Ingall, Timothy J. MB BS, PhD; Demaerschalk, Bart M. MD, MSc, FRCP(C)
Address correspondence to Dr Timothy Ingall, Mayo Clinic Hospital, 5E, 5777 East Mayo Boulevard, Phoenix, AZ 85054, firstname.lastname@example.org.
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Accurate coding is an important function of neurologic practice. This contribution to CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, Evaluation and Management coding, procedure coding, or a combination are presented, depending on which is most useful for the subject area of the issue.
For many years, physicians caring for acute stroke patients have called specialist physicians in larger hospitals to obtain advice regarding patient management. These “curbside consults” have been a mainstay of patient care for decades, but physicians providing advice have received no reimbursement. Although telemedicine became a tool for providing care remotely over 20 years ago, it was only after 2000 that improvements in both camera technology and the infrastructure of the Internet allowed physicians to effectively evaluate patients in real time in remote locations. The past decade has seen an explosion in the use of video and audio functionality provided over Internet connections to allow neurologists to perform virtual face-to-face consultations with acute stroke patients at remote locations and provide management recommendations to the remote staff involved with the care of the patient. While telestroke services have expanded dramatically, changes to how physicians and hospitals are reimbursed have lagged behind.
CODING, BILLING, AND REIMBURSEMENT CONSIDERATIONS OF TELESTROKE
In spite of a robust and growing evidence base supporting the use of telemedicine in general and telestroke in particular, a host of considerations remain incompletely resolved and thus constitute barriers to more widespread implementation. Among them are disparate licensing, credentialing, and privileging requirements between each state and the nation. Furthermore, current means of coding telemedical care and arbitrary restrictions on eligibility for billing and reimbursement serve as financial disincentives to establish a telestroke network.
The essence of telemedicine is to disseminate medical expertise to patients and local providers regardless of geographic boundaries. Currently, medical licensure and hospital credentialing processes run counter to that principle, as they are predicated almost entirely on geography. In the United States, medical licensure is under the purview of individual states. Furthermore, in most states, a physician must be licensed in the state where a patient seeks care. Therefore, a telemedicine physician must undergo the rigorous licensure process in nearly each and every state and US territory in order to provide telemedical care to patients in those locations. The exceptions, which have a mechanism to grant a telemedicine license for practitioners licensed in another state, include Alabama (ALA.CODE § 34-24-502), Louisiana (LA.REV. STAT.ANN. §1276.1), Minnesota (MINN. STAT. § 147.032), Montana (MONT.ADMIN.R. 24.156.802), Nevada (NRS 630.261[e]), New Mexico (NM STAT.ANN. 1978 61-6-6), Ohio (OH. REV.CODE ANN. 4731.296[C]), Oregon (OR.REV. STAT.ANN. 677.139), Tennessee (TCA 63-6-209[b]), Texas (22 TEX.ADMIN.CODE § 174.12) and Guam (10 G.C.A. § 12202). The Federation of State Medical Boards proposed the Model Act in 1995, which would afford a licensed physician in any state the privilege to practice telemedicine across state lines, limiting in-person medical care to the primary state of licensure. This act has not been formally accepted by any state to date, although the aforementioned states that grant telemedicine licensure based on a medical license in good standing elsewhere in the United States have enacted its basic tenet. A recent piece of federal legislation (42 CFR §§ 482.12 and 482.22) helped to streamline the process of being credentialed for a telemedicine site by allowing the credentialing process of the hub site to effectively transfer, so as to better avoid onerous, duplicative administrative barriers.
Reimbursement mechanisms for telemedical care have not kept pace with the expanded clinical use of telemedicine. The Centers for Medicare & Medicaid Services (CMS), the most prominent payer in the US healthcare system, requires that concurrent care by more than one provider be medically necessary (42 USC § 1395y[a]) and that the consultation originate within arbitrary geographic constraints designated as “rural” for reimbursement of service. Although these stipulations are ostensibly reasonable, in practice only very few payments are provided for telemedical care of Medicare beneficiaries. In addition, the current federal definition of “rural” does not encompass all underserved populations; thus, a provider is given a financial disincentive to practice telemedicine in other, nonrural, underserved areas. Nineteen states have enacted provisions that compel private insurers to cover a telemedical consultation, but the lack of a clear federal standard (Medicare payments are considered a benchmark for most medical services) leads to general ambivalence regarding how telemedical services should be reimbursed, which may impede investment of resources by physicians and industry. The lack of collaboration between government authorities, both state and federal, and third-party payers is a major hurdle to the implementation of appropriate reimbursement for telemedical services to physicians and hospitals. Payment to hospitals for acute stroke patients treated with IV thrombolysis at one hospital and then transferred immediately to a stroke center for further care (“drip and ship”) has been acknowledged by CMS as an issue that may warrant modification to the reimbursement system. In order to collect data that could help determine whether a change in reimbursement is necessary, CMS created a diagnostic code, V45.88, in 2008 that can be used by the receiving hospital to indicate that they treated a patient who had tPA administered in a different facility within the past 24 hours before admission to the receiving hospital.
A 73-year-old man living in a rural area was witnessed by his family to have the sudden onset of dysarthria and left-sided weakness, which persisted. The patient was transported by emergency medical services to his local community hospital within 60 minutes of the onset of symptoms, where he was evaluated by an emergency department (ED) physician. The hospital had a telestroke service agreement with a tertiary care hospital; the EDphysician initiated the system, and a telestroke consultation was provided by a vascular neurologist at the tertiary care hospital. A video-audio link was established over the Internet, and a virtual face-to-face consultwas performed by the neurologist with the assistance of an ED nurse who obtained the history and performed theNIHStroke Scale examination under the supervision of the neurologist. After performing a 30-minute evaluation, the vascular neurologist conferred with the ED physician, and they determined that the patient was a candidate for IV thrombolytic treatment,which was initiated in the ED. The patient was then transferred to the tertiary care hospital for ongoing care. The neurologist dictated a full consultation note, which was available in the community hospital’s medical record system.
CMS has written a guideline that provides information for health care professionals providing telehealth services.1 Previous CONTINUUM articles have addressed coding issues related to stroke prevention2 and critical care coding for stroke patients.3
The receiving hospital diagnosis coding should include the “drip-and-ship” International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code V45.884 (after October 1, 2014, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code is Z92.825). For reimbursement, the health care provider has a contract with either the hospital or the entity providing the telemedicine service and is reimbursed per the specifics of the contract.
2. Powers LB. Coding issues: coding for stroke prevention. Continuum (Minneap Minn) 2011; 17 (6 2ndary Stroke Prevention): 1344–1348.
3. Levine SR, ed. Appendix: stroke coding guide for critical care coding. Continuum (Minneap Minn) 2008; 14 (6): 133–136.