Expanding the NP's role through telemedicine

Nurse Practitioner, Apr 2000

Telemedicine, with its antiquated, expensive, cumbersome, and non-user-friendly equipment, has been around for several years in the health care industry.

The few telemedicine applications available have been directed toward physicians, used for administrative meetings or educational offerings, and are often funded through various grant moneys. Often, no clear or identifiable outcome measurements are available. Historically, the health care industry blamed lack of reimbursement as one of the major reasons that the telemedicine industry had not become more widely used, but it continued to tout the cost-savings capabilities of telemedicine through demonstrated reductions in direct time and mileage.

TECHNOLOGIC ADVANCES

Now, however, this country is experiencing a technology explosion that is producing smaller, more portable and userfriendly telemedicine equipment that functions over various communications modalities, including telephone lines. This equipment provides improved visual and audio capabilities over previous versions at considerably less cost.

REIMBURSEMENT ISSUES

Although telemedicine technology has demonstrated vast improvements, legislative changes geared toward reimbursement have been slow. Currently,15 states have passed laws that allow varying degrees of coverage for telemedicine that include full reimbursement equivalent to a face-to-face visit with physicians, specialists, and some nonphysician professionals, including NPs and PAs.l NPs wishing to check the status of their own state regarding telemedicine laws can do so by logging onto http://www.hcfa.gov/medicaid/telelist.htm or checking with the Department of Health and Human Services in their state.

Probably the most significant telemedicine reimbursement changes were identified in the 1997 Balanced Budget Act (BBA). Section 4206 of the BBA provides coverage and payment for professional consultations with physicians and certain other practitioners via telecommunications systems. The BBA requires that Medicare Part B pay for professional consultation via telecommunications systems by January 1,1999. Consultations rendered in this manner are titled teleconsultations.

The definition of professional consultation services via telecommunications systems states that the teleconsultation must be an interactive patient encounter that meets the criteria in the physician's current procedural terminology (CST) descriptor for a given consultation service and includes the following:

a clinical assessment via medical examination directed by the consultant (specialist)

the use of audiovisual communications equipment that permits real-time communication among the beneficiary, the consultant, and the presenting practitioner

participation of a referring practitioner appropriate to the medical needs of the patient and as needed to provide information to and at the direction of the consultant and feedback of the consultation assessment to the referring practitioner?

Medicare beneficiaries residing in rural health professional shortage areas (HPSAs) are eligible to receive teleconsultation services. Covered services include initial, follow-up, or confirming consultations delivered via interactive audiovisual telecommunications systems with specific CPT code designations and assigned modifiers. Medicare payment for the services of the consultant and for the services of the referring practitioner is bundled. The consultant must remit 25% of the payment received for the teleconsultation to the referring practitioner, and only the consulting practitioner may bill for teleconsultation.

Identified consultants include MDs, PAs, NPs, CNSs, and CNMs. Referring practitioners include MDs, PAs, NPs, CNSs, CNMs, clinical psychologists, and clinical social workers.

TELEMEDICINE MD THE PRACTICING NP

These legislative changes open the door for NPs not only to expand their current modality of practice provisions for improving patient access to health care but also provide a potential financial opportunity as well. Working within the specified telemedicine payer law (state, federal, or third party), NPs could theoretically continue to conduct traditional house calls and nursing home and clinic health care-related visits and then connect back to a consulting physician via a laptop telemedicine communication system operating from telephone lines, which provide two-way, interactive audiovisual capabilities complete with desired peripherals. The referring NP and consulting MD can complete the necessary physical assessment with patient interaction. Dialogue between the NP and consulting MD is enhanced with the ability to perform two-way annotation on snapped pictures.

Store-and-forward capabilities allow consultation pictures and notes to be filed in a customized patient record system for future use. The consulting MD then completes the necessary consultation visit billing information with specified telemedicine modifiers and, in the case of Medicare, retains 75% of his or her Medicare fee and reimburses the NP the remaining 25%. In the case of state Medicaid or other third-party payers, both the referring and consulting practitioners may be reimbursed equal to that of a traditional face-to-face consultation. Traditionally, third-party payer arrangements and state telemedicine laws have been more favorable in terms of reimbursement to providers than the current BBA federal law.