2019 was a landmark for telemedicine services - The Centers for Medicare & Medicaid Services started to reimburse healthcare providers for a broader range of telemedicine services. This post provides an overview of telehealth and telemedicine and updates regarding newly covered services.
Telehealth and Telemedicine
As telehealth and telemedicine continue to evolve, so do their definitions. Regulatory bodies and payers may have different definitions for these terms. Furthermore, these terms are often used interchangeably, which can cause confusion about what is included.
What is Telehealth?
The Health Resources Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.[1] For CMS, telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health.[2] CMS defines telehealth services as a set of services furnished to patients in specific geographical locations (e.g. rural areas) in which the provider uses an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient. These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.[2]
What is Telemedicine?
Overall, it is accepted that telemedicine relates specifically to remote clinical services, that is, to the practice of medicine using technology to deliver care at a distance.[3] Entities may however have specific definitions that differ among them, as illustrated below:
- According to the U.S. Federation of State Medical Boards: "Telemedicine means the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider." [4]
- According to the U.S. Office of the National Coordinator for Health Information Technology: "telemedicine refers specifically to interactive health communications with clinicians on both “ends” of the exchange." Examples include [1]:
- Video conference Grand Rounds
- Transmission of X-rays between radiologists
- A remote practitioner presenting a patient to a specialist for consultation
How is Telehealth different from Telemedicine?
There is general agreement that telehealth is different from telemedicine because it refers to a broader scope of remote healthcare services than telemedicine. While telemedicine refers specifically to remote clinical services, telehealth can refer to remote non-direct patient care services, in addition to clinical services.[1][3][5] Examples of remote non-direct patient care services include [1]:
- Provider training
- Administrative meetings
- Continuing medical education
It also includes medical devices that collect and transmit health information to help monitor or manage chronic conditions.[1] Examples of medical devices include:
- Smartphone apps
- Activity trackers
- Automated reminders
- Blood glucose monitors
As definitions may vary across organizations, when working with a specific organization it is advisable to understand and use the terms as they are defined that organization.[5]
What are the basic 4 Telehealth methods?
- Live videoconferencing: a two-way audiovisual link between a patient and a care provider
- Store-and-forward (asynchronous) videoconferencing: transmission of a recorded health history to a health practitioner, usually a specialist.
- Remote patient monitoring (RPM): the use of connected electronic tools to record personal health and medical data in one location for review by a provider in another location, usually at a different time.
- Mobile health (mHealth): health care and public health information provided through mobile devices. The information may include general educational information, targeted texts, and notifications about disease outbreaks.
Does Medicare reimburse Telehealth/ Telemedicine?
Up until 2018, Medicare reimbursed Telehealth services only if the beneficiary was presented from an originating site located in a
county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. [6] However, recognizing the limitation of these rules and the bigger demand for telemedicine in metropolitan areas, starting in 2019, Medicare implemented the following services [7]: Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)
- Practitioners are separately paid for the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. This will increase efficiency for practitioners and convenience for beneficiaries.
- WoundReference's Free TeleVisit Tool Video Chat Edition is the easiest real-time communication tool for this need.
Interprofessional internet consultation (CPT codes 99446, 99447, 99448, 99449, 99451, 99452)
The CPT codes below can only be billed by those practitioners that can independently bill Medicare for E/M services. Patient consent needs to be documented and will be responsible for the corresponding co-payment.
- CPT 99446: Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
- CPT 99447: Same as 99446, but 11-20 minutes of medical consultative discussion and review
- CPT 99448: Same as 99446, but 21-30 minutes of medical consultative discussion and review
- CPT 99449: Same as 99446, but 31 minutes or more of medical consultative discussion and review
- CPT 99451: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time
- CPT 99452: Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes
Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)
- Service of remote evaluation of recorded video and/or images submitted by an established patient will allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.
Chronic care remote physiologic monitoring (CPT codes 99453, 99454, and 99457)
- CPT 99453: “Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”
- CPT 99454: “Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”
- CPT 99457: “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
Telehealth for Opioid Recovery
- CMS is implementing a provision from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act to allow individuals treated of a substance use disorder or a co-occurring mental disorder at their home for services furnished after July 1, 2019.
Telehealth for end-stage renal disease (ESRD) receiving home dialysis and beneficiaries with acute stroke
Effective in 2019 as well:
- HCPCS codes G0513 and G0514 (Prolonged preventive service(s)): CMS to implement the requirements of the Bipartisan Budget Act of 2018 for telehealth services related to beneficiaries with end-stage renal disease (ESRD) receiving home dialysis and beneficiaries with acute stroke effective January 1, 2019.
Resources
Acknowledgements
We thank Julie Rhee ScM, for style editing
References
- Health IT Playbook - Section 5 Patient Engagement
- Telehealth Services - MLN Booklet
- Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
About the Authors
Elaine Horibe Song, MD, PhD, MBA
Dr. Song is a Co-Founder and Chief Executive Officer of WoundReference, Inc., a clinical and reimbursement decision support & telemedicine platform for wound care and hyperbaric clinicians. With a medical, science and business background, Dr. Song previously served as medical director for a regenerative medicine-focused biotech company in California, and for a Joint Commission International-accredited hospital network. Dr. Song also served as a management consultant for Kaiser Permanente, practiced as a plastic surgeon in private practice and academia, and conducted bench and clinical research in wound healing, microsurgery and transplant immunology. Dr. Song holds a position as Affiliate Professor, Division of Plastic Surgery, Federal University of Sao Paulo, and is a volunteer, Committee Chair of the Association for the Advancement of Wound Care. She has authored more than 100 scientific publications, book chapters, software registrations and patents.
