Telehealth CoveragePatient-centered healthcare and electronic health record (EHR) interoperability is a critical element in the nation’s health information network. This portends extremely positive prospects for future of the telehealth industry. In fact, telemedicine is on its way to greater heights. Fast internet connections and increased adoption of mobile devices are urging healthcare providers to use virtual platforms to reach out to their patients. Medical billing companies are keeping track of evolving insurance standards and coding rules to ensure that practitioners are appropriately reimbursed for telemedicine services.

The 2017 Leadership survey of the American Telemedicine Association (ATA) revealed an increasing demand for telehealthcare services. The report covered 171 respondents in executive leadership positions representing telehealth service providers, healthcare practices, and hospital systems. Up to 98 percent of telemedicine executives said that organizations offering telemedicine have a competitive advantage over those that do not. Today, telemedicine and e-health are widely used in preplanning and in post-disaster response. In the aftermath of the recent U.S. hurricanes that battered Texas, Louisiana, Florida and California, telemedicine allowed victims to access healthcare regardless of their location.

CMS proposes making some changes to its payment for telehealth services in 2018. This includes adding some new codes to the existing covered list and doing away with the requirement to use the GT modifier.

Expansion of Telehealth Services with Seven New Codes

  • HCPCS code G0296 Visit to determine low dose computed tomography (LDCT) eligibility
  • CPT code 90785 Interactive Complexity
  • CPT codes 96160 and 96161 Health Risk Assessment
  • HCPCS code G0506 Care Planning for Chronic Care Management
  • CPT codes 90839 and 90840 Psychotherapy for crisis, first 60 minutes + crisis code add on for each additional 30 minutes

Medicare pays both a facility fee to the originating site as well as the “distant site practitioner furnishing the service.”

Proposal to Eliminate Requirement for Modifier GT

Starting January 1, 2017, CMS introduced a new Place of Service (POS) Code describing the location where services are furnished via telehealth. Currently, Medicare pay for these services using the Medicare Physician Fee Schedule (MPFS). The telehealth POS code is not applicable to originating site facilities billing a facility fee. Claims for Telehealth services with the POS code 02 require a GT or GQ modifier.

In 2018, CMS proposes to eliminate the requirement for the use of modifier GT on professional claims in 2018. They feel that modifier GT for billing professional services (CMS 1500 Claim Form) is redundant with the new POS code for telehealth. This is expected to reduce the administrative burden for practitioners. Related changes include:

  • For institutional claims which use the UB-04 and do not use a POS code, it is proposed that distant site providers bill under CAH Method II and continue to use modifier GT for their institutional claims.
  • The federal telemedicine demonstration programs in Alaska or Hawaii will still use modifier GQ.

Organizations Urging CMS to further Boost Support for Telehealth

According to a recent MHealthIntelligence article, healthcare organizations and advocacy groups are striving to compel the Centers for Medicare & Medicaid Services (CMS) to enhance telehealth and telemedicine coverage. The Healthcare Information and Management Systems Society (HIMSS), American Medical Association (AMA), American Medical Informatics Association (AMIA), Center for Connected Health Policy (CCHP) and Personal Connected Health Alliance (PCHA) have submitted comments to the above-mentioned CMS proposals. They are urging CMS to go beyond these measures and improve the access to connected care services.

HIMSS has called on CMS to “promulgate a precise definition of what service characteristics fit within the statutory definition of telehealth” and “consider applying waivers as broadly as is legally permissible on statutory and regulatory restrictions related to telehealth.” MHealthIntelligence reported that HIMSS has called upon CMS to support the following:

  • Telehealth CoverageCollaborative decision-making involving diverse care-teams: Besides the patient and the physician, electronic technologies allow the patient’s family, advisors, as well as other allied health professionals to participate in the decision-making process.
  • Expanded care locations and always-on monitoring: HIMSS notes that “When patients are always connected, care (the interpretation of data and decision support) can occur at any time and in any place.”
  • Reliance on technology, connectivity and devices: Communication systems in connected health use a variety of components, which may be managed by the provider, the patient, or others involved in patient care.
  • Empowerment tools and trackers: These allow patients to participate actively in the continuum of care outside of the hospital setting and drive long-term engagement which, in turn, contributes to a healthier population.
  • Expand and refine CPT codes: HIMSS is also urging CMS to further expand CPT codes to further support remote patient monitoring services, and to develop a separate model under the CMS Innovation Center to test telehealth services under the Medicare Diabetes Prevention Program.

Finally, the organizations are encouraging CMS to adopt a reimbursement system that recognizes the unique characteristics of connected health that enhances the care experience for the patient, providers and caregivers.

Practitioners that provide telehealth services should clearly document the context and detail of the patient encounter. CPT manual lists 79 codes that can be billed if telemedicine used, and in 2018, there will be the new codes to deal with. Partnering with an experienced medical billing and coding service provider is the best option when it comes to choosing the right codes, appending the modifiers correctly and submitting claims to comply with the billing rules of Medicare and other third-party payers.