An overview of Teledermatology Reimbursement

Learn more about the reimbursement components  for telemedicine in dermatology and discover if it is possible to have it reimbursed in your state. 

Author: Jon Friis, founder and CEO of Miiskin

Covered in this article:
What is Reimbursement | Reimbursement components | Reimbursed telehealth types | Reimbursement by state | Telehealth Reimbursement Scenarios | Types of Reimbursement codes | Insurance companies

Teledermatology has gained popularity during the pandemic, but its use has decreased as the world slowly gets back to normal. One of the challenges is a lack of knowledge about reimbursement, which this guide for practitioners addresses.

The complexity involved in the reimbursement for teledermatology is the most significant barrier that stops doctors and patients from using it.

However, this article will help you learn more about the various aspects of reimbursement for teledermatology in the US, including an overview of these guidelines and some helpful scenarios.

Teledermatology Reimbursement Components 

The U.S. reimbursement system encompasses three critical components:

• Coverage
• Coding
• Payment

These elements are essential for adequate telehealth reimbursement. For example, simply having a code to bill for a procedure or service does not ensure insurance coverage or payment.

1. Coding

Healthcare providers must submit completed claim forms to the appropriate payer to receive services and procedures.

Providers use code systems to communicate with the payer that describes the patient’s diagnosis, the conditions, the services provided, the procedures performed, and the equipment used to treat the patient.

Coding can be referred to as the link between coverage and payment.

The three main types of codes used to bill services and procedures are:

• Current Procedural Terminology (CPT Codes)   
• Healthcare Common Procedure Coding System (HCPCS Codes) 
• International Classification of Diseases (ICD-10) Codes, including Diagnosis Codes (CM)

2. Coverage

Coverage includes the process, criteria, and policies used by payers to determine whether to pay for a medical procedure.

The term Payers includes the Center for Medicare and  Medicaid Services (which are joint federal and state programs in the US for people with low-income, disabilities, or who are retired and do not have private health insurance) and private payers, including large insurance companies (e.g., Aetna,  BCBS plans, United Healthcare) and the Veterans Administration.

Payers make coverage decisions based on several factors, including medical necessity,  effectiveness, and outcomes.

3. Payment

Payment refers to the amount of money a payer is willing to pay for a procedure or service, dependent on coding and coverage.

If there is a favorable coverage decision and an existing code, payment will be made, although the amount can vary depending on the payer.

If there is no insurance coverage, no payer payment will be made – patients will have to self-pay.

Medicare payment is available through publicly available fee schedules. The contractual arrangement between the payer and the provider determines the amount by private payers.

Private payer information is confidential. The level of payment by private insurance companies is often based on the Medicare fee. However, they have no obligation to cover the Medicare amount.

Ensuring coverage, coding, and payment is the ultimate goal of all healthcare providers, and reimbursement should be an ongoing process.

Types of Telehealth Technologies that are Reimbursed

Telehealth involves a collection of means or methods to enhance health care and health education delivery through telecommunication technologies. It includes various technologies to deliver virtual medicine and health education.

Telehealth includes four modalities. The first three are most often seen in payer policies and relevant to telemedicine reimbursement,  whereas mobile health is mentioned much less, although it is a rapidly growing field.

Live video (synchronous)

Live, two-way interaction between a patient and a provider using audiovisual telecommunications technology. This type of service is also referred to as “real-time” and may serve as a substitute for an in-person encounter when it is not available.

Store-and-forward (asynchronous)

Transmission of recorded health history (for example, pre-recorded videos and digital images such as photos through a secure electronic communications system to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction.

Remote patient monitoring (RPM)

This term refers to personal health and medical data collection from patients via electronic communication technologies to a provider for related support. This type of service allows providers to continue monitoring healthcare data to reduce readmission rates.

mHealth (mobile health)

Health education, information, or public health services provided by a mobile device, e.g., health education apps or wearable devices. This area is much broader than the prior three modalities and is still developing.

Medicare Telehealth Reimbursement per State

Until now, the most predominantly reimbursed form of telehealth is via synchronous or live video conferencing (LVC)  telehealth. Every state in the US offers some reimbursement in its Medicaid program. Still, some restrictions on the type and the amount of consultation with some Medicaid programs limit reimbursable services¹.

Store-and-forward teledermatology reimbursement

Typically, asynchronous or store-and-forward (SAF) teledermatology services are only reimbursed by Medicaid Programs in 22 states:

Alaska, Washington, Minnesota, Michigan, New York, Vermont, Maine, Iowa, Oregon, Nevada, Missouri, Kentucky, West Virginia, Maryland, California, Arizona, Tennessee, Virginia, New Mexico, Texas, Georgia, Hawaii, Ohio, and North Carolina.

Reimbursement Scenarios

The patient or guardian should request the visit for the telehealth visit to be reimbursed.

To be reimbursed, a teledermatology visit should furthermore adhere to the following guidelines.

Scenario I: Telephone consultation

1. The patient initiates contact by phone (with or without images or pre-recorded videos)
2. This virtual consultation is not related to a previous consultation that took place during the last seven days.
3. The patient cannot be given the next available physical consultation  
4. The phone conversation should last at least  5-10 minutes, or more²

Miiskin commentary: Although telephone consultations are beneficial in many medical specialities, in dermatology it is often hard to offer a consultation over the telephone as patients can’t adequately describe the visual appearance of their skin problem. In dermatology, a visual examination of the patient’s skin condition is essential.

A store-and-forward teledermatology solution can improve the patient experience since providers can see patient reported images and history, and follow up with a short telephone conversation. With this technology, a phone conversation can support an asynchronous teledermatology visit.

Scenario II: Synchronous/live telehealth consultation

1. Patient initiates contact through a synchronous/live platform 
2. This virtual consultation is not related to a previous consultation that took place during the last seven days
3. The patient cannot be given the next available physical consultation  
4. The synchronous/live consultation is less than 10 minutes; it counts as a triage consultation
5. The synchronous/live consultation is more than 10 minutes; it counts as a telehealth consultation²

Miiskin Commentary: While live video consultations can offer a means of a visual examination of the patient’s skin, for instance, a poor internet connection can cause the quality of the video stream to be too low for the provider to be able to see the skin condition clearly.

It can also be uncomfortable for the patient if the lesion is located next to a private body part or in an area that is difficult to point the camera towards when on the call with the doctor. Furthermore, both telephone and video calls still take a lot of time out of the busy dermatologist’s schedule. Due to this, most dermatologists will conclude that the patient might as well come in for an in-person consultation since there isn’t any efficiency gain for the dermatologist in a synchronous telehealth visit versus an in-person consultation.

An asynchronous store-and-forward telehealth solution could be the preferred choice of many dermatologists due to its convenience both for the patient and provider and the fact, that it is now reimbursable at a comparable rate to in-person consultations. 

Scenario III: Asynchronous/store-and-forward telehealth consultation

1. Patient initiates contact through an asynchronous/store-and-forward platform. 
2. This virtual consultation is not related to a previous consultation that took place during the last seven days.
3. The patient cannot be given the next available physical consultation  
4. There were images sent with the written communication
5. The information exchanged took place via a HIPAA-compliant platform²

Miiskin Commentary: As can be seen in the above discussion of the other variants of telehealth, we see on a daily basis that dermatology is facing a significant opportunity to modernize itself with asynchronous teledermatology software.. 

A store-and-forward solution optimized to fit into the dermatologist’s daily schedule can be a game-changer to the individual clinic or larger health system and patients love being able to skip the waiting room and long waiting lists. 

Insurance Companies that Reimburse Telemedicine Services

There are approximately 1,500  private insurance companies in the United States, some are nationwide, and some are regional. National insurance companies, such as Aetna, Cigna, United Healthcare,  Humana, Anthem, and other Blue Cross Blue Shield Plans, determine their coverage and reimbursement policies, which vary per contract.

Pre COVID-19, coverage for telehealth policies was usually minimal.

However, in response to COVID-19, a growing number of companies made telehealth more widely available.

Below you can see examples of insurance companies that offer telehealth coverage. It is our estimate that upwards of 80% of insurance companies have some degree of teledermatology reimbursement in place. Especially the largest insurance providers have initiated substantial coverage in the last few years.

Please note that the insurance teledermatology landscape is ever-changing. We try to keep this resource up-to-date, but to get the inside view on the latest and future development, please reach out to us for a talk with one of our reimbursement experts. We are also able to send you more in-depth material than what can be provided in a web guide.

List of private insurance companies in the US that reimburse teledermatology services:

• United Healthcare (United Health)
• Blue Cross and Blue Shield (BCBS)
• Cigna 
• Humana 

The review listed above indicates a growing trend by large insurance companies to expand coverage for telemedicine services during the pandemic and even permanently.

It is important to note that the lack of a published policy is not equivalent to noncoverage. Insurance companies can also make coverage determinations on an individual, case-by-case basis when no coverage policies exist.

These companies will be persuaded by evidence demonstrating that telehealth technology such as Miiskin PRO improves health outcomes compared to what is currently covered.

How to get store-and-forward Teledermatology Reimbursement

The American Medical Association (AMA), established the GQ Modifier for telehealth services rendered via asynchronous telecommunication systems.

The GQ Modifier in combination with standard E/M codes such as 99202-99215 offers a reimbursement rate comparable to in-person consultations; therefore, providers should look up if the patient’s insurance company accepts the GQ Modifier.

If the GQ Modifier is not accepted by the insurance company, providers should enquire if the 95 Modifier is accepted. 

The Center for Medicare and Medicaid Services (CMS) and private payers require the use of the 95 Modifier for E/M telehealth services.

According to AMA, E/M procedures involving electronic communication as a substitute for in-person encounters require an audio meeting. By having an asynchronous telehealth visit followed by a phone call, providers can use the 95 Modifier for reimbursement.

Click on the image to view it in full size

If the requirements described above are not met, providers can then use E/M the asynchronous teledermatology codes G9868 – G9870  to review images and patient-reported information for established patients with straightforward cases.

The last alternative is for providers to use the telehealth-specific Online Digital Evaluation and Management codes  99421-99423 for established patients with straightforward cases.

References:
¹ https://www.cchpca.org/policy-trends/
² https://assets.ctfassets.net/1ny4yoiyrqia/46W1Kyu78YqIed1ACGBMWa/68598d3432b7fd31790b0251c813e7ff/AAD-Coding-Teledermatology-Flowchart-2022-updated.pdf
³ https://jamanetwork.com/journals/jamadermatology/fullarticle/2778026

Request a Free Reimbursement Consultation

Name: *

Email: *

Organization Name: *

How did you hear about us: * —Please choose an option—NewsGoogleSocial MediaAdvertisingWord of MouthOther

City: *

Country: *

Your email will only be used to contact you with information about Miiskin PRO and to schedule a demo. Read our privacy policy.

// remove privacy policy part