3. Policy BarriersPolicy Barriers
ReimbursementReimbursement
State Licensure and regulation (cross-State Licensure and regulation (cross-
border care)border care)
Liability concernsLiability concerns
PrivacyPrivacy
4. ReimbursementReimbursement
Look to CMS to set the tone for reimbursementLook to CMS to set the tone for reimbursement
www.cms.hhs.gov/telehealth/www.cms.hhs.gov/telehealth/
Telemedicine is the use of medical informationTelemedicine is the use of medical information
exchanged via electronic communication toexchanged via electronic communication to
improve a patient’s health, use of interactiveimprove a patient’s health, use of interactive
telecommunications equipment, two-way, realtelecommunications equipment, two-way, real
time. A cost-effective alternative to face-to-facetime. A cost-effective alternative to face-to-face
care. (42 CFR 410.78)care. (42 CFR 410.78)
5. AsynchronousAsynchronous
Does not meet the definition ofDoes not meet the definition of
telemedicine set forth by CMStelemedicine set forth by CMS
6. ReimbursementReimbursement
CMS: reimbursed for medically coveredCMS: reimbursed for medically covered
services including those with telemedicineservices including those with telemedicine
applications…must satisfy federalapplications…must satisfy federal
requirements of efficiency, economy, andrequirements of efficiency, economy, and
quality of carequality of care
7. Partial Medicare reimbursement forPartial Medicare reimbursement for
telehealth services was authorized in thetelehealth services was authorized in the
Balanced Budget Act of 1997.Balanced Budget Act of 1997.
Benefits Improvement and Protection ActBenefits Improvement and Protection Act
of 2000 removed some prior constraintsof 2000 removed some prior constraints
yet maintained substantial limitations toyet maintained substantial limitations to
geographic location, originating sites, andgeographic location, originating sites, and
eligible telehealth serviceseligible telehealth services
8. Unlike Medicare, Medicaid programs oftenUnlike Medicare, Medicaid programs often
provide reimbursement for health care-provide reimbursement for health care-
related transportation costsrelated transportation costs
9. Federal Medicaid Statute (Title XIX ofFederal Medicaid Statute (Title XIX of
Social Security Act) does not recognizeSocial Security Act) does not recognize
telemedicine as a distinct service.telemedicine as a distinct service.
States may choose to cover theseStates may choose to cover these
services.services.
27 states offer some reimbursement for27 states offer some reimbursement for
telehealth servicestelehealth services
10. Examples of CoverageExamples of Coverage
CPT 98966 Health Care ProfessionalCPT 98966 Health Care Professional
Phone call 5-10 minutesPhone call 5-10 minutes
(not being reimbursed)(not being reimbursed)
11. CPT 99441 Phone E&M by Physician 5-CPT 99441 Phone E&M by Physician 5-
10 minutes10 minutes
(not being reimbursed)(not being reimbursed)
12. CPT 99444 online E&M by physicianCPT 99444 online E&M by physician
(not being reimbursed)(not being reimbursed)
13. CPT 93293 Pace maker eval by phoneCPT 93293 Pace maker eval by phone
(Medicare = $56.98)(Medicare = $56.98)
14. DefinitionsDefinitions
Originating or Spoke SiteOriginating or Spoke Site
Location of the PatientLocation of the Patient
Distant of Hub SiteDistant of Hub Site
Where the health care provider is at the timeWhere the health care provider is at the time
of the serviceof the service
TelepresenterTelepresenter
Person needed to facilitate the servicePerson needed to facilitate the service
15. Facility fee to the originating siteFacility fee to the originating site
HCPCS Q3014 (telehealth originated site)HCPCS Q3014 (telehealth originated site)
Medicare $23.35; MA $15.72Medicare $23.35; MA $15.72
If they just have to set up the patient orIf they just have to set up the patient or
stay with the patient the whole timestay with the patient the whole time
16. Technical support, transmission charges,Technical support, transmission charges,
equipmentequipment
HCPCS T1014 (telehealth transmission perHCPCS T1014 (telehealth transmission per
minute)minute)
Unclear what the reimbursement isUnclear what the reimbursement is
17. Physician fee at the distant sitePhysician fee at the distant site
Bill as professional services (CPT code)Bill as professional services (CPT code)
18. Modifier “GT” – via interactive audio andModifier “GT” – via interactive audio and
video telecommunication systems allowedvideo telecommunication systems allowed
with code 99201-99205 (office or otherwith code 99201-99205 (office or other
outpatient services) and 99241-99245outpatient services) and 99241-99245
(Office or Other Outpatient Consultations)(Office or Other Outpatient Consultations)
Medicare does not recognize this modifierMedicare does not recognize this modifier
in PAin PA
19. Medicare Conditions of ProvisionMedicare Conditions of Provision
(limit some telehealth practices)(limit some telehealth practices)
Face-to-face visit in long-term careFace-to-face visit in long-term care
facilities on a regular schedulefacilities on a regular schedule
(telemedicine as a supplement)(telemedicine as a supplement)
Home health requires some face-to-faceHome health requires some face-to-face
visits (telemedicine as a supplement)visits (telemedicine as a supplement)
20. Audiology ExamplesAudiology Examples
LACELACE
CPT 92626 (evaluation of auditory status –CPT 92626 (evaluation of auditory status –
first hour)first hour)
Reimbursed at about $76.41 ($91.61)Reimbursed at about $76.41 ($91.61)
Assessment in the clinic or as part of theAssessment in the clinic or as part of the
LACE program?LACE program?
What would an audit show?What would an audit show?
22. LicensureLicensure
Professional services take place where theProfessional services take place where the
patient is locatedpatient is located
National Council of State Boards of Examiners inNational Council of State Boards of Examiners in
SLP and Audiology indicates that the audiologistSLP and Audiology indicates that the audiologist
should be licensed in the state in which theshould be licensed in the state in which the
consumer is receiving the service.consumer is receiving the service.
In 2003, 17 states adopted an InterstateIn 2003, 17 states adopted an Interstate
Compact for Licensed NursingCompact for Licensed Nursing
Allows nurses licensed in their home state to practiceAllows nurses licensed in their home state to practice
in any other party statein any other party state
23.
24. States’ barriers are a restraint on trade inStates’ barriers are a restraint on trade in
violation of the Commerce Clause of theviolation of the Commerce Clause of the
United States Constitution.United States Constitution.
There is a strong legal presumptionThere is a strong legal presumption
against federal preemption of stateagainst federal preemption of state
licensure lawslicensure laws
25. Health care professional to health careHealth care professional to health care
professional may not require a localprofessional may not require a local
licenselicense
27. MalpracticeMalpractice
Like professional licensing, malpracticeLike professional licensing, malpractice
insurance requires a provider to beinsurance requires a provider to be
licensed in each state in which they deliverlicensed in each state in which they deliver
services.services.
Subject to the jurisdiction of where theSubject to the jurisdiction of where the
patient is locatedpatient is located
28. Internal RegulationsInternal Regulations
When a manufacturer can take over yourWhen a manufacturer can take over your
computer in order to assist in patient carecomputer in order to assist in patient care
or to train personnel…or to train personnel…
DIACAPDIACAP
DoD Information Assurance Certification andDoD Information Assurance Certification and
Accreditation ProcessAccreditation Process
29. External Regulations: FDAExternal Regulations: FDA
Does remote mapping of a cochlearDoes remote mapping of a cochlear
implant have to be approved by the FDA?implant have to be approved by the FDA?
Is this a new use?Is this a new use?
CI companies do not provide directCI companies do not provide direct
support from a customer support linesupport from a customer support line
What about remote hearing aidWhat about remote hearing aid
programming?programming?
30. ConsentConsent
Recommend Consent to receive careRecommend Consent to receive care
through telehealth delivery systemthrough telehealth delivery system
Consent implies choiceConsent implies choice
31. Disclaimers/ConsentsDisclaimers/Consents
Fax disclaimerFax disclaimer
Email disclaimerEmail disclaimer
Email Consent (2 pages)Email Consent (2 pages)
E-mail risks and your responsibilityE-mail risks and your responsibility
Conditions for the use of e-mailConditions for the use of e-mail
InstructionsInstructions
Patient Acknowledgment and agreementPatient Acknowledgment and agreement
32. Support PersonnelSupport Personnel
Who is responsible for training?Who is responsible for training?
Are there safety issues?Are there safety issues?
Who pays these people?Who pays these people?
33. PrivacyPrivacy
Health Insurance Portability andHealth Insurance Portability and
Accountability Act (HIPPA)Accountability Act (HIPPA)
Privacy and confidentiality of protectedPrivacy and confidentiality of protected
health information (PHI)health information (PHI)
