Telemedicine: CMS definition and reimbursement guidelines

 Quoted directly from Centers for Medicare and Medicaid Services website:

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.

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.

Posted via web from Connected Care Solutions

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Telemedicine allows for long-distance diagnoses

Link: Telemedicine allows for long-distance diagnoses - The Washington Times.

As mentioned in an earlier post, 4 years ago Telemedicine was in its infancy, perhaps used for monitoring status of patients with pacemakers... Now, according to this article in the Washington Times, Dr. Kenneth Bird, a Harvard professor affiliated with Massachusetts General Hospital, innovated an approach to patient care using monitors and remote access to hospitals to examine, diagnose and treat his patients.

Also, according to the article, patients are wearing monitors that can be remotely tracked and physicians can be notified and/or paged when necessary. Telemedicine (a.k.a. Telehealth) is not a substitute for direct patient care, but rather, it is an augmentation to the existing delivery of care. That said, installation/implementation can be a huge expense (ranging between $2.5 and $3.5 million), so larger hospitals are more likely to implement remote monitoring.

The article continues with explanation of "concierge" medicine approaches, which are light years ahead of the status quo. The benefits to patients is purportedly rapid care from providers, from home or within a specialized, technology enabled facility.

It's an interesting thought, and another example of how technologies can be used to improve patient care if used appropriately. That said, there are likely significant privacy and security issues related to the "transaction" between patient and providers. For more information about HIPAA Requirements, The HIPAA Privacy Rule, The Security Rule, or The HITECH Act visit The Online HIPAA Survival Guide.

And, if you are interested in keeping current on the issues, sign up for the FREE HITECH/HIPAA Compliance Newsletter.

via feedproxy.google.com

Courtesy of Healthcare & Technology Blog (By: Deborah Leyva): http://www.myhealthtechblog.com/2009/10/telemedicine-allows-for-long-distance-diagnoses.html

Telemedicine (Telehealth) is starting to get the attention it deserves, but innovation will not occur in a vacuum of unsustainable business models. Until self-sustainability for for telemedicine initiatives is achieved and replicated on a widespread basis it will not be as significant in the provision of care as it should be.

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AHRQ Report: Consumers Need to be Empowered in Health IT Debate

via scribd.com

A new study out the Agency for Healthcare Research and Quality (AHRQ) suggests that by excluding consumers from the broader implementation of health information technologies, the medical community is marginalizing themselves and prolonging the time it will take to reach high levels of consumer adoption. Just another reason to add to the list of flawed approaches/perspectives on information technology among health professionals, though quite possibly the one issue that if addressed effectively could make all of the other impediments to ubiquitous adoption of highly advanced IT systems evaporate in the face of overwhelming consumer demand.

Posted via web from Connected Care Solutions

BreakThrough: Teletherapy startup gaining some mainstream popularity, but business model is very misleading

From the website of telemedicine startup BreakThrough:

Overview

BreakThrough connects mental health professionals with clients through secure video, phone, and web.

We have a mental health epidemic

More than 57 million Americans – one in four adults – have a diagnosed mental illness. Tens of millions more struggle with stress and relationship issues. Institutions such as hospitals, prisons, schools, companies, health plans, and veterans centers are overcrowded with patients needing help, but growing costs and shrinking budgets are decimating quality of care.
Even though seventy to eighty percent of patients with mental illness improve with treatment, patients remain woefully underserved. Two–thirds of Americans with a mental illness do not receive treatment due to cost, stigma, inconvenience, and low access, particularly in rural areas. This is despite Americans spending $121 billion on mental health and substance abuse treatment.

The solution of telemedicine

Telepsychiatry and teletherapy – mental health services delivered through secure video, phone, and web – have emerged as effective, affordable, convenient, and safe methods of treating stress and mental illness. Telemedicine has several substantial benefits:

Effectiveness:

over fifteen years of research confirm that telemedicine is as effective as in–person treatment. This is particularly true in psychiatry and clinical psychology where much of the treatment is doctor–patient communication. Click here for a list of research studies on the effectiveness of telemedicine.

Convenience:

fifty percent of therapy clients drop out after a few sessions, but research shows teletherapy can boost retention to over ninety percent. Because clients can hold sessions anywhere with phone or internet access, they are much more likely to go and stay in treatment. BreakThrough supports sessions via video, phone, email, and live chat.

Affordability:

telemedicine sessions can cost ten to fifty percent less due to reduced overhead, travel time, and staffing needs. On BreakThrough, providers set rates that are almost always more affordable than in–office visits.

Access:

research shows the fit between clients and mental health providers is essential to positive outcomes. Most people will not travel to a provider beyond fifty miles, but telemedicine lets clients work with the best licensed provider regardless of location. BreakThrough clients can find providers on a wide variety of criteria, including price, reputation, location, gender, experience, credentials, and more.

Confidentiality:

eighty percent of therapy clients worry about the stigma of treatment. To protect clients, BreakThrough requires minimal information, enabling treatment with a level of discreteness and security not possible with in–person treatment.

Peer support:

the support of friends, family, and other patients is essential to long–term recovery. BreakThrough offers forums, group sessions, and seminars to enable peers to support each other no matter where they live.

Telemedicine is legal and expanding

Telepsychiatry and teletherapy are legal and regulated by state–specific guidelines. Government and licensing boards are also rapidly evolving legislation to expand telemedicine access.
To protect providers and meet the highest levels of regulatory compliance, we currently allow providers to see clients only in states where the provider is licensed. Providers can typically apply for licensure in multiple states, either directly through state licensing boards or third–party services that streamline the application process.

Telemedicine is reimburseable

Since 2004, Medicare and the AMA have issued CPT codes to identify and reimburse telepsychiatry and teletherapy services. A list of eligible services and codes include:

• Individual psychotherapy: CPT 90804 – 90809
• Consultations: CPT 99241 – 99255
• Office or other outpatient visits: CPT 99201 – 99215
• Pharmacologic management: CPT 90862
• Psychiatric diagnostic interview examination:CPT 90801
• Neurobehavioral status examination: CPT 96116

CPT code descriptions can be found on the American Medical Association's CPT directory. The modifier GT may be necessary to identify that services were delivered via telemedicine. For Medicare reimbursement, clients generally must receive treatment at an eligible originating site, such as a doctor's office, hospital, nursing facility, mental health clinic, or similar facility. Private payers often do not have the same locality restrictions. More details on reimbursement are available through the American Telemedicine Association.

via breakthrough.com

The premise underlying the business model for BreakThrough may well be sound, particularly the evidence presented supporting the positive impact of teletherapy on psychiatric patient outcomes. However, the increase in quality of treatment via telemedicine is irrelevant without a method for sustaining the provision of treatment through reimbursement of attending psychiatrists.

The assertion that "Telemedicine is reimbursable" made in the final section above, while accurate technically, is misleading in that eligibility to be reimbursed and actually recouping fees for services provided are two entirely different issues. The CPT codes provided by the BreakThrough founders are a distraction from the real challenge of processing and collecting payment, which is overcoming the fact that CPT codes are very often (more often than not) ignored because of the GT modifier and the advanced standards of practice that must be met to be eligible under Medicare reimbursement policy.

Medicare mandates clearly that telemedicine services are only eligible for reimbursement when there is a two-way video transmission that allows doctor and patient to each see the other. Any health professional will tell you that private insurers will always follow Medicare's guidance when it comes to establishing standards of eligibility for reimbursement.

This is going to create a major obstacle for the well intentioned and otherwise exciting startup to achieve widespread adoption amongst mental health providers, as they are not likely to adopt therapeutic practices without demonstrable evidence that reimbursement above a significant percentage of total consults is achievable. I wish the BreakThrough team the best of luck!!

Posted via web from Connected Care Solutions

'Connected Health' Could Trim Costs by 40 Percent

A new survey released by the Massachusetts Medical Device Industry Council (MassMEDIC) and Cambridge Consultants, a technology product design and development firm, finds that a patient-centered and coordinated approach to healthcare could save billions of dollars. The survey also indicates care coordination will reduce wasteful spending in defensive medicine, inefficient claims processing, medical errors and emergency room services.

http://www.healthcareitnews.com/news/survey-connected-health-could-cut-healthcare-costs-40-percent

via healthcaregoesmobile.com

It makes little sense to me that the current debate in DC about health reform presupposes that the health care business is fundamentally unsustainable, as it has yet to adopt many of the most widely recognized enhancements in operational efficiency that have redefined nearly every other information intensive industry in America since the early 1990's. If 40-percent of costs can be trimmed without totally overhauling the system, which would leave 1/6th of our economy to exist in a vacuum for several years as we wait to see if our blind overhaul worked, I think this must be allowed to play itself out as it did in every other market. If any policy measures are useful at this stage in the modernization of health care, they are gradual, incentive-based measures that would help break-through barriers created within the medical community by undefined guidelines and a perception that such innovative activity would involve too much risk. Several programs launched through the stimulus package were a good start, but will be much less consequential if too much is done too soon by politicians focused not on patient care, but rather on their personal legacies.

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National Coalition for Health Integration (NCHI): Bringing order to the chaotic health information technology through grid computing

via scribd.com

The National Coalition for Health Integration (NCHI) initiative is an ambitious attempt to establish a truly interoperable environment for linking independent health information technology projects around the US through an open framework. With an all-star team of business and scientific directors funded entirely through private donations made by its principal founder, billionaire pharmaceutical entrepreneur Patrick Soon-Shiong, M.D., NCHI seeks to establish "virtual organizations" which combine numerous disparate health organizations across all sub-specialties and functional purposes (i.e. billing, administration, health records, etc.) without concern for traditional geographic constraints. It utilizes in an unprecedented fashion institutes of higher education and their leading academic innovators in bio-informatics and grid computing. Truly a revolutionary initiative which will undoubtedly emerge as a major foundational element of any long-term improvement in the delivery of quality care. (www.nchiconnect.org)

Posted via web from Connected Care Solutions

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Larry Summers: "The average supermarket has more information technology than the average doctor's office"

Larry Summers made this point on Meet the Press this morning while defending the American Recovery and Reinvestment Act (ARRA) and the massive investment made by several federal agencies over the next five years. Sadly, he is not exaggerating at all. What a sad reality, but why overhaul the entire system from the foundation up without first assessing the impact of this $58B+ investment on the physicians and their willingness to adapt to the 21st century? 

Why is "insurance reform" more important that tort reform? You cannot even put the health care business in the same league as the grocery sector when it comes to information technology adoption, the single greatest factor in the cost savings and productivity increases across nearly every other sector of the American economy for the last 15 years, but we can somehow call it a failed industry and support wholesale restructuring?? I cannot believe anyone still supports Obama's nonsense.

Dept of Labor Grant Announcement: Training a 21st Century Health Care Workforce

The Department of Labor (DoL) has released $225 million in the form of grants for job training in emerging and in-demand health care sectors such as health information technology, nursing and applied care. Below you will find a summary of the grant opportunity as well as the full text of the DoL guidelines issued in the Federal Register.  The money is part of the American Recovery and Reinvestment Act, popular known as the "stimulus", which was passed by Congress in February and was among the first official acts of the Obama Administration. 

Little detail of how the funds were to be spent was provided in the original legislation and federal agencies have largely sought to direct money toward areas of the economy determined to have the greatest potential return on investment. The decision to use stimulus funds to retrain an American workforce that is currently experiencing levels of unemployment not seen since the early 1980's makes a lot of sense, particularly when that retraining is focused on jobs in technology-intensive industries.

The industry in the greatest need of skilled information technology and otherwise technically proficient new workers is the health care sector, which has been the slowest of the major American industries to adopt information technology into its best practices in a meaningful way. This failure to keep pace with the general rate of innovation across the economy as a whole, especially across other similarly information intensive industries such as banking, is a significant contributor to the unrelenting rise in the cost of care at the center of the current health care reform debate in DC. Before radical industry restructuring is undertaken, it would be wise to wait and see how the major investments currently under deployment in innovating and modernizing the industry impact escalating costs. One need look no further than the experiences of other American industries to see the cost-benefit of ubiquitous IT adoption and the tremendous impact this cost savings has had on innovation generally.

Summary - Dept of Labor ETA HC HG Grants Fact Sheet

ARRA - Dept of Labor Grant Notice (SGA-DFA-PY-09-01-1)

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HR 3200: America’s Affordable Health Choices Act of 2009 (Full Text)

(Cross-posted at The World We'll Inherit)

Below is the final proposal for health care reform issued by the Democratic House of Representatives today, which Speaker Nancy Pelosi confidently asserted she could pass by the end of the summer session. That's right, we only have about four weeks to digest, debate, amend and vote on this 1018-page piece of legislation which seeks to fundamentally redefine the rules of our nation's largest industry. Turns out "change" sucks a whole lot more than the status quo sometimes.

Would love to hear everyone's thoughts...

HR 3200 - America’s Affordable Health Choices Act of 2009

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Report to the President on Guidelines for Upcoming Comparative Effectiveness Research Grants

The Annual Report on Comparative Effectiveness Research contains information describing current Federal activities on comparative effectiveness research and recommendations for such research conducted or supported from funds made available by the Recovery Act (Full Text). $1.1B in grant funds, allocated to the Dept of Health and Human Services in the ARRA, will be released shortly under RFP through the NIH, AHRQ and HHS.

DHHS Comparative Effectiveness Plan

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