Is Telehealth On Your Radar Screen?

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is effort-free and/or that payment will be received. 

It seems just like yesterday when we watched the physician on Star Trek use tiny electronic devices to assess patients’ medical conditions and then cure those conditions with similar devices. Of course, we accepted that as fantasy and never believed we would have such technology. Now patients can monitor many conditions in their home with devices as small as their wristwatch. In addition, patients, family members, and medical professionals can now transmit videos, photos, etc., to specialists across the country and around the world.  

However, wound management professionals and providers have been slow to incorporate telehealth into their businesses for several obvious reasons:

• Payment systems did not reimburse for their assessment services and/or for all patients in all locations
• The wound photographs and videos were originally of low quality; or
• The medical devices were very large and very expensive.

Now wound management professionals and providers know they can take excellent digital photographs and videos with their mobile devices and can instantly share them with their friends, family, and colleagues all around the world. They also know many diagnostic tests can be performed at home, that monitoring equipment can fit in patients’ pockets or on their wrists, that voice-activated technology can remind patients to take their medications and change their wound dressings, and that most of this technology is within reach of the budgets of patients, providers, and payers. Therefore, is this the time for wound management professionals and providers to place telehealth on their radar screen? The technology is now readily available, but what about the reimbursement?

Because many patients with chronic wounds are insured by Medicare fee-for-service, let’s look at how that payment system is currently paying for telehealth services. Currently, Medicare fee-for-service pays for a limited (but growing) number of Part B services furnished by physicians or other qualified healthcare professionals (QHPs) to eligible beneficiaries via telecommunication systems that substitute for in-person encounters. An interactive audio and video telecommunications system, which permits real-time face-to-face communication between the physician/QHP at a distant site and the beneficiary at an originating site, must be used. Asynchronous “store and forward” technology, the transmission of medical information that the distant site physician/QHP reviews later, is permitted only in Federal telehealth demonstration programs in Alaska and Hawaii.

Where can eligible Medicare beneficiaries be located to receive telehealth services?

The location of an eligible Medicare beneficiary at the time the telehealth service occurs is called the “originating site” and must be in a: 

• County outside of a Metropolitan Statistical Area (MSA); or 
• Rural Health Professional Shortage Area (HPSA) located either outside of an MSA or in a rural census tract. 

To determine if a potential originating site is eligible for Medicare telehealth payment, simply visit the Medicare Telehealth Payment Eligibility Analyzer.¹ Each calendar year, the geographic eligibility of an originating site is established based on the status of the area as of December 31 of the prior calendar year. Such eligibility continues for the full calendar year.

The Centers for Medicare & Medicaid Services (CMS) makes some exceptions to the telehealth geographic requirements:

• If you are part of an entity that participates in a Federal telehealth demonstration project in Alaska or Hawaii approved by (or receiving funding from) the Secretary of the U.S. Department of Health & Human Services as of December 31, 2000, that entity qualifies as an originating site regardless of geographic location.
• Three additional geographic location exceptions began on January 1, 2019: 
  1. Patient’s home: if the patient is receiving home dialysis end-stage renal disease-related clinical assessment;
  2. Renal dialysis facility: if the patient is receiving home dialysis end-stage renal disease-related clinical assessment; or 
  3. Any hospital, critical access hospital, mobile stroke unit (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth originating sites: to provide acute stroke telehealth services


• One additional geographic location exception will become effective on July 1, 2019: 
  1. Patient’s home: if the patient is being treated for a substance disorder or a co-occurring mental health diagnosis.

The telehealth originating sites authorized by law are: offices of physicians or practitioners, hospitals, critical access hospitals, rural health clinics, federally qualified health centers, hospital-based or critical access hospital-based renal dialysis centers (including satellites), skilled nursing facilities, and community mental health centers.

NOTE: The patient’s home cannot be an originating site if the patient is insured by Medicare fee-for-service.

What are the telehealth equipment requirements?

The telehealth equipment requirements are clearly defined in -42CFR 410.78 Telehealth Services (a)(3). “Interactive Telecommunications System means multimedia communications equipment that includes at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.” In addition, asynchronous “store and forward” technology is not permitted. 

Who can furnish telehealth services?

The physicians/QHPs at distant sites who may furnish and receive Medicare Part B payment for covered telehealth services (subject to State law) are: physicians, nurse practitioners,  physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, clinical social workers, and registered dietitians or nutrition professionals.

The telehealth services must be within the practitioner’s scope of practice under state law.

What telehealth services are payable under the Medicare Physician Fee Schedule? 

The Medicare-covered telehealth services can change from calendar year to calendar year. To see the complete list of covered telehealth services for 2019, visit the Medicare telehealth website.² In 2019, the CMS added 2 prolonged services add-on codes (G0513 and G0514) to the list of covered telehealth services. As you review the list of covered telehealth services, consider how you might be able to make your wound management expertise available to a larger number of patients with chronic wounds.

Is special documentation required when telehealth services are provided?

Wound management professionals should follow the same documentation guidelines as for any face-to-face encounter. In addition, telehealth documentation should include:

• A statement indicating that the service was provided via telehealth;
• The location of the patient;
• The location of the provider; and
• The names of all persons participating in the telehealth service and their role in the encounter.

Are there any frequency limitations to telehealth encounters?

Frequency edits are applied to the following codes submitted by distant site telehealth providers: 99231-99233, subsequent hospital care services, is limited to one telehealth encounter every three days; and 99307-99310, subsequent nursing facility care services, is limited to one telehealth encounter every 30 days.

How should telehealth services be coded and how does Medicare fee-for-service reimburse for the services?

For every telehealth service, Medicare should receive 2 claims: 1 from the originating site and 1 from the distant site provider. The Table displays a coding overview of telehealth services provided to Medicare beneficiaries who are enrolled in the Medicare fee-for-service program. The national average Medicare allowable rate for the originating site is intended to cover the costs of the space, staff, and related equipment and increased from $25.76 in 2018 to $26.15 in 2019. The national average Medicare allowable rates for the services performed by distant site physicians/QHPs via telehealth can be found by using the Medicare Physician Fee Schedule Look-Up Tool.³ Medicare beneficiaries are responsible for their normal deductible and coinsurance amounts of both the originating site and the distant site telehealth services. Visit the Medicare Claims Processing Manual chapter 12, section 190, for detailed coding and billing instructions for each telehealth originating and distant site.⁴

Does the CMS allow expanded telehealth services to any demonstration projects other than those in Alaska and Hawaii?

The CMS appears more accepting that telehealth services can be invaluable to providing quality outcomes, reducing the total cost of care, and improving the patient experience. Following are a few of the programs that CMS approved to provide expanded telehealth services. If wound management physicians/QHPs participate in these programs, they should consider taking advantage of these additional telehealth opportunities. 

• Next Generation Accountable Care Organizations⁵ have waivers that allow:
  • Telehealth services to originate in a beneficiary’s home (not located in a rural area)
  • Asynchronous (“store-and-forward”) telehealth in the specialties of teledermatology and teleophthalmology used to transmit a recorded health history to a practitioner who uses the information to evaluate the care or render a service outside of real-time interaction.⁶
• In 2020, beneficiaries assigned to Accountable Care Organizations (participating in performance-based risk tracks) may receive telehealth services in their homes and the geographic restriction of the telehealth originating site will be eliminated. In such cases no “facility fee” will be paid to the originating site and the telehealth services must be appropriate to furnish in a home setting.
• The Medicare Advantage Value-based Insurance Design (VBID) model is currently only available in certain geographic areas. Starting in 2020, the model will be open to Medicare Advantage payers in all 50 states and Washington D.C. VBID participants will be able to pursue telehealth services for eligible patients and disease states beyond the telehealth services permitted by Medicare fee-for-service.⁷

Are private payers or other health care providers offering telehealth services?

• Many private payers cover telehealth services and most of them cover home-based telehealth services. In fact, over 30 states and the District of Columbia have enacted statues requiring telehealth to be a covered benefit in commercial insurance policies. 
• The number of state Medicaid programs paying for telehealth services continues to increase. Most of those states pay for live telehealth consults between a patient and physician. About 20% of the states pay for asynchronous store-and-forward services.  
• The Department of Veteran Affairs (VA) is one of the largest providers of telehealth services: more than 700,000 veterans per year receive one or more telehealth services. 
• CVS is planning to offer nationwide telehealth service via its smartphone app for diagnosis of conditions such as colds and flu, skin issues, and general wellness matters. The telehealth service will be available 24/7 in a partnership with the virtual care company Teladoc. Patients will pay for the service by credit card or debit card. 
• Walgreens offers telehealth services through a partnership with MDLIVE. 

Summary

As telehealth services continue to expand, originating sites have more opportunities to partner with specialists to provide a wide range of services with less inconvenience to the patients. Wound management professionals have a wonderful opportunity to offer telehealth assessments to patient insured by Medicare fee-for-service, Medicare Advantage, Medicaid, the Veterans Administration, and private payers, as well as patients attributed to them in Accountable Care Organizations. Now is the time to brainstorm the variety of ways you can adjust your business model to leverage technology and telehealth innovation when in-person procedures are not required. Telehealth can be a win-win for wound management professionals and their patients: Baby boomers are getting accustomed to telehealth and millennials expect telehealth. 

Is telehealth on your radar screen? 

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. Health Resources & Services Administration. Medicare Telehealth Payment Eligibility Analyzer. CMS.gov. https://data.hrsa.gov/tools/medicare/telehealth. Accessed March 22, 2019.

2. Centers for Medicare & Medicaid Services. List of Telehealth Services. CMS.gov.

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.html. Accessed March 22, 2019. 

3. Centers for Medicare & Medicaid Services. Physician Fee Schedule Look-Up Tool. CMS.gov. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html. Accessed March 22, 2019.

4. Chapter 12, Section 190. Telehealth Services: In: Medicare Claims Processing Manual. Baltimore, MD: Centers for Medicare & Medicaid Services; 2018:181-197.https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 22, 2019.

5. Next Generation Accountable Care Organization-Implementation. Baltimore, MD: Centers for Medicare & Medicaid Services; August 24, 2018. MLN Matters No. SE1613. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1613.pdf. Accessed March 22, 2019.

6. Next Generation Accountable Care Organization (NGACO) Year Three Benefit Enhancements. Baltimore, MD: Centers for Medicare & Medicaid Services; August 4, 2017. Transmittial No. 177. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R177DEMO.pdf. Accessed March 22, 2019.

7. Centers for Medicare & Medicaid Services. Medicare Advantage Value-Based Insurance Design Model. CMS.gov. https://innovation.cms.gov/initiatives/vbid. Accessed March 22, 2019.