Telemedicine: CMS definition and reimbursement guidelines

Telemedicine and Telehealth

Telemedicine

For purposes of Medicaid, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient's health. Electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient) that states may choose to cover. This definition is modeled on Medicare's definition of telehealth services located at 42 CFR 410.78. Note that the Federal Medicaid statute (Title XIX of the Social Security Act) does not recognize telemedicine as a distinct service.

Distant or Hub Site means the site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.

Originating or Spoke site means the location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service.

Asynchronous or "Store and Forward" means transferring data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous or "store and forward" applications would not meet the above definition of telemedicine--see telehealth.

Reimbursement/Billing—Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy and quality of care. With this in mind, States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology. For example, States may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site. States can also reimburse any additional costs such as technical support, transmission charges, and equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service. While telemedicine is not considered a distinct Medicaid service, any State wishing to cover/reimburse for telemedicine services should submit a State Plan Amendment to the Centers for Medicare and Medicaid Services for approval.

Medical Codes—States may select from a variety of HCPCS codes (T1014 and Q3014), CPT codes and modifiers (GT, U1-UD) in order to identify, track and reimburse for telemedicine 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 includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit patient data for monitoring and interpretation. While they do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and reimbursed as part of a Medicaid coverable service under section 1905(a) of the Social Security Act such as laboratory service, x-ray service or physician services.

Other Considerations:

Medicaid guidelines require all providers to practice within the scope of their state practice act. Some States have enacted legislation which requires providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the State are binding under current Medicaid rules. Medicare Conditions of Participation (COPs) applicable to settings such as long-term care facilities, and hospitals may also impact reimbursement for services provided via telemedicine technology. For instance, the Medicare COPs for long-term care facilities require physician visits at set intervals. Current regulations require that the physician must be physically present in the same room as the patient during the visit. This requirement must also be met for Medicaid to pay for services provided to Medicaid eligible patients while in a Medicare or Medicaid certified facility. Similarly, federal regulations require face-to-face visits for home health, and telemedicine cannot be used as a substitute for those visits. However, a telemedicine encounter may be used as a supplement to the required face-to-face visits

  via cms.hhs.gov

Anyone eager to make a business out of remote care and telemedicine technologies must carefully read, re-read, and ultimately memorize the one-page guidelines above if they hope to remain a sustainable investment in the current environment. In my estimation, the most valuable by-product of a Billion-dollar US Connected Health sector will be its utility as a stimulant of hyper-innovation. Without a business plan and patient care protocols/procedures that achieve 75-100% reimbursement rates from CMS, any telemedicine program is doomed to be a money-pit regardless of the altruistic motives of its proponents. The entrepreneur who will emerge best-of-breed in telemedicine will be he/she who finds the shortest path to demonstrating "Meaningful Use" in the form of real improvement in patient outcomes.

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