Legislation Increased Medicare Telestroke Billing, But Underbilling And Erroneous Billing Remain Common

Abstract

In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

Exhibit 1.

Percent of episodes for acute stroke and acute mental illness associated with a billed Emergency Department Medicare telemedicine consultation, January 2016 to March 2021 SOURCE: Authors’ analysis of a 100% sample of fee-for-service Medicare claim records, January 2016 through March 2021. NOTES: FAST Act = Furthering Access to Stroke Telemedicine (FAST) Act of 2018. ED = Emergency Department. During the pre-FAST Act period, only care in rural communities was eligible for telemedicine reimbursement. During the FAST Act period, telestroke was eligible in both rural and urban communities, while telepsychiatry remained eligible only in rural communities. During the Pandemic period, all telemedicine visits were eligible for reimbursement.

Exhibit 3.

Percent of rural and urban hospital episodes for stroke and acute mental illness with a billed ED Medicare telemedicine consultation, January 2016 to March 2021 SOURCE: Authors’ analysis of a 100% sample of fee-for-service Medicare claim records over the period January 2016 through March 2021. NOTES: FAST Act = Furthering Access to Stroke Telemedicine (FAST) Act of 2018. ED = Emergency Department. During the pre-FAST Act period, only care in rural communities was eligible for telemedicine reimbursement. During the FAST Act period, telestroke was eligible in both rural and urban communities, while telepsychiatry remained eligible only in rural communities. During the Pandemic period, all telemedicine visits were eligible for reimbursement.

Exhibit 4.

Stroke episodes with a billed ED Medicare telestroke consultation, by consistency with Medicare billing code regulations ^a SOURCE: Authors’ analysis of a 100% sample of fee-for-service Medicare claim records over the period January 2016 through March 2021. NOTES: FAST Act = Furthering Access to Stroke Telemedicine (FAST) Act of 2018. ED = Emergency Department. ^a As part of the FAST Act legislation, the HCPCS modifier code “G0” was introduced for use beginning in January 2019, to indicate/verify the professional consultation billed was for Medicare telestroke (i.e., was a telemedicine consultation for acute stroke reimbursible under current regulations). “Consistent” Medicare telestroke claims included the “G0” modifier. “Inconsistent” telestroke claims did not include the “G0” modifier, instead providing another telemedicine code in its place (HCPCS/CPT codes G0406–8, G0425–7, G0508–9; modifier codes GT, 95; or place of service code “02”).