Frequently Asked Questions
Table of Contents
Definition of Telemedicine
Texas Medical Board Rules for Telemedicine
What about Credentialing & Privileging?
Telemedicine Defined by the American Telemedicine Association
Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth.
Telemedicine is not a separate medical specialty. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services.
Telemedicine encompasses different types of programs and services provided for the patient. Each component involves different providers and consumers.
TMB Telemedicine Board Rules for Telemedicine
The Texas Medical Board adopted amendments and additions to its telemedicine rules at its August 2010 meeting. The changes became effective October 17, 2010. To view these changes, go to http://www.tmb.state.tx.us/rules/changes/2010/101710.php. The following is a list of frequently asked questions.
1. What types of telemedicine models are allowed under the rules?
In general, two models for telemedicine have been identified, each for a different situation: either from an established medical site or from the patient’s home.
A. Established Medical Site:
In the first model, a patient receives care through telemedicine at an “established medical site,” such as a hospital or clinic or other site that has the required medical professionals and equipment. There are no specific limitations on the types of care that a patient may receive at an established site, and both initial visits and follow up visits may be done at this type of site.
At these sites, patient site presenters are available to assist in the interface between the patient and the physician (or PA or APN), who is located at a distant site, and sufficient diagnostic equipment must be available. One exception is that if the health care provided is related to mental health, a patient site presenter is not required unless patients may be a danger to themselves or others.
B. At Home:
In the second model, patients can access health care via telemedicine (video conferencing with a live feed) from their homes. The basic requirement for an in home evaluation is that the patient must be a pre-existing patient previously seen in person either by the physician or PA with whom the patient is teleconferencing or by another physician who has referred the patient to the physician providing telemedicine care and the referral is documented in the medical record. Once that initial diagnosis is made in person or at an established site, the patient may receive follow-up care for that pre-existing condition via telemedicine in their homes.
In addition to the above, distant site providers can treat pre-existing patients in their homes for new symptoms that appear unrelated to the pre-existing condition based on the following criteria and clarifications:
- Distant site providers may treat patients at home for up to 72 hours as long as the patient is advised to see a physician in a face-to-face visit within 72 hours if the symptoms do not resolve.
- Distant site providers may not provide continuing telemedicine medical services for new symptoms to a patient who is not seen within 72 hours.
- The rule intends that for a patient presenting minor symptoms, a provider may prescribe a course of treatment that runs longer than 72 hours, such as a 10 day course of antibiotics or a 30 day course of medication to relieve allergy symptoms. It is intended that this option be used judiciously and within the standard of care. It is not intended that ongoing prescriptions for new diagnoses made from the patient’s home would be issued.
A physician may not:
- Make an initial diagnosis of a new patient via telemedicine at a patient’s home (or other non-established medical site) unless the physician has conducted a prior face-to-face initial consultation or the patient has been referred to the distant site provider by a physician who evaluated the patient in-person.
- Provide ongoing medical treatment to a preexisting patient with a new chronic condition unless a physician conducts a timely in-person evaluation after the diagnosis of the new condition.
Finally, the patient being seen via teleconferencing from his or her home must be seen by a treating physician for an in-person evaluation at least once a year and no chronic pain treatment with scheduled drugs may occur through this treatment model.
2. What are some examples of facilities that meet the definition of an “established medical site?”
In addition to a hospital or clinic, a site could be a facility such as a nurse’s station in a public or private school, a volunteer fire department, an EMS station, a residential or institutional care facility, or even a pharmacy. The key criteria are the availability and presence of:
- A patient site presenter who is a licensed or certified health care professional, such as a nurse, emergency medical technician (EMT), or pharmacist; and
- Sufficient technology and medical equipment to allow for an adequate physical evaluation.
The rule also intends that an established site be sufficient in size to accommodate patient privacy and to facilitate the presentation of the patient to the distant site provider.
Any location that meets these requirements will be considered an established site.
3. Is there anything that cannot be an established site?
Generally, anyplace that does not meet the requirements in #2 is not considered an established site. Additionally, A private home is not considered an established medical site. Hospice facilities and nursing homes are not considered to be private homes.
4. Do the rules accommodate the use of Skype or similar forms of web videoconferencing as a means for a distant site provider to provide telemedicine medical care in a patient’s home?
Yes, this would be allowed as long as all the other requirements for home treatment (Sec. 174.7) are met.
5. What is the definition of a “face-to-face visit?”
The definition of a “face-to-face visit” is an evaluation performed on a patient where the provider and patient are both at the same physical location or where the patient is at an established medical site. For example:
- Provider (physician, PA, or APN) performs in-person evaluation of patient while both are physically present in the same location.
- Provider (physician, PA, or APN) performs an evaluation of patient where the patient is located at an established medical site but the provider is located elsewhere with the ability to visually interface with the patient.
Final Rule Streamlines Telemedicine Credentialing & Privileging Process
The Centers for Medicare & Medicaid Services (CMS) issued a final rule on May 5, 2011, offering hospitals and critical access hospitals (CAHs) the option to streamline the credentialing and privileging process for physicians and non-physician practitioners providing telemedicine services. The revised guideline will allow small hospitals and CAHs to expand access to specialty patient care services provided by remote practitioners and receive those services from another Medicare-participating hospital or other distant-site telemedicine entity in a timely manner.
Telemedicine is defined in the final rule as “provision of clinical services to patients by practitioners from a distance via electronic communications. The distant-site telemedicine physician or practitioner provides clinical services to the hospital or CAH patient either simultaneously, as is often the case with teleICU services, or non-simultaneously, as may be the case with many teleradiology services.”Telemedicine is defined in the final rule as “provision of clinical services to patients by practitioners from a distance via electronic communications. The distant-site telemedicine physician or practitioner provides clinical services to the hospital or CAH patient either simultaneously, as is often the case with teleICU services, or non-simultaneously, as may be the case with many teleradiology services.”
“Simultaneous” telemedicine services are performed in real time, similar to medical services provided during a face-to-face encounter.
“Non-simultaneous” telemedicine services are requested by the patient’s attending physician or practitioner and may involve interpretation of diagnostic testing. The interpreting telemedicine practitioner does not assess the patient in real time, but transmits the interpretation results to the attending physician or practitioner for patient diagnosis or management.
A “distant-site telemedicine entity” is defined in the final rule as “one that (1) provides telemedicine services; (2) is not a Medicare-participating hospital (therefore, a non-Medicare-participating hospital that provides telemedicine services would be considered a distant-site telemedicine entity also); and (3) provides contracted services in a manner than enables a hospital or CAH using its services to meet all applicable CoPs, particularly those requirements related to the credentialing and privileging of practitioners providing telemedicine services to the patients of a hospital or CAH.”
Under the current condition of participation (CoP), all hospitals must credential and assess privilege for all physicians or non-physician practitioners who provide services to their patients, including telemedicine practitioners. The hospital’s governing body is responsible for accepting practitioners to its medical staff and granting privileges after thorough examination, verification of credentials and evaluation of specific criteria. CAHs that are members of a rural health network must follow a similar process, but also must maintain an agreement with another hospital that is a member of the same health network, a Medicare Quality Improvement Organization (QIO) or another qualified entity. The CAH credentialing and privileging process also requires assessment and approval of its medical staff by this outside entity. CMS recognized the process was burdensome and that small hospitals and CAHs might not have the resources or clinical expertise within their medical staff to evaluate and assign privileges to specialists providing telemedicine services.
Effective July 2, 2011, the final rule revised sections of the CoP for hospitals and CAHs to allow the governing body (or responsible individual for CAHs) to accept the “credentialing and privileging decisions made by the distant-site telemedicine entity” for individual physicians or non-physician practitioners asked to provide telemedicine services. In addition, the governing body must obtain a written agreement specifying the distant-site entity as a “contractor of services” and stating the distant-site entity ensures all furnished services will comply with applicable CoP criteria for hospitals or CAHs.
There is an exception to the requirement for a CAH to have an agreement with one or more Medicare-participating providers or suppliers. The CoP now allows for an agreement with a distant-site, non-Medicare-participating entity providing telemedicine services. Specifically, the final rule says an agreement can exist “between a CAH and a distant-site telemedicine entity for the entity’s distant-site physicians and practitioners to provide telemedicine services to the CAH’s patients.”
The final rule for credentialing and privileging of telemedicine services is a significant advancement for specialty medical care providers, particularly rural hospitals and CAHs. Facilities considering implementing this streamlined process may experience initial cost in developing agreements with the distant-site telemedicine entity. Essentially, the benefits of expanding access to specialty services should outweigh any administrative cost.