The terms coverage and reimbursement are often used interchangeably, in large part because both are often relatively comprehensive, consistent, and widespread. For telehealth, in contrast, Medicare coverage is relatively restrictive, and reimbursement has some oddities. This situation is largely because Medicare telehealth provisions reflect a snapshot of late 1990s best-use cases, when they were last significantly updated. There have been major increases, nevertheless, in the use of Medicare's essentially static coverage as reported recently by the Medicare Payment Advisory Commission 1 and shown in Figure 23-1.
Utilization of Medicare telehealth visits per 1,000 Part B beneficiaries, 2006 to 2014. (Source: MedPAC analysis of Medicare carrier file claims data. From Medicare Payment Advisory Commission. June 2016 Report to the Congress: Medicare and the Health Care Delivery System; 2016:240.)
The core provision in Medicare law about telehealth is Social Security Act section 1834(m)—also known as 42 U.S.C. 1395m(m)—and in regulation is 42 CFR 410.78 and 414.65.
The U.S. Centers for Medicare and Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient via an interactive audio and video telecommunications system. 2
Unfortunately, the hallmark of Medicare telehealth is how restrictive its coverage essentially is:
No coverage for video-based services for about 80% of beneficiaries in metropolitan areas
No coverage for video-based services to a beneficiary at home or locations other than a designated type of health establishment
No coverage for some types of providers otherwise covered for in-person services, such as rehabilitation therapists
No coverage of remote biometric monitoring of a beneficiary with one or more chronic conditions
No coverage for “asynchronous” interpretations of visual medical information, such as an annual retinal scan of a beneficiary with diabetes or dermatological images
Coverage is limited to Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure codes specified by the CMS and updated annually
On the positive side, CMS defines many of the most common uses of distant physicians as “physician services,” not as telehealth. In part, the CMS definition includes services when a physician “is able to visualize some aspect of the patient's condition without the interposition of a third person's judgment.” This is important for most of the remote interpretations of radiologists and clinical pathologists. This distinction is followed by most other payors.
These remote services are not considered “telehealth” or “telemedicine” by CMS. Rather, they are considered the same as services delivered in-person and are to be coded and will be paid in the same way. There are no geographic or facility limitations on these services.
Special CPT codes are used for the remote assessment of pacemakers as well as the collection and assessment of data from cardiac event recorders.
For telehealth coverage, a beneficiary must be in a “rural” area and at a designated health facility (a so-called originating site). A rural area is basically a county outside of a standard metropolitan statistical area (MSA) or in a medically underserved census tract in the low-population-density fringes of a metropolitan area.
The originating site must be one of the following:
The office of a physician or practitioner
A hospital, including a critical access hospital
A rural health clinic
A federally qualified health center
A skilled nursing facility
A hospital-based dialysis center
A community mental health center
It is important to note that for coverage purposes, the beneficiary may not be at their home or other common nonhealth locations.
There is no limitation on the location of the health professional delivering the medical service (the so-called distant site).
Medicare telehealth coverage is further limited by provider and procedure.
The following health professionals may claim reimbursement for some telehealth services:
The major health professional categories otherwise covered for in-person services but not telehealth services are rehabilitation therapists (physical, occupational, speech and hearing, and respiratory).
Medicare law has been a long-standing role model for payors in not requiring a “telepresenter” (a second provider) to be with the patient. (Having a telepresenter is left to the professional judgement of the remote treating provider.)
Medicare is one of the shrinking number of payors who limits coverage by procedure code (the CPT codes established by the American Medical Association of the HCPCS codes established by CMS). For 2016, Medicare covers 82 CPT or HCPCS codes for telehealth.
The use of telehealth is concentrated in a few codes. The Medicare Payment Advisory Commission recently reported, “The most common types of telehealth services in 2014 were evaluation and management (E&M) or other outpatient visits and psychiatric visits (individual psychotherapy and psychiatric diagnostic interview examinations).” 3 More detailed MedPAC analysis of utilization by type of service is shown in Table 23-1.
Frequency of Telehealth Visits at Distant Sites by Service Type, 2014
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Frequency of Telehealth Visits at Distant Sites by Service Type, 2014
|Type of service ||Number of visits ||Share of visits |
|Evaluation and management visits ||115,430 ||66.0% |
|Individual psychotherapy ||19,914 ||11.4 |
|Psychiatric diagnostic interview examination ||12,952 ||7.4 |
|Follow-up inpatient telehealth consultations ||7,642 ||4.4 |
|Telehealth consultations, emergency department or initial outpatient ||7,626 ||4.4 |
|Subsequent hospital care services ||4,902 ||2.8 |
|Subsequent nursing care services ||3,341 ||1.9 |
|Pharmacological management ||1,766 ||1.0 |
|End-stage renal disease–related services ||1,078 ||0.6 |
|Other ||347 ||0.2 |
|Total ||174,998 ||100.0 |
Medicare also covers two types of cardiac monitoring:
Transtelephonic monitoring of cardiac pacemakers (CPT code 93293) is for identifying early signs of possible pacemaker failure, thus reducing the number of sudden pacemaker failures requiring emergency replacement.
Ambulatory electrocardiography (AECG) refers to services rendered in an outpatient setting over a specified period, generally while a patient is engaged in daily activities. AECG devices are intended to provide the physician with documented episodes of arrhythmia, which may not be detected using a standard ECG. AECG is most typically used to evaluate symptoms that may correlate with intermittent cardiac arrhythmias and/or myocardial ischemia. The AECG are both patient/event-activated and continuous recorders and use CPT codes 93271 and 93012. These services are performed by independent diagnostic testing facilities (IDTFs).
National and Local Coverage Determinations
In addition, national and local coverage determinations may alter or expand the services that are eligible for reimbursement. Certain national coverage determinations by CMS have further expanded and explained coverage, such as the cardiac monitoring just discussed. Local intermediaries are allowed to make their own local determinations regarding covered services which may further expand coverage. For example, the Arkansas Blue Cross Blue Shield – Rhode Island intermediary has a ruling titled “Transtelephonic Spirometry,” where patient-initiated spirometric recordings per 30-day period of time, including reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration, and physician review and interpretation, are covered.
Claims for professional consultations, office visits, individual psychotherapy, and pharmacologic management provided via a telecommunications system are submitted to the carrier that processes claims for the performing physician/practitioner’s service area. Physicians/practitioners submit the appropriate CPT procedure code for covered professional telehealth services along with the 95 (formerly GT) modifier (“via interactive audio and video telecommunications system”). By coding and billing the 95 modifier with a covered telehealth procedure code, the distant site physician/practitioner certifies that the beneficiary was present at an eligible originating site when the telehealth service was furnished.
Physicians and practitioners at the distant site bill their local Medicare carrier for covered telehealth services, for example, 99245 GT. CMS has also established that the “place of service” code to be used for all telehealth services is now “02.” Of more consequence for telehealth providers, CMS recently decided to pay all using the “practice expense” factors for facilities, which are lower or equal to the factors for non-facility providers.
Physicians’ and practitioners’ offices serving as a telehealth originating site bill their local Medicare carrier for the originating site facility fee. To claim an originating site fee, physicians/practitioners bill HCPCS code “Q3014, telehealth originating site facility fee”—short description “telehealth facility fee.” The type of service for the telehealth originating site facility fee is “9, other items and services.” For carrier-processed claims, the “office” place of service (code 11) is the only payable setting for code Q3014. There is no participation payment differential for code Q3014, and it is not priced off of the Medicare Physician Fee Schedule Database file. Deductible and coinsurance rules apply to Q3014. By submitting HCPCS code “Q3014,” the biller certifies that the originating site is located in either a rural health professional shortage area (HPSA) or a non-MSA county.