non–primary care, new patient visits generally involved more complex cases than low-complexity visits throughout the period. For existing patients, moderate-complexity visits gradually increased, surpassing low-complexity visits by 2021. These trends suggest a shift in non–primary care toward managing more complex cases via telemedicine for both new and existing patients, as specialists become more familiar with handling complex cases remotely. Emerging evidence from surgical specialties supports this shift, showing that telemedicine can effectively facilitate initial consultations with new patients, and it can be an effective way to plan complex interventions.²⁴ Similarly, in endocrinology and gynecology specialties, telemedicine has proven its effectiveness in managing complex conditions, improving access, and enhancing the patient experience.²⁵ The findings align with existing literature highlighting the substantial care needs of patients with multimorbid or complex conditions, which are often managed by specialists,^26,27 with similar trends emerging in telemedicine practices. Additionally, the increasing complexity of telemedicine visits in non–primary care settings likely contributes to the higher EHR-induced work-outside-work⁷ for specialists, as noted in recent studies.⁹ This shift also underscores the importance of ensuring that specialty providers are adequately prepared to deliver complex telemedicine care.

These findings should be interpreted with certain limitations in mind. The data are from a single health system, limiting generalizability, and exclude audio-only telemedicine visits. Additionally, we did not differentiate between patients new to the health system and those new to telemedicine. Future studies could inform how each of these factors influences telemedicine utilization and care delivery by controlling for returning telemedicine patients and comparing data from multiple health systems.

CONCLUSIONS

Telemedicine necessitates a shift in care delivery workflows, as it generally excludes clinical support staff, but can involve levels of care complexity that are already on par with those of in-person visits.^28,29 This study highlights an increasing trend in patient-care complexity, particularly for existing patients in non–primary care, underscoring the need for appropriate resource allocation to address the evolving demands amid work-outside-work concerns among providers. The observed E/M coding trends also suggest that primary care physicians tend to undercode telemedicine services, as noted in the literature,³⁰ which underscores the need to revisit coding policies to ensure equitable reimbursement and support across specialties. Addressing these challenges is essential for integrating telemedicine seamlessly into health care delivery. 

Author Affiliations: Department of Population Health, New York University Grossman School of Medicine (SM, DMM), New York, NY; Department of Technology Management and Innovation, New York University Tandon School of Engineering (SM, ON), New York, NY; Department of Management, New York University Leonard N. Stern School of Business (BMW), New York, NY; MCIT Department of Health Informatics, NYU Langone Health (DMM), New York, NY.

Source of Funding: This work was supported by National Science Foundation (NSF) grants (award nos. 1928614 and 2129076).

Author Disclosures: Drs Wiesenfeld, Mann, and Nov report receiving NSF grant 2129076 (Co-Development of Telehealth, Remote Patient Monitoring, and AI-based Tools for Inclusive Technology-Facilitated Healthcare Work of the Future) and NSF grant 1928614 (Future Expert Work in the Age of “Black Box,” Data Intensive, and Algorithmically Augmented Healthcare). Dr Mandal reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SM, BMW, DMM, ON); acquisition of data (SM, DMM); analysis and interpretation of data (SM, DMM); drafting of the manuscript (SM, BMW, ON); critical revision of the manuscript for important intellectual content (SM, BMW, DMM, ON); statistical analysis (SM); obtaining funding (BMW, DM, ON); and supervision (BMW, ON).

Address Correspondence to: Soumik Mandal, PhD, New York University, 180 Madison Ave, New York, NY 10016. Email: Soumik.mandal@nyulangone.org.

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