Telestroke and teleneurology are technological innovations that are changing the way stroke care is delivered. Telestroke uses robotic technology to allow neurologists to remotely examine and interact with stroke patients. Teleneurology uses video conferencing to provide remote consultations and care for stroke patients. These technologies are improving access to specialized stroke care, particularly in rural areas without on-site neurologists.
However, billing and reimbursement for these services remains a challenge. This page provides an overview of telestroke and teleneurology billing considerations, challenges, and strategies.
Telestroke Billing
Telestroke uses robotic telepresence technology to allow neurologists to remotely control a robot at the patient’s bedside. The neurologist can examine the patient, review imaging, and consult with on-site providers just as if they were physically present. This gives rural hospitals 24/7 access to neurologists without requiring the neurologist to be on-site.
There are several telestroke robotic platforms including InTouch Health’s RP-Vita, Reach Health’s RETIA, and Avizia’s Carebot. Under Medicare rules, use of these robotic platforms is considered telehealth. Therefore, telestroke consultations are typically billed using the same codes as regular telehealth visits.
This includes:
- 99201-99215 (office/outpatient evaluation and management codes)
- 99231-99236 (subsequent hospital care codes)
- 99238-99239 (hospital discharge day management codes)
Modifiers GT or GQ must be appended to indicate the service was provided via interactive audio-video telehealth. The service is billed by the consulting neurologist.
Medicare reimburses telestroke telehealth consultations at the same rate as in-person consultations if certain criteria are met:
- Originating site (patient location) is a rural health professional shortage area or county outside a Metropolitan Statistical Area
- Service provided at an originating site clinic, hospital, or Critical Access Hospital
- Telepresenter such as nurse is with the patient at time of service
If these rural telehealth criteria are not met, Medicare reimbursement is reduced to match the facility fee for a regular telehealth visit. This is around $26 currently. Confirm payer policies as commercial insurers have more flexibility than Medicare to cover telestroke without rural restrictions or facility fee reductions.
Challenges for telestroke billing include:
- Ensuring proper documentation, coding, modifiers, and billing practices are followed
- Navigating inconsistencies between Medicare and commercial payer policies
- Educating payers on emerging telestroke technology and concepts
- Justifying the value of telestroke services to payers
- Obtaining reimbursement for lower-level telestroke consultations (ED triage, transfers, etc.)
Strategies such as developing detailed telestroke policies, validating correct coding, establishing value, and negotiating contracts can help enhance reimbursement.
Teleneurology Billing
Teleneurology uses video conferencing to connect neurologists to patients for remote consultations, follow up visits, and other neurological care.
Common teleneurology services include:
- Stroke and headache consults
- Medication management
- Cognitive/behavioral assessments
- Epilepsy care
- Movement disorder follow up
- General neurology video visits
Teleneurology visits are billed using the regular E/M codes (99201-99215) with a GT or GQ modifier to denote telehealth. If video connectivity is temporarily disrupted, telephone codes 99441-99443 can be used for established patients.
The key considerations for teleneurology billing are:
- Documenting a detailed HPI, exam, medical decision making, and total visit time to support E/M code level selection. Some payers expect the exam to be performed by a telepresenter at the patient site.
- Meeting proper coding criteria such as time, key components, nature of presenting problem, counseling, care coordination, or critical care when needed to support high complexity visits.
- Using an audiovisual connection that has real-time interactive capabilities to qualify as telehealth. Email, phone, and patient portals do not constitute telehealth (except for use of 99441-99443 codes as above).
- Checking payer telehealth policies as Medicare has geographic and site of service restrictions while commercial payers are more flexible.
- Using POS 02 (telehealth distant site) for the neurologist’s location or POS 11 (office) if less than 50% of their day involves telehealth.
- Reporting diagnosis codes to represent all discussed conditions, not just the primary diagnosis code.
- Challenges with teleneurology billing stem from insurers viewing it as lower complexity than in-person care.
Strategies to boost acceptance and reimbursement include:
- Validating time, counseling, care coordination, and medical necessity clearly in the note.
- Providing HPI and exam details obtained remotely or from patient and other clinician input.
- Citing evidence and society guidance confirming quality and equivalence of telehealth care.
- Negotiating payer contracts to include telehealth payment parity clauses.
- Using structured teleneurology documentation tools that prompt for elements needed to support billing.
Emerging Directions
Billing practices for telestroke and teleneurology continue to evolve along with technology and payer policies.
Some emerging trends include:
- Increased payer openness to reimbursing lower-level telestroke triage and transfer consultations.
- Integration of telestroke and teleneurology into value-based and population health reimbursement models versus fee-for-service.
- Billing for virtual check-ins, remote patient monitoring, and asynchronous telehealth interactions.
- Reimbursement for hub-and-spoke telestroke networks with bundled billing arrangements.
- Payment for telestroke quality metrics and outcomes versus simple consumption of services.
Innovative platforms like the AAN’s Axon Registry and Neurology Care Group’s Teleneurology Outcome Assessment Program allow tracking of quality metrics and outcomes to demonstrate the value of telestroke and justify enhanced reimbursement approaches.
Additional Information on Telestroke and Teleneurology
As telestroke and teleneurology become more prevalent, pressure will continue mounting for payers to modernize their policies and provide equitable coverage and reimbursement. Medicare and commercial insurers will need to reduce rural restrictions, facility fee penalties, and other telehealth limits that undermine utilization and access. Payment parity legislation is being advocated federally and within states to prohibit telehealth coverage exclusions and lower payment rates compared to in-person care. While important for driving policy changes, legislative approaches take time.
In the interim, providers can leverage clinical data to justify enhanced telestroke and tele-neurology reimbursement. Metrics on patient satisfaction, quality of care, readmission rates, door-to-needle times, IV tPA treatment rates, and other outcomes can demonstrate VALUE. For example, a telestroke program reporting reduced stroke-related transferred out of their hospital would support cost savings claims. Apply to participate in alternative payment model demonstrations focused on telehealth through CMMI or seek engagement with payers to develop value-based contracting focused on telestroke quality improvement.
Concurrently, refining documentation and billing practices provides opportunities to maximize revenues under current policies. Audit E/M coding regularly to ensure care rendered during telestroke and teleneurology encounters supports the level charged. Provide ongoing training to clinicians on documenting exam elements visualized or described remotely. Develop tools prompting clinicians to address certain history, counseling, care coordination, or medical complexity factors that help reach higher code levels within the scope of each encounter.
With attention to improved documentation, outcomes data, legislative momentum, and payer engagement, the path forward for telestroke and tele-neurology reimbursement can progress. Neurologists and healthcare administrators will need concerted focus on coding, billing and payment innovation to fully deliver on the promise of virtual care in stroke and broader neurology practice.
Summary
Telestroke and teleneurology are innovative methods for delivering high quality stroke care and neurological services to underserved areas. However, unlocking the full potential of these technologies requires evolution in billing practices and insurer reimbursement approaches.
Detailed documentation, adherence to coding rules, validating medical necessity, and demonstrating quality outcomes provide the foundation for fair telestroke and teleneurology reimbursement now and in the future.
Neurologists, healthcare administrators, payers and policy makers must collaborate closely on coding, billing and payment reform to enable sustainable widespread implementation of telestroke, teleneurology, and other emerging virtual care technologies which can profoundly impact patient access and outcomes.
