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WEDI Brief Outlines Challenges to Telehealth Reimbursement

A new WEDI report finds that providers seeking reimbursement for their telehealth or telemedicine programs have to wade through a CPT code system that hasn't yet caught up to the technology.

By Eric Wicklund

- Healthcare providers face many challenges in launching and sustaining a telehealth program – including finding the right CPT codes, if they exist, for reimbursement.

In many cases, a telehealth or telemedicine procedure is so new, a proper definition and guidelines haven’t been written for it yet, the Workgroup for Electronic Data Interchange (WEDI) reports in a new issue brief. Without those definitions, payers won’t reimburse for the service - and if health systems aren’t getting paid for it, they likely won’t use it.

CPT (Current Procedural Terminology) code sets, part of the Healthcare Common Procedure Coding System (HCPCS), are maintained by the American Medical Association’s CPT Editorial Panel and used by the Centers for Medicare & Medicaid Services (CMS) for definition and reimbursement. With terms like telemedicine and telehealth entering the healthcare lexicon over the past two decades, the AMA has been slowly working to refine the codes to include new services. The organization even launched a 50-member Telehealth Services Workgroup in late 2015.

"The CPT code set is the foundation upon which every participant in the medical community - physicians, hospitals, allied health professionals, payers and others - can efficiently share accurate information about medical services," AMA President Steven J. Stack, MD, said in announcing the workgroup’s launch. "Input from the Telehealth Services Workgroup will help the CPT code set reflect new technological and telehealth advancements available to mainstream clinical practice, and ensures the code set can fulfill its role as the health system's common language for reporting contemporary medical procedures."

CMS has tried to add codes that can be used by healthcare providers to cover telehealth services, including the 99490 code for chronic care management services in 2015 and a new “95” modifier added this year “for reporting synchronous telehealth services delivered via real-time interactive audio and video.” But while they and groups like the American Telemedicine Association are constantly looking for new codes that could be used to aid in telehealth reimbursement, there are still many roadblocks that keep health systems from adopting telehealth.

The WEDI brief outlines seven:

  1. A lack of definitions to distinguish telehealth data generation from telehealth patient services;
  2. The assumption of gaps in current codes to identify telehealth services;
  3. The creation of codes for universal use that still capture various nuances of telehealth services;
  4. Significant variations in the way payers view coverage, valuation and payment of telehealth services;
  5. Payers’ own requirements that must be met for a valid telehealth service;
  6. Limitations on the aggregation of gathered data into consumable reports; and
  7. Variations in each state in how telehealth terms are defined.

Among the stakeholder groups working to better define the many nuances of telehealth is the Connected Health Initiative, a subcommittee of ACT | The App Association. Last year the CHI issued a “consensus document” on the definition of asynchronous, or store-and-forward, telehealth. Members of the group say they expect to “hit the ground running” this year with documents that tackle several other ill-defined terms.

“There are 50 million definitions out there for eHealth,” Brian Scarpelli, the ACT’s senior policy counsel and a CHI member, told last year. More importantly, he said, “there are conflicting messages” within state and federal agencies that affect how eHealth, mHealth, digital health, connected health, telehealth, telemedicine and all those other terms are used.”

“We’re going to have to develop consensus definitions for a lot of different terms,” he added. “And there are a lot of stakeholders who will want to contribute.”

Likewise, the WEDI brief points out that the CPT codes may define a telehealth procedure, but that doesn’t mean every payer is going to reimburse providers for it.

“While there is a link between procedure codes and reimbursement, they are also separate,” the brief points out. “The payers determine whether … telehealth services are covered and what requirements must be met for coverage to apply. The procedure codes provide the explanation of what service was provided in order for the payer to determine the coverage. Providers wishing to offer telehealth services need to refer to their payers’ information on what services are covered and how to code for those services.” 


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