Understanding Telehealth Medicare Payment Rules for Orthopedics

One of the most basic concerns about telehealth is the disruption of workflows that inevitably occurs with a technology upgrade. Telemedicine changes how we deliver care but it also presents some restrictions on how that care is reimbursed.

According to Health Affairs, about one-half of an orthopedist’s payment comes from private insurance, another one-third comes from Medicare or Medicaid, and the remainder comes from self-pay patients.

Since private payers have their individualized requirements for telehealth reimbursement, we thought it might be a good idea to cover the ins and outs of receiving payment from the Center for Medicaid and Medicare Services (CMS), which for the average orthopedist is their second largest payment source. As of 2016, 20% of the American population was enrolled in Medicare. In the next 20 years, that number is expected to double. If current trends hold, by 2035 there will be 80 million Americans enrolled.

CMS has a number of hurdles for telehealth reimbursement. The first is that they currently do not cover store-and-forward or asynchronous telehealth visits. Instead, they require two-way live (synchronous) virtual visits between a clinical provider and their patient as the first requirement for being paid. There is a caveat under current rules that allows Federal telemedicine demonstration programs in Alaska or Hawaii to use asynchronous technology.

The next reimbursement requirement extends to the location of the eligible Medicare beneficiary when the virtual visit is conducted. While there are some laws pending that would eliminate this rule, 2018 regulations require the patient to be at an “originating site” when the telemedicine visit occurs.

According to CMS, the geography of an originating site must be either:

• A location outside of a Metropolitan Statistical Area (MSA), which is “a core area containing a substantial population nucleus.”
• Or, a rural Health Professional Shortage Area, which are areas of the country that lack primary care, mental health, or dental providers.

Within this geography, the originating site where the patient receives the virtual visit must fall within one of the following locations:

• A physician office.
• A hospital.
• Critical Access Hospitals.
• Rural health clinics.
• Federally Qualified Health Centers (FQHC)
• Hospital-based renal dialysis centers.
• Skilled nursing facilities.
• Community mental health centers.

Last but not least, CMS has rules related to the types of clinical providers that can treat Medicare-eligible patients. In 2018, the list includes:

• Doctors.
• Nurse practitioners.
• Physician Assistants.
• Nurse-midwives.
• Clinical nurse specialists.
• Certified registered nurse anesthetists.
• Clinical Psychologists.
• Clinical social workers.
• Registered dietitians or nutrition professionals.

Now that we understand where the patient can receive treatment and the types of providers that can offer telehealth services, let’s look at the types of services allowed under telehealth Medicare reimbursement for orthopedic practitioners.

The CMS rules issued for this year for treatments covered by telehealth run to four pages. We’ve picked out a few common ones that are typically used by orthopedists to treat patients during the virtual visit. For example:

• Telehealth consultations, emergency department, or initial inpatient. Use HCPCS codes G0425—G0427.
• Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or skilled nursing facilities. Use HCPCS codes G0406—G0408.
• Office or another type of outpatient visit. Use CPT codes 99201-99215.
• Telehealth pharmacologic management. Use HCPCS code G0459.

Now let’s look at state telehealth laws and reimbursement policies for Medicaid.

The Center for Connected Health Policy (CCHP) ranks telehealth Medicaid state reimbursement. This year they pointed out that “no two states approach telehealth in the same way.

Medicaid is our country’s largest healthcare assistant program for low-income people. The states and the federal government fund the program, although the states are allowed to create their own rules and regulations. CCHP says, “Each state can set their own program features and requirement.”

The end result is about 50 different approaches and rules governing telehealth reimbursement. While this is confusing enough for the solo practitioner, imagine the large multi-state hospital network to get a sense of how difficult these rules can be.

CCHP summarizes some of the typical rules we see today for Medicaid reimbursement for telehealth at the state level

• 15 states provide reimbursement for store-and-forward telehealth.
• 20 states provide Medicaid reimbursement for remote patient monitoring devices.
• 23 states strictly define the originating site by type of facility.
• 32 states require a telehealth facility fee.
• 38 states and the District of Columbia have laws governing commercial payer telehealth reimbursement.
• 49 states and the District of Columbia reimburse for live video conferencing via a telehealth feed.

However, we know that payment for telehealth is rapidly expanding over the next few years. As these barriers are removed, our ability to provide telehealth and receive payment for our services should become easier. It is expected that telemedicine will rapidly expand as a result.

CCHP points out that the majority of private payer health plans are now reimbursing for telehealth services. Some states have passed laws that require parity in payment, meaning, the virtual visit must be paid at the same rate as a telehealth visit.

CCHP also points out:

Regulations governing telehealth also vary across states, with limitations on cross-state licensing of health professionals being the most restrictive. Additionally, state health professional boards are releasing special telehealth standards for practitioners in their state.

So, should your practice offer telehealth?

We know that telehealth is widely used by the majority of hospitals around the country. But smaller practices have lagged behind. Yet telehealth research from organizations that have been using the technology shows the primary benefits tackle two of the biggest problems in healthcare today:

• Cutting costs;
• And improving outcomes.

OrthoLive offers an application that was created for busy orthopedic surgeons that want to improve their quality of life while offering patients an alternative to the traditional on-site visit. More than 70% of the initial orthopedic injuries can be diagnosed with our telemedicine application. Together, we help doctors improve the lives of the patients they serve.

Contact us today for a complimentary demo of our state-of-the-art, HIPAA compliant telemedicine application.