Clarifying issues for telehealth services

Beginning in January 2018, Medicare will pay for certain telehealth services for patients who are enrolled in Part B and live in a Health Professional Shortage Area or in a county that is not included in a metropolitan statistical area.

While there are still miles to go regarding implementation of telehealth services and payment, progress is being made.

There are some patients who cannot easily get to the physician's office. Reasons vary for the need for telehealth services. The office can be too far away, transportation may not be available, or the patient may be too ill to travel. Some rural areas do not have primary care physicians, and others do not have many, or any, subspecialists. Many private payers are beginning to see the value in telehealth and will reimburse services that follow their guidelines. Some large employers are covering telehealth so that employees do not have to miss several hours of work to go to see a doctor.

Beginning in January 2018, Medicare will pay for certain telehealth services that meet its criteria. It still restricts eligibility to certain geographic locations, beneficiaries, and sites. Patients who are eligible for telehealth services must be enrolled in Part B and must be in a rural Health Professional Shortage Area or in a county that is not included in a metropolitan statistical area. The patient must be at a qualified location (“telehealth originating site”) such as a rural health center, federally qualified health clinic, physician office, hospital, or other authorized center, and the service must be furnished by a physician or other authorized practitioner. The telehealth service must be provided through a real-time interactive telecommunications system, defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and clinician. Patients at their personal residence using their own equipment do not qualify at this time.

When all of these conditions are met, Medicare will pay a facility fee to the practitioner providing the service and the patient's local practitioner will be paid the normal fee for the service. Both practitioners should list the place of service (POS) as 02 on the claims. GT modifiers should no longer be used. (Federal demonstration programs in Alaska and Hawaii, however, will continue to use the GQ modifier.)

Some examples of telehealth services that Medicare now covers that would most likely be used in internal medicine practices, besides the outpatient evaluation and management codes, are as follows:

96160: Patient-focused health risk assessment;

96161: Caregiver health risk assessment;

99495: Transitional care management, within 14 days of discharge;

99496: Transitional care management, within 7 days of discharge;

99497: Advance care planning, first 30 minutes;

99498: Advance care planning, additional 30 minutes;

G0108: Diabetes management training, individual;

G0506: Comprehensive assessment and care planning, chronic care management (CCM) service (list separately from primary monthly CCM service).

In addition, Medicare will pay for CPT code 99091 (technology-assisted monitoring of patient conditions). 99091 can be billed once per patient during the same service period as CCM (CPT codes 99487, 99489, and 99490) and transitional care management (CPT codes 99495 and 99496). It should be noted that time counted toward the CCM codes generally refers to time spent by clinical staff furnishing care management services, while CPT code 99091 refers to practitioner time. CMS notes that time spent furnishing these services cannot be counted toward the required time for both codes (99091 plus either CCM or transitional care management) in a single month.

As for payment by payers other than Medicare, state rules vary on coverage requirements, reimbursement rates, and technology specifications. For instance, there may be caps or the telehealth rate may be less than the in-person encounter rate. It is important to keep this in mind when talking with payers about payment for telehealth services.

Physicians who wish to provide telehealth services should consider potential issues related to licensure. Physicians furnishing telehealth services must abide by the licensure rules of the state in which the patient is located (“place of service”). States have different licensing laws with regard to telehealth, and certain services, such as physician-to-physician consultation, may be considered exempt from these licensure laws. Most states require a full medical license in that state for physicians to “see” patients via telehealth. Some states may allow for licensure reciprocity with bordering states or may allow physicians to “see” patients in their state as long as their license is in good standing, they fill out the appropriate paperwork, and they pay an associated fee.

For example, “snowbirds” wintering in warmer climates than their own residence would not be eligible to be seen by their established physicians via telehealth unless the physicians are licensed in the place of service, the state offers some kind of licensure portability or reciprocity, and the requirements of the patients' payer are met. The patchwork of state laws on telehealth can be a deterrent for physicians wishing to incorporate telemedicine into their practices. The Federation of State Medical Boards' Interstate Medical Licensure Compact is an effort to expedite the process of obtaining multiple medical licenses and as a result increase the utilization of telehealth. To date, 29 medical and osteopathic boards in 22 states have adopted the compact.

To learn about the benefits and risks of telemedicine, see ACP's policy paper on telemedicine. For information about interstate medical licensure, go to the Interstate Medical Licensure Compact's website.