Telemedicine, as defined by the World Health Organization, is “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”¹ Telemedicine is not new; the military and space industries have used it since the 1960s.² Alaska initiated its 1998 Telehealth Solutions program³ to improve access to care in a state with too few physicians and more than 600,000 square miles of territory. Medicare began its telehealth demonstration project in Alaska and Hawaii in the early 2000s. According to the Office of Inspector General, Medicare spending for telehealth increased from $61,302 in 2001 to $17,601,996 in 2015.⁴ Telemedicine has grown rapidly because it offers the benefits of increased access, cost effectiveness, improved quality, and convenience for patients.⁵

Within telemedicine, the term “originating site” refers to the location of the patient, while the term “distant site” refers to the location of the specialist or remote diagnostic testing facility with no physical contact with the patient. When telemedicine is applied to remote imaging of diabetic patients to assess diabetic retinopathy, the retinal camera is located at the “originating site” while the ophthalmologists or optometrist reading the digital images is at the “distant site.”⁶ Medicare will pay for telehealth services when an interactive telecommunications system is used and sometimes when a “store and forward” system is used, whereby images or video are taken, stored, and viewed later by a health care practitioner.⁴

In 2011, the AMA added 2 telemedicine codes, 92227 and 92228, to CPT to “… meet the needs of diabetic retinopathy screening programs which provide remote imaging and data submission to a centralized reading center.” The codes are similar but differ in important ways. Code 92227 is remote imaging for detection of retinal disease, such as retinopathy in a patient with diabetes, with analysis and report under physician supervision, unilateral or bilateral. Code 92228 is remote imaging for monitoring and management of active retinal disease, such as diabetic retinopathy, with physician review, interpretation, and report, unilateral or bilateral.

In the first code, emphasis is on detection of retinal disease, while the second code emphasizes management of retinal disease. Code 92227 is screening, and 92228 is evaluation and management of chronic eye disease. Significantly, 92227 is performed under physician supervision but omits an interpretation, while 92228 requires “interpretation and report.”

In 2019, CPT added 3 new procedure codes to report various aspects of remote physiologic monitoring:

• 99453: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.
• 99454: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
• 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

Remote physiologic monitoring treatment management services are provided when clinical staff members, physicians, or other qualified health care professionals use the results of remote physiologic monitoring to manage a patient under a specific treatment plan. To report remote physiologic monitoring, the device used must be a medical device as defined by the FDA, and service must be ordered by a physician or other qualified health care professional.

The addition of these CPT codes was hailed as a positive move that expands telehealth for the Medicare program.⁷ Medicare administrator Seema Verma said, “There has been a telehealth benefit mostly for rural providers, but access to care is not just a rural issue, it’s something that patients struggle with across the country.”⁸ CMS says, “Studies note that remote patient monitoring has a positive impact on patients as it allows patients to share more live-time data with their providers and caregivers, which will lead to more tailored care and better health outcomes.”⁸ CMS also says, “It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places including their homes, rather than requiring them to go to a health care facility to receive telehealth services.”⁸

Remote physiologic monitoring of intraocular pressure (IOP) has the potential to help ophthalmologists and optometrists manage glaucoma better through closer monitoring of high-risk patients and to alert them to inadequate treatment before extensive damage of the optic nerve occurs. For most patients, IOP measurements during periodic eye exams provide sparse data that may be misinterpreted by the physician due to diurnal variability and unreliable patient compliance with medications. More frequent IOP measurements taken by the patient at home and periodically transmitted to the physician fit squarely within the meaning of remote physiologic monitoring. A device intended for this purpose, and FDA cleared, is the Icare Home Tonometer (Figure 1). It is a handheld device that a trained and certified patient can use to safely and reliably measure IOP at home without local anesthesia. Compared with Goldmann applanation tonometry, Icare Home measurements are comparable.⁹ The favorable Medicare coverage and payment policy for remote physiologic monitoring offer a new avenue to provide better eye care to patients. GP

References

1. World Health Organization. Telemedicine opportunities and developments in member states. 2010. https://www.who.int/goe/publications/goe_telemedicine_2010.pdf . Accessed July 12, 2019.
2. Wicklund E. Is there a difference between telemedicine and telehealth? PHI in the news. June 3, 2016. https://www.phi.org/news-events/1021/is-there-a-difference-between-telemedicine-and-telehealth . Accessed July 12, 2019.
3. Schnatz J. Alaska’s Telehealth Solutions programme. October 9, 2018. https://www.centreforpublicimpact.org/case-study/alaskas-telehealth-solutions-programme/ . Accessed July 12, 2019.
4. Jarmon GL. CMS paid practitioners for telehealth services that did not meet Medicare requirements. April 2018. https://oig.hhs.gov/oas/reports/region5/51600058.pdf . Accessed July 12, 2019.
5. American Telemedicine Association. Telehealth basics. https://www.americantelemed.org/resource/why-telemedicine/ . Accessed July 12, 2019.
6. CMS Medicare Learning Network. Telehealth services. January 2019. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/telehealth-services-text-only.pdf . Accessed July 12, 2019.
7. Centers for Medicare & Medicaid Services. CMS finalizes policies to bring innovative telehealth benefit to Medicare Advantage. Press release. April 5, 2019. https://www.cms.gov/newsroom/press-releases/cms-finalizes-policies-bring-innovative-telehealth-benefit-medicare-advantage . Accessed July 12, 2019.
8. Wicklund E. CMS to reimburse providers for remote patient monitoring services. mHealth Intelligence. November 2, 2018. https://mhealthintelligence.com/news/cms-to-reimburse-providers-for-remote-patient-monitoring-services . Accessed July 12, 2019.
9. Mudie LI, LaBarre S, Varadaraj V, et al. The Icare Home (TA022) study: performance of an intraocular pressure measuring device for self-tonometry by glaucoma patients. Ophthalmology. 2016;123:1675-1684.

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernardino, California.