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Billing and Reimbursement

The relationship between telemedicine reimbursement and access to care is complex.Billing

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 payors and states in coverage for telehealth services may shift costs from payors to providers and patients, preventing adoption.

  • Opportunity cost of non-reimbursed care is a major barrier to telemedicine implementation and prevents many physicians and health systems from potentially valuable offering telemedicine services to their patients.
  • When reimbursement is limited, patients are under-served by telemedicine services.


Parity in coverage and payment is not yet mandated, but is expected to become the norm.

  • 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.  
  • 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
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, thirty-nine states and DC have laws that govern private payer telehealth reimbursement policies.
  • Forty-nine 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.

References:
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 is making 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://www.medicare.gov/coverage/telehealth
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.    
   
New Changes in 2019 (announced 10/26/18):

  • Brief communication technology-based service (eg, 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)

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
 
Proposed for 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
  • Will remove requirement to go to a health care facility as the originating site of service. Instead, patient can receive telemedicine services from home.

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:

  • 49 states and Washington DC provide reimbursement for some form of live video in Medicaid fee-for-service
  • 15 states reimburse for store and forward delivered services. States that only provide reimbursement for teleradiology were not counted in this number.
  • 20 states reimburse for remote patient monitoring (RPM)
  • 9 states reimburse for all three
  • 32 states provide a transmission and/or facility fee

https://www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies?jurisdiction=All&category=128&topic=1
https://www.cchpca.org/sites/default/files/2018-10/CCHP_50_State_Report_Fall_2018.pdf

 

Commercial Insurers are focused on cost-savings and operational efficiency

39 jurisdictions have laws that govern private payer reimbursement of telehealth. Some laws require reimbursement be equal to in-person coverage, however most only require parity in covered services, not reimbursement amount, and depending on how the law is written, may provide payors 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
 

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.
 

Codes

In many cases, coding for telemedicine services is done using the corresponding codes for an in-person E/M visit, but with the -95 modifier (synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) appended. Place of service should be designated as “02”. Some private payers permit telemedicine visits for new patients, but not with the standard new patient CPT codes. Instead, they require billing with code 99499 (Unlisted evaluation and management code) with place of service “02”. This may be associated with lower reimbursement than an in-person new patient visit. Medicare used to require modifier GT for synchronous visits and GQ for asynchronous visits, but this has been eliminated as of January 2018. Instead, the place of service code should also be designated as “02”. Alternatively, the CPT code 99444 or 98969 can be utilized to designate an online evaluation. In this case, no modifier would be necessary, but place of service should still be designated as “02”.

Due to this variability, it is best to check with each individual payor to determine how best to code telehealth visits.

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

Here is an example of a BlueCross Telemedicine reimbursement Policy:
https://www.bluecrossnc.com/sites/default/files/document/attachment/services/public/pdfs/medicalpolicy/telehealth.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. 15 minute visit, with over 50% time spent in counseling/coordination of care.
 
Option 1 (Private Insurance): Bill based on time
CPT code: 99213
Modifier: 95 (may be optional)
Place of service: 02 (required)
 
Option 2 (Private Insurance): Bill using online E/M codes
CPT: 99422 (only for established patients)
Place of service: 02 (required)

Option 3 (Medicare):
CPT: 99213
Place of service: 02
Originating site (physical location of patient) also bills: CPT Q3014
 
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, with over 50% time spent in counseling and coordination of care.
 
Option 1 (Private Insurance): Bill based on time
CPT: 99203
Modifier: 95 (may be optional)
Place of service: 02 (required)
 
Option 2 (Private Insurance): Bill using unlisted E/M code
CPT: 99499
Modifier: 95 (may be optional)
Place of service: 02 (required)
 
Option 3 (Medicare):
CPT: 99203
Place of service: 02 (required)
Originating site (physical location of patient) also bills: CPT Q3014

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

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