Unfortunately, the relatively rapid expansion of remotely provided clinical services from non-reimbursed "novelty/niche/research" items to more mainstream (and even reimbursed) services, has resulted in some current definition inconsistencies among different coding/payer methodologies (and sometimes even within a single payer).  The following definitions rely heavily on Medicare's policies/procedures.   Private payers may have different codes, definitions and requirements for reporting these services.

Telehealth (or Telemonitoring) is “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.”  Telehealth is a broad term and can refer to clinical and non-clinical services involving medical education, administration, and research.  Telehealth includes technologies such as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit data for monitoring and interpretation.  For example, physicians use email to communicate with patients, order drug prescriptions and provide other health services.

Telemedicine is more narrowly defined.  Per CMS, “Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.  This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”  This is referred to as an “Interactive” system.

Some technologies used in the broader category of Telehealth do not meet the definition of Telemedicine. These are referred to as “Asynchronous, or store and forward, applications”, and include the use of a camera (e.g., audio clips, video clips, still images) to record (store) an image that is transmitted (forwarded) to another site for review at a later time.  Per CMS guidelines, asynchronous technology is permitted only in federal Telehealth demonstrations programs conducted in Alaska or Hawaii.

Teleconsultations is another broad term that includes using telecommunications between a patient and a health professional for use in rendering a diagnosis and treatment plan.  Generally, in order to bill Medicare, the service provided should meet the definition of Telemedicine. 

Yes.  CMS requires the reported telemedicine services include both an originating site and a distant site.  The originating site is the location of the patient at the time the service is being furnished.  The distant site is the site where the physician or other licensed practitioner delivering the service is located.

A telehealth facility fee is paid to the originating site.  Claims for the facility fee should be submitted using HCPCS code Q3014:  "Telehealth originating site facility fee."  Originating sites include: the office of a physician or practitioner, Hospitals, Critical Access Hospitals (CAH), Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Hospital-based or CAH-based Renal Dialysis Centers (including satellites), Skilled Nursing Facilities (SNF), and Community Mental Health Centers.

The 2013 Medicare (HCPCS) telehealth descriptor codes and RVUs are listed below:

Information regarding state government policy on coverage of telemedicine services can be found at: www.americantelemed.org/i4a/pages/index.cfm?pageID=3604.

Claims for professional services should be submitted using the appropriate service code  and the modifier "GT" or “GQ”.

GT modifier- Providers at the distant site submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service along with the modifier GT, “via interactive audio and video telecommunications system” (e.g., G0426 GT). Appending the GT modifier with a covered procedure code indicates that the distant site physician certifies that the beneficiary was present at an eligible originating site when the service was furnished.

GQ modifier- Providers participating in the federal telemedicine demonstration programs in Alaska or Hawaii must submit the appropriate CPT or HCPCS code for the professional service along with the modifier GQ, “via asynchronous telecommunications system”.

NOTE:  While Medicare contractors may require the GT or GQ modifier and do not allow CPT consultation codes, some private payors request CPT consultation codes without the Medicare modifiers.  Medicaid policies also vary state to state.  Since payer polices vary, you are advised to check with the local payors with which you participate regarding use of these modifiers.

Yes.  In order to report remote video-conferenced critical care, the physician(s) in the distant site must have real-time access to the patient's medical record including progress notes, nursing notes, medications, vital signs, laboratory tests, and radiographic images. The physician must also be able to enter orders, videoconference with the on-site health care team, speak to family members, and observe the patient.  The review and/or interpretation of diagnostic information is included in reporting remote critical care and should not be reported separately.

Critical care E/M codes (99291 and 99292) describe critical care services provided at the bedside and environs, and are not appropriate for reporting remote critical care via videoconferencing. Instead, two new Category III CPT codes were established in 2009.  Codes 0188T and 0189T are used to report the time spent providing video-conferenced critical care services.  The usual criteria for critical care apply including time spent reviewing test results, images, discussing the patient's care with family members and consultants, and documenting the record.  The time does not have to be continuous. Only one physician may report Critical Care Services (99291, 99292) or video-conferenced Critical Care for the same period of time.  Remote critical care cannot be reported if another physician reports Pediatric or Neonatal Critical Care or Intensive Care services (99468-99476) on the same date of service.

Code 0188T is used to report the first 30 to 74 minutes of videoconferenced critical care.  Video-conferenced critical care of less than 30 minutes should not be reported.  Presumably, services less than 30 minutes on the same date can be reported with the G0425-G0427 codes, if all necessary requirements are satisfied.  Code 0189T is used to report each additional 30 minutes.  (See table below)

1. American Telemedicine Association. “Telemedicine Defined.” Available online at www.americantelemed.org/i4a/pages/index.cfm?pageid=3333

2. Centers for Medicare and Medicaid Services. “Telemedicine and Telehealth.” Available online at http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html?redirect=/telehealth

3. The Telemedicine Reimbursement Handbook.  California Telemedicine and eHealth Center.  http://crihb.org/files/Telemedicine-Reimbursement-Handbook.pdf