Health care services have traditionally been conducted through face-to-face exchange of information between provider and patient, but advanced technology has changed how, when, and where patient care can be delivered. For example, many patients prefer to communicate with their provider online, patient portals allow patients immediate access to their medical information, and providers can collaborate about patients via telemedicine, which has become a cost-effective alternative to face-to-face patient services.
The term “telemedicine” refers to the remote diagnosis and treatment of patients by means of telecommunications technology. For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician/practitioner and the Medicare beneficiary. Commercial payers are beginning to follow Medicare payment guidelines and are also creating innovative ways of paying for health care services outside the scope of a traditional face-to-face encounter. You will need to review your payer contracts for the specific payment policies related to telehealth services.
To ensure Medicare coverage, however, a telehealth service must be:
- On the list of covered Medicare telehealth services (see below).
- Furnished via an interactive telecommunications system.
- Furnished by a physician or other authorized practitioner.
- Furnished to an eligible telehealth individual.
- Furnished to an individual receiving the service in a telehealth originating site and participating in the telehealth visit.
When all of the above conditions are met, Medicare pays a facility fee to the originating site (the location of the Medicare beneficiary at the time the service is being furnished) and a separate payment to the distant site practitioner (at the site where the physician or practitioner providing the professional service is located at the time the service is provided).
Medicare beneficiaries are eligible for telehealth services only if the originating site is located in a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract or in a county outside of a MSA. Entities that participate in a federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of the Department of Health and Human Services qualify as originating sites regardless of geographic location. Each calendar year, the eligibility of an originating site is established based on the status of the geographic area as of December 31 of the prior calendar year; eligibility continues for the full calendar year.
Medicare eligible telehealth services include (see the complete list at the link at the end of this article):
- Office or other outpatient services.
- Outpatient mental health services.
- Health and behavior assessment/intervention.
- Outpatient substance abuse services.
- Transitional care management services:
- CPT 99495 & 99496
- Complex chronic care services for patients with multiple chronic conditions under certain conditions:
- CPT 99487 & 99489
- Prolonged service inpatient procedures:
- CPT 99356 & 99357
- ESRD-related services for home dialysis:
- CPT 90963 – 90966
The above services may be billed (subject to state law) if they are performed at the “distant site” by a physician, nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical nurse specialist (CNS), clinical psychologist (CP), clinical social worker (CSW), CRNA, or a registered dietician or nutritional professional.
The opportunity for telemedicine services is growing rapidly, faster than reimbursement at this point. For example, some new innovative ways that telemedicine is being used include remote patient monitoring for population management and remote intensive care monitoring through eICU programs (e.g., early warning signs of sepsis). With the right tools and technology, many other opportunities will be created for remote patient care services.
There are many benefits to providing services via telemedicine. It mitigates access barriers related to distance, increases efficiency of tertiary centers, keeps health care dollars in local communities, and likely reduces health care costs. In addition, it can improve overall quality of care by:
- Allowing patients to be seen more quickly and in a location they can get to, particularly for specialty care.
- Improving communication among providers.
- Educating both the consultant and primary care provider.
- Increasing satisfaction for the patient and the provider.
- Increasing local perception of quality of care.
Coding and Documentation for Telehealth Services
The originating site (where the patient is) should report the HCPCS code Q3014 (telehealth originating site facility fee) under type of service 9 (other items or services) in the place of service 11 (office). This facility fee is a separately billable Part B service. For the professional service (at the distant site), the CPT code for the specific service provided would be reported, appended by the GT modifier (via interactive audio and video telecommunications system).
Strategies for Successful Implementation
In order to ensure an efficient implementation in your organization, be sure to:
- Obtain institutional and administrative support for telemedicine services.
- Integrate with existing infrastructure for documentation/coding/billing processes.
- Start with low hanging fruit services where opportunity exists to address specific patient needs that are not currently being met.
- Identify the outcomes you wish to measure and develop a system to do so.
- Develop (and share) quality metrics, demonstrating the “win-win” for both sides.
- Partner with policymakers and support further enhancements to reimbursement for telemedicine services.
For more information, please refer to the most recent MedLearn Matters article at: *https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
The 2016 list of eligible telehealth services can be found at:
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