In the United States, the vast majority of health care costs are paid by private insurers, Medicare, and Medicaid. The following information provides a snapshot of reimbursement for telehealth services commonly provided by RDNs:
Private insurance coverage and reimbursement for MNT in general varies significantly by insurance company and specific products/plans. Since there is no federal legislation requiring private payer reimbursement for telehealth services, states are left to determine if and how they will regulate telehealth practice and reimbursement. According to a survey from Foley & Lardner LLP, more states are adopting telehealth commercial payer laws, with 42 states and DC having such statutes in place as of their 2019 report. However, several of these state laws do not actually require coverage or payment parity (meaning requiring private insurers to cover telemedicine provided services comparable to that of in-person or paying at the same rate). Currently, only 10 states offer true payment parity. Thirteen states require commercial health plans to cover remote patient monitoring services. Some insurance companies value the benefits of telehealth and will reimburse a wide variety of services. Others have not yet developed comprehensive reimbursement policies, so payment for telehealth may require prior approval. Each insurer will set its own policies related to coverage, coding and payment for these services.
The Medicare Part B program allows several services provided by RDNs and nutrition professionals to be offered via telehealth. These services include:
- Medical nutrition therapy (MNT), individual and group
- Diabetes self-management training (DSMT), individual and group
- Intensive behavioral therapy for cardiovascular disease (must be billed by the primary care provider)
- Intensive behavioral counseling for obesity, individual (must be billed by the primary care provider)
- Annual wellness visit (must be billed by the primary care provider)
For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit:
- Medicare Telehealth Services and Registered Dietitians
- Medicare Learning Network Telehealth Services Fact Sheet
While national guidelines for payment for telehealth services under the Medicare program are clearly defined, such is not the case with state level coverage policies. Medicaid coverage and reimbursement for MNT in general varies significantly across the country. Since there are no federal laws around Medicaid coverage of telehealth services, laws are generated at the state level and vary greatly from state to state. Each state will set its own policies related to coverage, coding and payment for these services.
The Center for Connected Health Policy 's (CCHP) Fall 2019 edition of "State Telehealth Laws and Medicaid Program Policies," offers policymakers, health advocates, and other interested health care professionals the most current summary guide of telehealth-related policies, laws, and regulations for all 50 states and the District of Columbia. Read the report and use the interactive map on their website to learn more about coverage for telehealth services in your state. All 50 states and Washington DC have some form of Medicaid reimbursement for telehealth, although the details vary widely. It should be noted that the Telehealth service needs to first be a covered service of the state Medicaid program before the Medicaid program will pay for the service when provided via Telehealth. In general, email, telephone and fax are not acceptable forms of delivery, with states being either silent of explicitly excluding these forms of service delivery. The practice of restricting reimbursable telehealth services to rural or underserved areas is decreasing. It is a common practice for state Medicaid programs to limit the type of facility that may serve as an originating site, although the number of states adding the home, schools and/or federally qualified health centers and rural health centers to their list of eligible originating sites is increasing. Thirty-nine states require some type of informed consent for telehealth encounters.
Additional Medicaid Resources:
- State Medicaid Directors
- The Center for Connected Health Policy 's State Telehealth Laws and Reimbursement Policies Report
- American Telehealth Association
For information for your state, contact your Affiliate Reimbursement Representative. Visit the Academy 's Leadership Directory and click on Affiliates to send him/her an email.
CPT Codes for Telehealth
Each payer determines the Current Procedural Terminology (CPT®) codes they will recognize for reimbursement of covered telehealth services. In general, in-person services such as MNT delivered via telehealth are billed using the same CPT® codes as used when the service is delivered in person (e.g., 97802, 97803, 97804) as telehealth is a delivery modality. Modifiers are used to indicate the service was delivered as a telehealth encounter. There are a few CPT® and G codes developed specifically for online or digital services.
Medicare require providers to use Place of Service (POS) code 02 to indicate that a procedure or service was delivered as a telehealth encounter.
As of January 1, 2017, CPT modifier code "95 Synchronous Telemedicine Service Renders Via a Real-Time Interactive Audio and Video Telecommunications System" was established to indicate that a procedure or service that is typically performed face-to-face was delivered via real-time telehealth. Appendix P of the American Medical Association 's Current Procedural Terminology (CPT®) manual includes a list of CPT codes with which the 95 modifier code can be used. It is important to note that CMS does not recognize use of this modifier code.
Prior to delivering a service via telehealth, RDNs should check their payer contracts as well as each client 's individual health plan benefits for use of CPT code and specific coverage parameters.
Some common CPT codes payable under the Medicare Physician Fee Schedule that may also be that may be recognized by other payers can be on the CMS website.
Privacy and Security
Covered entities, including credentialed nutrition and dietetics practitioners, must comply with the HIPAA privacy regulations for use and disclosure of patient and client information. The rules require covered entities to:
- Distribute a privacy notice to all patients
- Post the privacy notice in practitioner 's offices
- Make good-faith-effort to obtain the written acknowledgement from the patient of their receipt of the notice
- As requested allow patients access to their records
- Complete training and train staff to understand and fully implement privacy requirements
Keeping patient and client information private is also indicative of a good security system to ensure breeches do not occur. Healthcare Information and Management Systems Society (HIMSS) has information on privacy and security.
- Email email@example.com with your questions regarding payment for MNT and other services delivered via telehealth.