Basic Technical Requirements of a Telemedicine Consult:
- Synchronous telemedicine visits should utilize a high-resolution video camera coupled with broadband technologies.
- Connection speed of at least 384 kbps in both the downlink and uplink directions is recommended.
- Videoconferencing systems must use HIPAA-compliant encryption software. HIPAA requires 128-bit encryption and password-level authentication.
The American Medical Association (AMA) has prepared information on telemedicine with "how-to" guides to start a telemedicine program in your practice.
Payment for Telemedicine:
Medicare: The Centers for Medicare & Medicaid (CMS) reimburses for only a limited set of services that may subsequently be reported as telehealth services. When a service is provided and has been designated by the CMS as payable under Part B of the Medicare program, the modifier GT must be appended to the code on the claim. GT indicates to the claims processors that the service was provided “via interactive audio and video telecommunications systems” and the claim is paid according to Medicare’s established guidelines and payment policies.
In addition to the use of the GT modifier on the claim, there are other requirements for the provision and subsequent reimbursement for telehealth services under the Medicare program. The telehealth service must be provided to the beneficiary located at a Medicare approved, originating site. An originating site is the location of the beneficiary at the time the telehealth service is rendered and for Medicare reimbursement purposes must be located in a rural location as defined by the following two geographical conditions:
- A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or
- A county outside of an MSA.
The originating site (location of the beneficiary) must then be in a medical facility such as:
- Physician or other practitioner office
- Hospital
- Critical Access Hospital (CAH)
- Rural Health Clinic
- Federally Qualified Health Center
- Hospital-based or CAH-based Renal Dialysis Center (including satellites
- Skilled Nursing Facility
- Community Mental Health Center
The beneficiary’s home is not an approved originating site for the provision of telehealth services.
Medicare Telehealth Approved Codes of Interest to Infectious Disease Physicians,
- Office or other outpatient visits: CPT codes 99201-99215
- Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days: CPT codes 99231-99233
- Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days: CPT codes 99307-99310
- Telehealth Pharmacologic Management: HCPCS code G0459
- Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour: CPT code 99354
- Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes: CPT code 99355
- Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient evaluation and management service): CPT code 99356
- Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service): CPT code 99357
List of all Medicare approved telehealth services may be found on the CMS website: Medicare List of Telehealth Services
Medicare Payment for Telehealth Services: Changes on the Horizon:
Recently introduced Senate legislation, if passed, would eliminate or lessen the restrictions that are currently in place for Medicare reimbursement for telehealth services. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act would provide for additional approved originating sites including telestroke evaluation and management sites, Native American health service facilities as well as some dialysis facilities.
The bill would also allow the use of telehealth and remote patient monitoring for those providers that would participate in alternative payment models, patient-centered medical homes, and payment bundling programs, without the current regulatory restrictions to telehealth services. In essence, the bill would remove many of the requirements such as originating site requirements and types of locations that are permissible as originating geographical locations. A brief description of the bill’s provisions and the list of endorsers can be found here: CONNECT for Health Act
CMS Waives Certain Restrictions for Telehealth Services Under New Payment Model
Another change to telehealth services is the recently implemented Medicare Comprehensive Care Joint Replacement Payment Model. While it may seem that this Medicare payment model has very little to do with telehealth, this model in fact has waived the requirements of the originating site location and the geographic location of the patient. Under this payment model, patients may be located in their homes and may be located in any geographic location and still be allowed to receive a telehealth service. All other requirements for the provision of telehealth services remain as is. An educational article is available here: CMS CCJR Payment Model and Telehealth Services
Medicaid:
While there are restrictions on reimbursement for telehealth services under the Medicare program, many states provide reimbursement for telehealth services under state Medicaid programs. States have discretion as to how telehealth services will be reimbursed and therefore many states currently provide separate payment for telehealth services under state Medicaid programs. Presently, 49 states and the District of Columbia provide some coverage for telehealth services, while nine states including Alaska, Arizona, California, Illinois, Minnesota, New Mexico, Oklahoma and Virginia reimburse providers for the provision of store and forward services. In addition, there are 17 states that have some form of reimbursement for remote patient monitoring. Providers should check with their state Medicaid agencies to understand the requirements and restrictions of Medicaid payments in their respective state.
Commercial/Private Payers:
Commercial insurance companies may set their own policies regarding coverage and reimbursement for telehealth services, however there are some states that mandate coverage for telehealth services in order to do business within that state. At this time, there are 32 states and the District of Columbia that have telehealth private payer laws. Providers should check with each insurance carrier to determine what types of telehealth services are covered.
The National Conference of State Legislatures recently released a white paper detailing trends in telehealth policies (including the states the cover telehealth services) as well as outlining the considerations that providers must think about before implementing telehealth policies. The paper can be accessed here: Telehealth Policy Trends and Considerations