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Billing and Reimbursement

BillingThe relationship between telemedicine reimbursement and access to care is complex.

Telemedicine has the potential to improve access to care and reduce healthcare expenditures. Examples:
•    In the emergency setting where specialists may not be on site, virtual consultations can limit the need for transportation of patients to other facilities for care. Estimates predict that teleconsults can obviate the need for up to 850,000 transfers and save $537 million per year.
•    Specific to allergy, a pilot study of 50 patients utilizing telemedicine to evaluate patients for penicillin allergy demonstrated high patient satisfaction and potential savings of over $30,000 due to increased access to specialty allergy care and improved antibiotic stewardship.

However, inconsistency among payers and states in coverage for telehealth services may shift costs from payers to providers and patients, preventing adoption.
•    Cost of non-reimbursed care is a major barrier to telemedicine implementation and prevents many physicians and health systems from potentially offering telemedicine services to their patients. A 2019 report from telemedicine provider American Well revealed that the top concern of clinicians pertaining to telemedicine adoption is uncertainty about reimbursement.
•    When reimbursement is limited, patients are under-served by telemedicine services.

Parity in coverage and payment is not yet mandated, but was temporarily expanded by the emergence of the COVID-19 pandemic
•    Coverage parity = both in-person and telemedicine services are covered for the same indication
•    Payment parity = reimbursement for telemedicine services approximates that of the equivalent in-person E/M service.

Parity increases adoption of telemedicine.  
•    Almost 90% of both users and non-users (of telemedicine) said they would use telehealth if they were to be reimbursed.  
•    A 77.5% increase in telehealth adoption was noted after implementation of parity in Michigan.

References:
http://www.amdtelemedicine.com/telemedicine-resources/documents/ATATelemedicineResearchPaper_impact-on-healthcare-cost-and-quality_April2013.pdf
 
Mary L. Staicu, Anne Marie Holly, Kelly M. Conn, Allison Ramsey. The Use of Telemedicine for Penicillin Allergy Skin Testing. The Journal of Allergy and Clinical Immunology: In Practice, Volume 6, Issue 6, 2018, Pages 2033-2040

Telehealth Index: 2019 Physician survey. American Well 2019. https://static.americanwell.com/app/uploads/2019/04/American-Well-Telehealth-Index-2019-Physician-Survey.pdf Accessed May 15, 2020.

https://www.ajmc.com/newsroom/lack-of-reimbursement-barrier-to-telehealth-adoption

https://www.forbes.com/sites/quora/2018/07/31/what-are-the-latest-trends-in-telemedicine-in-2018/#7f61f19a6b9e
 
VARIABILITY IN REIMBURSEMENT RULES AMONG STATES CONTRIBUTES TO CONFUSION
No two insurers or states are alike in how they define or cover telehealth services.

•    Currently, 43 states and Washington, DC, have laws that govern private payer telehealth reimbursement policies.
•    All 50 states and Washington, DC, provide reimbursement for some form of live video in Medicaid fee-for service, with fewer states covering store-and-forward or remote physiologic monitoring.

Know if your site qualifies for billing a facility fee. Also, be familiar with the rules if the referring physician and the consulting physician are at the telemedicine visit at the same time. For example, the consulting physician would bill for the visit and the referring physician would bill a facility fee if the visit was conducted at the referring physician’s office.

Interactive 50 state map of telemedicine reimbursement policies
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00027460&_adf.ctrl-state=vwspk2moq_4&_afrLoop=363070704114502#!

https://jamanetwork.com/SsoTokenHandler.ashx?returnUrl=https%3a%2f%2fedhub.ama-assn.org%2fsteps-forward%2fmodule%2f2702689&instSigninUrl=&referralUrlKey=

CMS HAS MADE SWEEPING CHANGES IN TELEMEDICINE REIMBURSEMENT, DESIGNED TO IMPROVE ACCESS TO CARE
CMS has historically placed strict limits on criteria for telemedicine reimbursement:
•    Rural location of patient
•    Originating site must be a health center
•    Service must be synchronous live video

https://data.hrsa.gov/tools/medicare/telehealth

However, these strict limits on telehealth services may have contributed to thwarting innovation and increased adoption of new technologies, thereby limiting access to care. Therefore, CMS has pivoted to enhanced coverage of telemedicine over the last few years.    
   
Changes in 2019:
•    Brief communication technology-based service (e.g., virtual check-in, HCPCS code G2012)
•    Remote evaluation of pre-recorded patient information (HCPCS code G2010)
•    Interprofessional internet consultation (CPT codes 99452, 99451, 99446, 99447, 99448, and 99449)

Changes in 2020:
•    Expanded access for Medicare Advantage enrollees
•    Part of government funded “basic benefits” instead of supplemental services
•    Available to enrollees in both urban and rural areas
•    Removed requirement to go to a health care facility as the originating site of service, instead, patient can receive telemedicine services from home

https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf

https://www.cchpca.org/sites/default/files/2018-11/FINAL%20PFS%20CY%202019%20COMBINED_0.pdf

https://www.cchpca.org/sites/default/files/2018-11/Finalized%20PFS%202019%20Infographic%20Final%20V.%204.pdf

https://www.cms.gov/newsroom/press-releases/cms-proposes-modernize-medicare-advantage-expand-telehealth-access-patients
 
MEDICAID HAS GENERALLY HAD BROADER COVERAGE FOR TELEMEDICINE SERVICES THAN MEDICARE, BUT IT VARIES FROM STATE TO STATE
The current state of Medicaid reimbursement:
•    Fifty states and Washington DC provide reimbursement for some form of live video in Medicaid fee-for-service
•    Eighteen state Medicaid programs reimburse for store and forward delivered services, and an additional four states have laws requiring such reimbursement in the absence of an associated Medicaid policy. States that only provide reimbursement for teleradiology were not counted in this number.
•    Twenty-one states reimburse for remote patient monitoring (RPM)
•    Ten states reimburse for all three
•    Thirty-two states provide a transmission and/or facility fee

https://www.cchpca.org/sites/default/files/2020-10/CCHP%2050%20STATE%20REPORT%20FALL%202020%20FINAL.pdf
 
COMMERCIAL INSURERS ARE FOCUSED ON COST-SAVINGS AND OPERATIONAL EFFICIENCY
Fourty-three states and Washington, DC, have laws that govern private payer reimbursement of telehealth. As of January 1, 2021, only seven states require reimbursement be equal to in-person coverage. Most jurisdictions only require parity in covered services, not reimbursement amount, and depending on how the law is written, may provide payers with the ability to limit the amount of that coverage. Not all laws mandate reimbursement.

https://mhealthintelligence.com/news/study-states-private-payer-laws-are-harming-telehealth-growth

https://www.cchpca.org/sites/default/files/2020-10/CCHP%2050%20STATE%20REPORT%20FALL%202020%20FINAL.pdf

SELF-PAYMENT REMAINS AN OPTION FOR THOSE PATIENTS WITHOUT INSURANCE COVERAGE FOR TELEMEDICINE SERVICES
Although not ideal, many patients would prefer to pay a convenience fee to access non-covered telemedicine services. Costs vary significantly, but tend to be lower than the charges for an in-person evaluation.

IN 2020, COVID-19 USHERED IN A DRAMATIC EXPANSION OF TELEMEDICINE
In 2020, governments and payers rapidly expanded telemedicine coverage and payment in an effort to ensure public access to healthcare in the midst of an infectious pandemic. As part of the expansion of telehealth services during the COVID-19 public health emergency (PHE), a number of remote services which were previously non-covered by payers gained temporary coverage. In addition, reimbursing for telemedicine visits at the same rate as in-person visits has been instrumental in encouraging increased telemedicine adoption among providers during the PHE.

For the most part, states continue to keep their temporary telehealth COVID-19 emergency policies siloed from their permanent telehealth policies. This gives jurisdictions flexibility to revert to their permanent policies once the PHE comes to an end. However, extensive lobbying is occurring to make at least some of the COVID-19-associated telehealth reimbursement expansion permanent.

For an updated list of state-specific actions related to the expansion of telehealth during the COVID-19 pandemic, see the following link for the Center for Connected Health Policy:
https://www.cchpca.org/covid-19-related-state-actions

A list of payer-specific telehealth policies is available here:
Aetna: https://www.aetna.com/health-care-professionals/covid-faq/telemedicine.html.html
Cigna: https://static.cigna.com/assets/chcp/resourceLibrary/medicalResourcesList/medicalDoingBusinessWithCigna/medicalDbwCVirtualCare.html
Humana: https://dctm.humana.com/Mentor/Web/v.aspx?chronicleID=0900092982d3d342&searchID=1d15c5b1-2d49-494e-9824-46631dddcce3&dl=1
United Healthcare: https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19/covid19-telehealth-services.html

CODES

In most cases, coding for telemedicine services is done using the corresponding codes for an in-person E/M visit, but with specific modifier(s) and place of service designation to clearly identify the service as telehealth.

Code: Telemedicine coding can be based on either time or medical decision-making. As of 2021, time-based coding includes the total time spent on the encounter on the day of service, rather than only face-to-face time.
Telemedicine Coding
https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx

Modifier: For both private payers and CMS, the -95 modifier (synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) should be appended to E/M codes 99202-99215. (Medicare used to require modifier GT for synchronous visits and GQ for asynchronous visits, but this was eliminated as of January 2018.)

Place of Service: Historically, the place of service has been designated as “02” on the bill to signify a telemedicine service. However, this changed for most payers in 2020 when PHE-related telehealth expansion ushered in payment parity for many telehealth services. Updated guidance for Medicare and most commercial payers is that for the duration of the COVID-19 PHE, telemedicine services should be billed using the place of service that would have been used if the service was provided in person, along with modifier -95. For outpatient allergy practices, this is place of service “11.” Doing so will ensure that the claim is paid at parity with non-facility face-to-face rates for Medicare and most commercial payers.

Bajowala SS, Milosch J, Bansal C. Telemedicine Pays: Billing and Coding Update. Curr Allergy Asthma Rep. 2020;20(10):60. Published 2020 Jul 27. doi:10.1007/s11882-020-00956-y

Due to this variability, it is best to check with each individual payor to determine how best to code telehealth visits, and to understand when COVID-19 specific billing and coding guidelines will expire.

CMS has provided the following pamphlet to provide coding guidance for telehealth providers:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Examples of Telemedicine Coding
Online synchronous video visit with an established patient to evaluate a new onset pruritic rash. Diagnosed as atopic dermatitis and prescribed emollients and triamcinolone 0.1% ointment. 20 minute visit.
 
Option 1 (Private Insurance):
CPT code: 99213
Modifier: 95 (may be optional)
Place of service: 11 (required)

Option 2 (Medicare):
CPT: 99213
Modifier: 95
Place of service: 11
Originating site (physical location of patient) also bills: CPT Q3014 (optional)
 
Online synchronous video visit with a new patient with multiple food allergies who wishes to obtain a second opinion about dietary management and review emergency action plan. 35 minute visit.
 
Option 1 (Private Insurance):
CPT: 99203
Modifier: 95 (may be optional)
Place of service: 11 (required)
 
Option 2 (Medicare):
CPT: 99203
Modifier: 95
Place of service: 11 (required)
Originating site (physical location of patient) also bills: CPT Q3014 (optional)

These links are for research only. They are not endorsed by the American Academy of Allergy, Asthma & Immunology (AAAAI).