Telepsychiatry Obstacles Need to Be Removed

This is in response to APA President Jeffrey Lieberman’s column titled “Will The Government Do The Right Thing?,” which appeared in the July 5 issue.

One quick and easy change that the federal government could make immediately to improve access to psychiatric care is to remove obstacles to telepsychiatry. Psychiatric providers are in short supply in many locations. As a geriatric psychiatrist with experience in providing care by telepsychiatry, I know that it works well and have firsthand experience with these obstacles, and I see no good reason for them to be in place.

One serious obstacle is that the Centers for Medicare and Medicaid Services (CMS) will reimburse providers only for services provided via telepsychiatry if the patient is in a location designated as a rural health professional shortage area (HPSA). Even if the patient is in a mental HPSA that is not also designated a rural one, CMS will not reimburse. This seems very unreasonable; the patients still have very limited access to mental health providers even if not “rural.”

The second main obstacle is the unreasonable CMS reimbursement frequency of the subsequent hospital care E/M codes (99231-3), which are limited to one visit every three days; this is inappropriate for inpatients. A new lesser HCPCS code (G0459) was created that can be reimbursed for the days in between, but the 9923X codes should not be limited just because the service was provided via telemedicine. Also, be aware that Medicare HMOs often have even more limitations on telemedicine reimbursements than regular Medicare.

The Telemedicine Promotion Act of 2012 (HR 6719, 112th Congress) introduced by Rep. Mike Thompson (D-Calif.) would likely have remedied most of these unreasonable limitations, but to my knowledge has not yet been introduced in the 113th Congress.

Thank you for your concern in this matter. I would very much like to hear of any progress made in this area.

ANDREW POWELL, M.D.Cabot, Ariz.

Response from Janice Brannon, M.A., deputy director for state affairs in APA’s Department of Government Relations:

Thank you very much for responding to Dr. Lieberman’s column. In your response, you indicate that unfettered telepsychiatry could help solve psychiatric workforce shortages and improve access to care—we couldn’t agree more. There are still far too many annoying barriers to the daily use of telemedicine. State licensure laws and Medicare reimbursement requirements are two of the largest.

The good news is that private payers and Medicaid in many states are aware of the cost, service, and quality benefits provided by the use of telemedicine and have changed their policies to cover services provided through telecommunication. In fact, approximately 19 states have passed mandates that private insurance must cover and reimburse health care services provided via telemedicine to the same extent as those provided in person. Under Medicaid, approximately 44 states have some form of reimbursement in their programs.

Again, this is the good news on the reimbursement front. The tougher area for change has been Medicare. Despite this program being an early adopter of telemedicine years ago, it has been slow to keep up with the technological and societal changes that make this service delivery method such an accepted norm today.

This is not to say that APA hasn’t been an active advocate for telemedicine. Just last year, APA cowrote a letter with the American Telemedicine Association to CMS on a CPT coding issue regarding the elimination of code 90862 for pharmacologic management. CMS’s new code did not work for providing telemedicine oversight of patients with mental health diagnoses in rural hospitals who needed to be seen on rounds more than every three days. This collaboration resulted in getting CMS to clarify the code definition and to assign a value to it—a small step forward but a step forward nonetheless.

Now, to your point about CMS’s requirement for services to be reimbursed only when provided in areas designated “rural”: your timing is impeccable. CMS has recently proposed alterations to its urban/rural definitions for telemedicine. The proposed definitions should extend reimbursable telemedicine services to 1 million more beneficiaries living in large metropolitan areas. The proposed rule was published in the Federal Register July 19. We encourage all telepsychiatry advocates to comment on the proposal. As the public and providers’ acceptance and use of technology continues to evolve, we must all work together to assure that the government looks beyond the metaphorical walls it has built and “does the right thing.”

The proposed rule is posted at http://www.regulations.gov/#!documentDetail;D=CMS-2013-0155-0010; comments may be submitted at the top right side of the page under “Comment Now.” ■