Telemedicine Reimbursement
Synopsis
Historically, HCFA has denied
payment for telemedicine consultations (referred to as
teleconsultations) because they lacked personal face-to-face contact
between the provider and the patient. Though vastly different and
much richer in content, teleconsultations were equated with
telephone inquiries. However, HCFA has accepted reimbursement for
certain diagnostic telemedicine applications for several years on
the assumption that these diagnostic services do not normally
require face-to-face contact. These diagnostic services include
teleradiology, telepathology (with some exceptions) and
telecardiography. The American College of Radiology in cooperation
with the National Electrical Manufacturers Association formed a
joint committee and developed a set of standards for transferring
images and associated information devices manufactured by various
vendors, which were first issued in 1985 (1). These standards
specified a hardware interface, a minimum set of software commands,
and a consistent set of data formats. The standards have evolved ,
now designated Digital Imaging and Communications in Medicine (2).
Standard CPT codes can be used in billing for these services.
Reimbursement for teleconsultations has been provided under special
waivers secured by HCFA for specific research/demonstration projects
and under other federally supported grants and contracts. The US
Congress has moved toward supporting telemedicine and in providing
reimbursement for teleconsultations under specified conditions. The
first such legislation was introduced under the Balanced Budget Act
of 1997 ( Public Law 105-33). Under Subtitle C, Section 4206
stipulated that Part B payments would be made for professional
consultation via telecommunications systems with a health care
provider furnishing a service for which Medicare payment would be
made for a beneficiary residing in a rural county that was
designated as a Health Professional Shortage Area (HPSA). It also
stipulated that teleconsultations were to be limited to synchronous
(real time) transmission and the approved fees must be shared
between referring and consulting providers.
New legislation under the title, the "Telehealth Improvement and
Modernization Act of 2000", liberalized conditions for reimbursement
and eliminated the fee-sharing arrangement. The revised payment
methodology stipulated that the "physician or practitioner at a
distant site that provides an item or service…(shall) receive an
amount equal to the amount that such physician or provider would
have been paid had the item or service been provided without the use
of telecommunications system. Section 3 expanded the definition of a
telepresenter to include "any health care practitioner that is
acting on instructions from the referring physician or practitioner
may present the beneficiary or the provision of items and services."
In addition, under these conditions, the referring physician and the
practitioner shall not receive any reimbursement for such
presentation other than the payment that the referring physician
receives…". Residential eligibility of beneficiaries was also
expanded. Accordingly, an "eligible telehealth beneficiary" could
reside in (a) an area designated as a HPSA; (b) a county that is not
included in a Metropolitan Statistical Area; (c) an inner-city area
that is medically underserved; or (d) an area in which there is a
Federal telemedicine demonstration program. Finally, the Telehealth
Improvement Act amended Section 4206(a) of the Balanced Budget Act
by permitting reimbursement for the use of "store and forward
technologies" in the case of any Federal telemedicine demonstration
program in Alaska or Hawaii.
(1)
ACR Standards
(2)
Digital Imaging and Communications in Medicine (DICOM):
Summary of the New Legislation Regarding Reimbursement for
Teleconsultations and Home Health Care
The new legislation mandates
payment by HCFA (Medicare, Medicaid and SCHIP) for telemedicine
assisted clinical care rendered in specific settings. Whereas this
legislation applies to public programs only, private third party
payers, such as Blue Cross-Blue Shield in various States and others,
tend to follow HCFA's example and precedent, often with stipulations
of their own. The effective date of the new legislation is October
1, 2001.
The legislation focuses on reimbursement for telemedicine/telehealth
services rendered to rural sites. It includes a provider
reimbursement at the same rate as would normally be billed in a face
to face encounter for a particular service. It contains a provision
for a facility fee of $20.00 to be billed by the site where the
patient is located.
Specific site conditions for reimbursement:
Remote site is (site where patient
is located):
Either a HPSA (Health
professional shortage area)
Or county not included in
a Metropolitan Statistical Area
Or entity that participates in a
Federal telemedicine demonstration project approved/receives
funding from the Secretary of HHS as of 12/31/00
AND
Is the office of a physician or
practitioner
A critical access hospital
A rural health clinic
A federally qualified health
center
A hospital
Eligible telemedicine/telehealth services
include:
- Professional consultations
- Office visits
- Office psychiatry services
The secretary of HHS is mandated to
provide a process to update services (additions and deletions) on an
annual basis. HCPCS codes include: 99241-99275, 99201-99215,
90804-90809 and 90862.
Eligible remote site "providers":
(Remote site presenters)
- Do NOT have to be physicians or
practitioners, unless determined to be medically necessary by the
REMOTE site referring physician or practitioner.
Reimbursement for Home Health
Telemedicine Services (technically referred to as telehomecare):
Legislation clarifies that home
health agencies may use the prospective payment system (PPS) for
home health services, which may include telemedicine services so
long as
- These services do not substitute
for all in-person home health services as ordered and are part of
a care plan certified by a physician. In other words, the
physician responsible for creating the home health care plan must
contain a minimum in person visits (if applicable), which can be
supplemented with telemedicine assisted visits, as warranted, and
documenting these as the official care plan for a given patient.
Other
important legislation:
Interim Arrangements
for Securing Reimbursement
Currently,
reimbursement for telemedicine/telehealth services can be secured
under three options. Users are encouraged to discuss these options
with the TRC to ensure compliance with regulations and avoid
disappointment.
1. Contractual
Agreements
Currently, several clinical entities at the UMHS provide services in
off-site settings. Arrangements for these services are typically
made through the contracting office. Standard contractual
agreements have been developed for telemedicine services. The TRC
staff can assist with the development of these kinds of arrangements.
There are
important issues to be taken into account in negotiating such
contractual agreements as they pertain to telemedicine clinical
services. These include the capital cost of telecommunication
infrastructure and variable cost of line charges and equipment
maintenance that will be necessary to provide the service. Early
involvement of TRC staff can assist in the development process
to insure adequate reimbursement for the cost of telemedicine service
delivery.
2. Grant
Funding
Currently, some UMHS clinical telemedicine services are being
reimbursed from a federally funded grant. The Telemedicine Resource
Center is ready to assist in securing extramural funding from
federal and other sources. It can help with review of innovative
concepts and new initiatives, identification of potential sources of
funding, and proposal preparation. More specifically, the TRC staff
can answer questions regarding project development, overview and
budgets for telemedicine equipment, line charges and personnel.
UMHS faculty and staff contemplating projects in this area are
encouraged to discuss their plans with the TRC staff during initial
stages of proposal development for grant applications.
3. Direct
Billing
As noted above, direct billing can be made for diagnostic services
as well as consultative services under specified conditions,
utilizing the appropriate codes noted above.
Effective Use of the
TRC to Secure Reimbursement
The Telemedicine
Resource Center staff will be available to answer questions
regarding clinical activities and reimbursement questions. Resources
for identification of HPSA's, Metropolitan Statistical Areas, and
existing clinical contracts will be utilized to assist faculty and
providers with regards to reimbursement options for
teleconsultations.
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