AMA Proposes New CPT Reimbursement Codes to Advance Telehealth Services

The American Medical Association (AMA) has begun creating a new set of CPT codes to support the reimbursement process for telemedicine. Recently, the task force responsible for this initiative held its first meeting.



CPT, which stands for Current Procedural Terminology, is the official list and coding system of medical professional terminology in the United States, consisting of five-digit codes. Since its introduction in 1966, the American Medical Association (AMA) has released a new edition of CPT codes every October. These codes are commonly used by healthcare providers and insurance companies to facilitate communication among themselves and with patients. The first edition of CPT codes included only surgical services. Starting in 1983, the Centers for Medicare & Medicaid Services began using CPT codes for documentation and reimbursement for Medicare beneficiaries. These codes are critically important for Medicare and are subject to strict guidelines regarding coverage and reimbursement criteria.

A distinctive feature of the 2015 CCM codes is that they allow reimbursement for telehealth services through the application of care management principles. Currently, a variety of CPT codes are available for both face-to-face encounters and various telehealth services, as well as for modern medical reporting. However, a standardized and clearly defined set of codes will, for the foreseeable future, help providers achieve a smoother reimbursement experience for virtual care interactions. In some cases, reimbursement may cover not only the clinical service but also the underlying technology itself.

“The CPT code set is built on the foundation that every participant in the medical community can effectively share accurate information about healthcare services with others,” said AMA President Steven J. Stack in a statement. “Input from the Telehealth Work Group helps ensure that the CPT code set reflects new technologies and advances in telehealth available to mainstream clinical practice, and that the code set fulfills its role as the common language of the healthcare system for contemporary medical reporting.”

Comprising approximately 50 physicians, healthcare professionals, telehealth innovators, and health insurance representatives, the working group convened in Philadelphia last month. During the inaugural meeting, as reported by Modern Healthcare, positive momentum was evident, although further efforts are required. Moving forward, the working group will continue to operate through multiple internal subcommittees to explore future possibilities in telehealth, categorize existing telehealth use cases, and identify areas with the most urgent need for coding standards. The group aims to develop feasible recommendations and submit them to the Editorial Committee as soon as possible.

Although the CPT Editorial Panel is embracing telemedicine, other divisions of the American Medical Association (AMA) have adopted a more cautious stance. This summer, the AMA’s Council on Ethical and Judicial Affairs sought to reach an agreement on ethical guidelines to be considered in online medical consultations between patients and physicians. However, a physician from Texas has persuaded the council to reconsider its plan. The guidelines have been submitted to the council for further review.

Legislation and Reimbursement Accelerate the Adoption of Telemedicine Technologies

The use of telemedicine technology is growing in the United States, driven by recent legislative changes that have lifted restrictions on telemedicine websites, as well as increased spending on telemedicine services. Providers are expanding care across national borders, capitalizing on opportunities created by interstate medical licensure compacts and the adoption of telemedicine technologies.

Debra Jose, a telehealth partner at the U.S. law firm Jones Walker in Louisiana, told mHealthIntelligence.com in an interview about ongoing legislative reforms in the telehealth space and the impact of interstate medical licensure on the use of telehealth technologies.

New Telehealth Legislation Expands Healthcare Access

“Legislative changes are occurring at both the federal and state levels,” Dr. Lahiji began. “There is currently a promising bill, the TELE-MED Act, which I hope will be passed within the next year. It has supporters in both the Senate and the House of Representatives. This legislation would allow physicians participating in Medicare to treat insured patients across all 50 states with just one medical license.”

“The purpose of this bill is to lower the standards for accessing interstate care, while also providing more options for underserved areas and enabling providers to expand their reach, particularly among Medicare-eligible seniors who are most in need of these benefits.”

“The sole criterion of the TELE-MED Act is that healthcare providers must be physicians or medical practitioners participating in Medicare, and the care must be provided to Medicare beneficiaries,” explained DeLaJose. “Under this provision, patients can receive telemedicine care in their own state without the provider needing to obtain additional state licenses. However, if healthcare providers are treating non-Medicare patients, they must still go through the standard process for obtaining a medical license as required by their respective states.”

“Progress on interstate medical licensure was also made last year. The Federation of State Medical Boards completed the Interstate Medical Licensure Compact model in September 2014, requiring at least seven states to join.”

“As of today, 11 states have enacted the Interstate Medical Licensure Compact, including Wyoming, South Dakota, Utah, Idaho, Iowa, Illinois, and Alabama. These states are all members of the compact, and legislatures in eight additional states are advocating for its adoption,” she noted.

“Additionally, medical boards in 30 other states have endorsed the compact and expressed their intention to join it in the coming years. The Interstate Medical Licensure Compact expedites the process for physicians to obtain licensure. Each state retains full authority over the regulatory oversight of medical practice.”



Telemedicine Insurance Reimbursement vs. In-Person Medical Care

“There are several of my favorite pending bills that aim to address issues related to medical access and reimbursement. The Telehealth Enhancement Act of 2015 promoted and strengthened Medicare programs by removing some significant barriers,” the lawyer said.

“The 2015 Telehealth Enhancement Act expanded the original network of sites to include major urban primary care hospitals, community hospitals, and the most promising sector—home-based telehealth sites. Furthermore, all sites currently providing treatment for acute stroke under existing laws will be retained as permanent sites.”

“Essentially, the bill is expanding the geographic areas covered by telehealth services while broadening the scope of reimbursable services. The Telehealth Enhancement Act of 2015 also provided incentives under Medicare’s Hospital Readmissions Reduction Program.”

"Nowadays, if the 30-day readmission rate for discharged patients is high, hospitals will face fines from Medicare."

“This legislation stipulates that hospitals will bear the cost of incomplete treatment, which is undoubtedly an effective measure to constrain hospital professional management and reduce readmission rates. Under current law, revenue hospitals derive from readmitted patients will be offset by Medicare penalties,” explained Delohosse.

“This has significantly encouraged the use of telemedicine, particularly for post-acute or chronic conditions that can be managed directly at home through remote monitoring,” the lawyer continued.

“Following the Bipartisan Budget Act of 2015, which strengthened telehealth provisions, the Creating High Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2018 was enacted to address more specific reimbursement issues. This legislation allows healthcare providers participating in telehealth services to eliminate geographic barriers in rural areas, health professional shortage areas, and metropolitan areas. According to the telehealth services outlined therein, Jiang Yong expanded the program in three phases over a four-year period.”

“The 2015 Telehealth Equity Act expanded the scope of reimbursable telehealth services, covering remote patient monitoring for chronic conditions such as heart disease, chronic obstructive pulmonary disease (COPD), and diabetes. Its coverage also includes medical services provided by respiratory therapists, physical therapists, occupational therapists, speech-language pathologists, and audiologists,” she noted.

Challenges Telemedicine Providers Need to Overcome

“The challenge hospitals face is to further integrate telehealth systems—such as teleradiology, telestroke care, and tele-ICU—on top of traditional telemedicine specialties. Hospitals need to more proactively integrate telehealth systems to enable better remote monitoring of chronic diseases, particularly in home settings.”

“Physicians’ work has also encountered barriers with telemedicine, as they seek to determine how to integrate telemedicine transmission platforms into existing practices,” continued Dr. Lahousse.

“With the growing direct-to-consumer trend in telemedicine, many physicians are reluctant to lose their patients to virtual online consultations, as they do not offer telemedicine as a viable option. There must be a way for physicians to allocate time to manage online consultations for these digital patients.”

The Current State of Telemedicine Development

“Twenty years ago, I began studying and actively engaging in the telemedicine industry,” she explained. “What surprised me was the direct-to-consumer market and its boundless expansion. Over the years, we have been pioneers in telemedicine, striving to convince physicians and hospitals that it is an efficient and affordable way to deliver high-quality care to patients, particularly those in underserved areas.”

“The current direct-to-consumer market has elevated telemedicine to a new level—telemedicine is ubiquitous, taking place in companies, schools, prisons, and other settings where online consultations can be conducted. The market Walgreens has entered is enormous,” she remarked. “Individuals can purchase affordable medical devices from Walgreens and use them for remote health monitoring. Through its partnership with MDLive, Walgreens’ extensive network of professional physicians enables patients to access virtual online consultations covering medications and nearly any other area of need.”

“Telemedicine is no longer confined to hospitals,” the lawyer said.

Compiled by Xu Huiting

Editor: Zhang Nan