As Telemedicine Grows up, It Needs Some Ground Rules

elemedicine is a booming sector of the healthcare industry: Investments are ramping up as health systems fine-tune their EHRs, explore remote patient monitoring and look toward population health management.

But with this growth comes a need for guidance and regulation. Nearly everyone agrees this is necessary, but issues — including a lack of data, interoperability problems and segmented interests — present obstacles.

Now, work is under way on developing evidence-based clinical guidelines for providers and hospital systems. Leaders from multiple sectors of the industry have been tapped to work on what the guidelines should include and how they should be maintained.

These guidelines should focus on encouraging cooperation among organizations, Dr. Judd Hollander, an associate dean at Thomas Jefferson University who has led telehealth initiatives, told Healthcare Dive. But they should also remember that in the end, telemedicine has the same goal as all other medicine.

“We don’t need different guidelines for telemedicine," he said. "We need to achieve the goals in a different way."

Why guidelines are a must

At the recent American Telemedicine Association (ATA) annual conference, it was hard to find a panel that didn’t touch on the lack of clinical guidelines in the field of telemedicine. Along with the hype of new devices and improved cloud programs, an underlying trend was that the field can get more respect from others in the industry — and patients — with more evidence-based guidelines.

Steven Waldren, director of the Alliance for E-health Innovation at the American Academy of Family Physicians, said one reason guidelines are needed is that telemedicine training is still rarely included for up-and-coming doctors. And older doctors are even less likely to have had exposure to such training.

There are also legal reasons. When dealing with liability concerns, the standard of care must be crystal clear. Otherwise, doctors will be especially conservative in their treatment for fear of getting sued, Waldren said.

Mostly, doctors need to be armed with enough information to be confident in the telemedicine they are practicing, he said. “I think that the key issue is, 'Can I meet the standard of care with the level of tech I have in a virtual visit or not?' And the doctor has to make that decision.”

Currently, most of the guidelines that exist are too broad and simple, Hollander said, such as making sure you have a good video connection. “That’s not really useful," he said. "That’s common sense."

Obstacles in the way

Although telemedicine practices can yield mountains of data, the relative youth of the field means that not enough evidence is available to write guidelines that meet physicians’ standards. That can require many years worth of data gathering because guidelines must be rigorous and backed up by plenty of evidence.

Telehealth: A Very Useful Tool That Enables and Improves Patient Access

Telemedicine.  A relatively new phenomenon in healthcare with its own coding and billing rules.  In this edition of “In the kNOW”, we will look at some of the CPT coding particulars surrounding 

Orthopedic Telemedicine Portal

Telemedicine means using telecommunications systems (audio and visual) in order to diagnosis and/or treat a patient remotely. 

·         Psychotherapy

·         Psychoanalysis

·         Pharmacological management with psychotherapy

·         ESRD services

·         Remote imaging for retinal disease

·         Remote imaging for monitoring and management of active retinal disease

·         External mobile cardiovascular telemetry

·         Technical support for above

·         External patient auto activated ECG

·         Interrogation device evaluations-loop recorder

·         Interrogation device evaluations-implantable cardiovascular monitor system

·         Medical genetics and genetic counseling services

·         Neurobehavioral status exam

·         Health and Behavior Assessment/Intervention

·         Medical Nutrition Therapy

·         Education and Training for Patient Self-management

·         E&M for new patients

·         E&M for established patients

·         Subsequent hospital care

·         Office and inpatient consultations

·         Subsequent nursing facility care

·         Prolonged services

·         Behavioral Change Interventions, Individual

·         Transitional Care Management services

Modifier 95 is used to identify a synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.  Previously modifier GT was in use for telehealth billing but was discontinued at the beginning of 2018 because a new place of service code (02) indicates telehealth now.  However, GT it is still needed for any distant site telehealth services performed under Critical Access Hospital (CAH) method II billing.  There is also a GQ modifier to be used for asynchronous telecommunication systems visits but that applies only to services in Alaska and Hawaii. 

Medicare requires that the communication take place from a qualifying originating site such as:

Hospital

Physician or practitioner’s office

Rural health clinic

Critical access hospital (CAH)

Skilled Nursing Facility

Community Mental Health Center

Hospital-based or Critical Access Hospital-based renal dialysis center

Federally Qualified Health Center

An eligible Medicare beneficiary must be at one of the originating site locations listed above when the telemedicine service takes place.  These originating sites are required to be located in a rural Health Professional Shortage Area (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA).  Some sites have been participating with the Department of Health and Human Services on a demonstration project and therefore, are considered originating sites despite their geographic location.  Due to the complexity of determining the eligibility of an originating site, there is an on-line tool-the Medicare Telehealth Payment Eligibility Analyzer-to assist.

There are specific practitioners who are eligible to perform services and receive reimbursement for telemedicine services.  They are:

Physicians

Nurse practitioners

Physician assistants

Nurse-midwives

Clinical nurse specialists

Certified registered nurse anesthetists

Clinical psychologists and clinical social workers

Registered dietitians or nutritionists

These practitioners, located at the distant site, will use Place of Service code 02 for Telehealth.   They then bill the appropriate CPT code or HCPCS Level II code with the appropriate modifier.  Payment for the originating site is achieved by submitting HCPCS code Q3014.