Telemedicine for Medicare Patients FAQ

FAQ 1: How are the terms defined? 

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.

FAQ 2: Are the services reported differently if you are the hosting facility vs. the consulting provider?

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.

Until 2014, only originating sites in low population density rural counties were eligible for telehealth reimbursement.  As of January 1, 2014, originating sites in rural portions of urban and high population counties may also be eligible for reimbursement.  Below is the link for a Telehealth calculator to determine if your originating site is eligible for Medicare payment.

http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

FAQ 3: What codes are used by the consulting provider to report telemedicine:

In addition to being able to utilize Office or other outpatient codes (99201-99205) and subsequent hospital codes (99231-99233), the 2015 Medicare (HCPCS) telehealth descriptor codes and RVUs are listed below:                                                                                                                 

 

Code

 
 

Descriptor

 
 

Total Typical Time

 
 

RVUs

 
 

G0425

 
 

Emergency Department or initial inpatient telehealth consultation

 
 

30 minutes

 
 

1.92

 
 

G0426

 
 

Emergency Department or initial inpatient telehealth consultation

 
 

50 minutes

 
 

2.61

 
 

G0427

 
 

Emergency Department or initial inpatient telehealth consultation

 
 

70 minutes

 
 

3.86

 
 

G0406

 
 

Follow-up inpatient telehealth consultation, limited

 
 

15 minutes

 
 

0.76

 
 

G0407

 
 

Follow-up inpatient telehealth consultation, Intermediate

 
 

25 minutes

 
 

1.39

 
 

G0408

 
 

Follow-up inpatient telehealth consultation, complex

 
 

35 minutes

 
 

2.00

 

The newest code, 99490 is for chronic care management and remote monitoring of chronic conditions.

Other new relevant additions to telemedicine-covered codes include the ability to utilize more psychoanalysis and evaluation codes along with prolonged psychiatric evaluation codes.

The list of Telehealth provided reimbursable codes allowed by CMS/Medicare has expanded and can be found at the below link and can be used with the GT modifier.   

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

As of early 2016, 32 states and the District of Columbia have laws requiring private payers to reimburse for telehealth codes. 49 states and the District of Columbia provide reimbursement through Medicaid.  Many of these laws go into effect in 2016 or 2017. This push for participation came after more than 200 telehealth related bills were introduced in state legislatures in 2015 alone. The coverage varies by state, payer type, and individual characteristics of the encounter (patient setting, geographic location, type of provider, live video vs. electronically transmitted health information).  As clinical practice in the emergency department grows to accommodate telehealth technology, the code set will require gradual review and expansion.

http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf?sfvrsn=10

FAQ 4:  What modifiers are used when reporting telemedicine services?

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 payers 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 payers with which you participate regarding use of these modifiers.

FAQ 5:  Can I report remote critical care services when utilizing telemedicine?

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, video-conference 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 video-conferenced 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.  Unfortunately these codes are currently assigned zero RVUs.  (See table below)                                                   

 

Duration of Critical Care

 
 

Codes

 
 

<30 minutes

 
 

Do not report

 
 

30-74 minutes

 
 

0188T x 1

 
 

75-104 minutes

 
 

0188T x 1 and 0189T x 1

 
 

105-134 minutes

 
 

0188T x 1 and 0189T x 2

 

FAQ 6:  What are the telemedicine reporting requirements for non-Medicare payers?

Non-Medicare payers may want you to report telemedicine services using Medicare’s HCPCS codes as described above or the regular Emergency Department E/M CPT codes with the GT modifier. You are advised to contact your local carrier for final instructions on billing telemedicine services.

FAQ 7:  Where can I get more information about telehealth?

1. American Telemedicine Association. “Telemedicine Defined.” Available online at: http://www.amdtelemedicine.com/telemedicine-resources/telemedicine-defined.html

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. American telemedicine White Paper on State regulations and scorecards http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf?sfvrsn=10

Disclaimer 

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only.   The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided “as is” without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or dmckenzie@acep.org.

Updated 04/29/2016

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