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Getting Paid for Telehealth – Reducing the Physician Burden

Posted by James Baker, Chief Medical Officer | October 26, 2018 |
James Baker, Chief Medical Officer

One of the biggest concerns expressed by clinicians is that they’re unclear on how telehealth is billed. They’ve heard that there are burdensome licensure and billing requirements that make getting paid for a telehealth encounter unnecessarily complex.

Interestingly, this year, new rules were issued that made telemedicine reimbursement a little easier. For example, CMS just proposed a new rule that looks to be “the most significant reductions in provider burden undertaken by any administration.” Let’s look at how regulators and payers are changing how telehealth is paid with the goal of making the service a more attractive offering for hospitals and medical practices.

Gone But Not Forgotten – the GT Modifier in Telehealth Billing

At the beginning of the year, attorney Nathaniel Lacktman published an article in Healthcare Law Today that talked about the elimination of the GT modifier in telehealth billing. It was a substantial step; Medicare had been requiring CPT and HCPCS codes to have additional GT modifiers for telehealth reimbursement for over a decade.


Under the traditional rules, there were two modifiers to choose from:

  • GT, which established the visit was an synchronous or interactive telehealth visit between at least two parties on a live call.
  • GQ, which indicated the call happened during an asynchronous telehealth visit, which typically used pre-recorded videos or digital images and the Internet to transmit the data.

On January 1, 2018, CMS generally eliminated these modifiers. But they added a new rule to designate the “Place of Service” or POS. Today, a POS code must be placed on reimbursement documentation in or to be paid by Medicare. In the past, the POS designated where the patient was located during the professional service call. Starting in January, CMS used the POS for all Medicare services using telehealth technology. Using the POS code, Nathaniel Lacktman says, “rendered it unnecessary to also require the distant site practitioner report the GT modifier on the claim.”

However, with CMS there is almost always a caveat. In this case, CMS still wants the GT or GQ modifier for Critical Access Hospitals (CAS). Since institutions do not use the POS code, Medicare still needs a way to identify the encounter as a telehealth visit. There are also still a handful of providers participating in the federal telehealth demonstration programs in Hawaii and Alaska; they must also use the GQ/GT modifier. Nathaniel Lacktman points out:
Providers and hospitals that take steps to really understand which services are, and are not, covered under Medicare and Medicaid when delivered via telehealth, will be in a good position to scale up their services and reach more patients with confidence.

Coding for Dollars – Telehealth

Like most billing, telehealth still has regulatory hurdles to overcome. Medicare still has rules related to rural areas, the originating site for the visit, and other rules. At this time, the originating site for patients can’t be at home, and it should be noted that HHS is watching closely to be sure the rules are followed. The Healthcare Law Today article pointed out the OIG is in the process of auditing to match Medicare claims paid to distant sites with corresponding claims from originating sites. The goal is to be sure the originating site is a medical facility or practitioners office, not a home. They’re undergoing a similar audit for Medicaid, who says telehealth claims are increasing.

It should be noted that CMS is trying to reduce the technical burdens for reimbursement. In July they made another move to facilitate the move toward increased telehealth visits by releasing a new rule designed to ease “telehealth, documentation requirements and interoperability.”

According to Healthcare IT News, CMS is proposing to pay doctors for a new service called “brief check-ins” by telehealth visit as well as the remote evaluation of video and images in asynchronous telehealth. The new proposed reimbursement rule would:

  • Allow Medicare to pay for virtual check-ins via telehealth by phone. The Healthcare IT News article pointed out that these are effective for resolving patient concerns and building a supportive relationship between doctors and patients.
  • Allow telemedicine reimbursement without having to follow-up with an in-person visit.
  • Still requires an “established doctor-patient relationship” prior to offering the telehealth visit.
  • Also proposes changing the MIPS (Merit-based Incentive Payment System) Promoting Interoperability reimbursement category to align it with the government’s MyHealthEData Initiative.

CMS officials were quoted in the article as saying telehealth is not designed to replace the in-person visit, but to supplement existing services, improve access to care, and respond to patient demand. CMS currently estimates these slight changes could have a significant impact:

  • Saving clinicians more than 29,305 hours in administrative costs annually.
  • Saving healthcare providers $2.6 million annually in reduced administrative costs.

CMS says the big benefit is that they are trying to move from a system with four types of required documentation to one standardized rule.

The Future of Telehealth Reimbursement

To understand where telehealth is heading, watch the trends coming from Washington.

In the past year, CMS and Congress have taken several significant steps that signal their recognition of the value of telehealth to improve access to care (especially in rural communities), cut costs, and improve outcomes.

Here are a few examples:

  • In addition to the new actions covered in this article, CMS made a number of other changes to the 2018 Physician Fee Schedule rule allowing for increased reimbursement for telehealth for a variety of services like chronic care management and psychotherapy.
  • CMS finalized RMP, or remote patient monitoring, a telehealth subset, as billable under CPT code 99091. The rule allows patients to monitor and transmit physiologic data such as glucose levels or blood pressure, and then CMS reimburses for the service every 30-days.
  • Next Gen Accountable Care Organizations (Next Gen ACOs) received telehealth waivers this year that removed the geographic limitations and allowed the patient’s home to be the originating site.
  • CMS released their “Rural Health Strategy” document that prominently featured telehealth as a conduit to improved access for at-risk communities.

While some clinicians continue to express reluctance toward telehealth and their perceived roadblocks to reimbursement, it seems clear that regulations are lifting and the political impetus from Washington is seeking an expansion of telehealth services.

If your practice is considering telehealth, contact OrthoLive to talk about the best way to introduce these services, receive reimbursement, and improve your bottom line.

Topics: "telehealth", "reimbursement", "telemedicine", physician, Medicare

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