Virtual visits are on the rise.
However, despite the growing use of and demand for telehealth, experts say physicians still struggle to be adequately compensated for their services.
The Centers for Medicare & Medicaid Services (CMS) is addressing that concern by offering better reimbursement rates for telemedicine in its proposed 2019 Physician Fee Schedule (PFS). Yet physicians say getting reimbursed for virtual visits and digitally-enabled patient care remains a top challenge.
These reimbursement challenges stem, in part, from issues with medical coding: whether there’s a recognized alphanumeric code associated with a particular telehealth service; and if there is, whether a payer will accept it; and if there’s not, whether an alternative option for payment is available to the physician.
“There are all sorts of technology opportunities to interact in a non-face-to-face manner, but the payment and coding system has not kept up with that,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians (AAFP).
Technological advances over the past decade have created new ways of treating patients over the phone and via video outside of the traditional in-office visit. Patients also want to connect with their physicians via email and text and through patient portals. And some patients want to digitally share medical data, such as readings from their own personal medical devices, for evaluation.
But physicians aren’t always compensated for these visits. Medicare, Medicaid, and private payers vary in what virtual services they’ll cover. Medicare only pays for virtual visits where the physician and patient connect together in real time (synchronous visits). Medicaid, on the other hand, will pay in some states for visits where the physician and patient do not interact together at the same time (asynchronous visits), such as a patient sending a photo of a concerning rash that the physician later reviews and then prescribes a course of treatment.
As a result, physicians must educate themselves on how to code for telehealth to ensure the fiscal viability of their practices as medicine moves further into the Digital Age.
“If you don’t have a code, it’s harder to get paid—and it’s harder for the insurance company to know how to process the bill,” Moore explains.
Variants in coding sets add complexity
Most physicians already realize there are various medical coding sets with the American Medical Association’s Current Procedure Terminology (CPT) codes being the most prevalent. CMS uses CPT codes, too, but also uses Healthcare Common Procedure Coding System (HCPCS) codes to reimburse physicians for Medicare services.
But beyond the different code sets, there can be different codes for same procedures performed in the physician’s office and in outpatient settings. In other words, the code essentially describes not only what services were provided but where they were provided.
Experts say physicians should realize that using the appropriate codes isn’t always a guarantee to be reimbursed, however.
“There have been codes for telemedicine for years, but just because there’s a code doesn’t mean a health plan will pay. Coverage varies,” says Robert Tennant, director of health IT policy for the Medical Group Management Association (MGMA), headquartered in Englewood, Colo.
And that coverage can vary dramatically among payers, he and others note.
The nonprofit Center for Connected Health Policy (CCHP), which aims to increase the availability of telehealth services, explains in its 2018 report Telehealth Policy Barriers that, “Telehealth restrictions in the Medicare program include limitations on where telehealth services may take place, both geographically and facility-wise, the limited number of providers who may bill for services delivered via telehealth, a limited list of services that can be billed, and restricting, for the most part, to only allowing live video to be reimbursed.”
The CCHP says that although state Medicaid policies “have been more progressive, each state dictates what their policies are, which creates a patchwork quilt of telehealth laws and regulations across the nation.”
Beverly Gibson, MBA, CPC-I, a senior industry adviser at MGMA, says there are codes that should be used in certain cases, along with the restrictions on them. For example, she says telephone services and online medical evaluation (non-face-to-face services) codes are 99441 – 99444; however, she notes that the codes for these services when performed by a nonphysician are 98966 – 98969.