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• W2011211457 abstract "Remote monitoring of ICU patients through ICU telemedicine (tele-ICU) has increasingly gained a foothold in the United States. Most of these tele-ICUs consist of a facility-based central hub that contracts with individual hospitals to remotely cover their ICUs. These facility-based hubs then contract with physicians to enable them to provide remote coverage to the hospital. Physicians spend their shift in the “command center” and receive a direct payment from the facility (rate reported, $160-$200/h in 2007)1Breslow MJ Remote ICU care programs: current status.J Crit Care. 2007; 22: 66-76Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar independent of the type of services rendered (surveillance or intervention) to the patients being monitored. The physician is providing a service to the facility that benefits both the facility and the patients. Fundamentally, the physician is reimbursed for work by the facility (in a sense, Medicare Part A dollars) instead of by the patients (Medicare Part B dollars). This is similar to a number of physician reimbursement models that exists across the health-care system (employed model, trauma call, moonlighting arrangements, hospitalists). Currently, physicians are not able to directly bill patients for these services. There are a number of reasons why creating a professional fee billing process (ie, billing the patient) should not be considered. First, there is still a degree of uncertainty about the direct benefit of this service. There is a significant number of studies that speak to the efficacy of tele-ICU monitoring as well as a significant number that dispute these assertions. In a trial published in 2010 involving two community hospitals and >4,000 patients, no reduction in mortality, length of stay, or hospital cost attributable to the introduction of tele-ICU monitoring was found.2Morrison JL Cai Q Davis N et al.Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals.Crit Care Med. 2010; 38: 2-8Crossref PubMed Scopus (116) Google Scholar The conclusion of a study published in the Journal of the American Medical Association in 2009 was that tele-ICU monitoring is not associated with an overall improvement in mortality or length of stay.3Thomas EJ Lucke JF Wueste L Weavind L Patel B Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay.JAMA. 2009; 302: 2671-2678Crossref PubMed Scopus (166) Google Scholar Overall, there is no consensus on the direct benefit of tele-ICU in improving outcome. In today's world of professional fee billing, the creation of a Current Procedural Terminology (CPT) code requires supporting literature that demonstrates efficacy. At this time, the published data do not meet this standard, and it is unlikely that a CPT category 1 code could be created to transition the two CPT category 3 tracking tele-ICU codes 0188T, 0189T. However, if one takes the positive reviews of tele-ICU at face value, it has the potential to produce a considerable cost savings to hospitals by reducing hospital and ICU length of stay as well as improving compliance with evidence-based practices. Although these are critically important issues and valuable outcomes, they do not relate to patient-specific physician work that defines professional fee billing. The patient may never know that he or she was “seen” by the tele-ICU physician, and in fact, most patients monitored for any given time period will never have a meaningful interaction with the tele-ICU physician. The service provided by the physician is to the facility not to the patient, and the physician deserves to be reimbursed by the facility. Providing this physician support to the tele-ICU process is part of the cost of business to the hospital for this type service. Second, based on the preceding argument, it is fair to suggest that physicians currently are being reimbursed for their work in the tele-ICU setting by the facility. This reimbursement occurs by way of a direct payment to the physician without any need for the overhead associated with coding and billing patients and third-party payers. The purpose of the current Centers for Medicare & Medicaid Medicaid Services (CMS) fee-for-service model is to identify a service that is eligible for reimbursement and provide a process by which reimbursement occurs. This function already has occurred in the current tele-ICU business model. Third, the tele-ICU still requires “troops on the ground,” that is, a provider to deliver care to the patient at the bedside. This provider also is likely to want to bill for these services, which leads to the complicated problem of reimbursing both virtual and bedside physicians for doing the same job. Currently, non-face-to-face services are considered part of the preservice and postservice work of an evaluation and management service (until the next evaluation and management service). Any activity that a tele-ICU physician would bill is currently part of the reimbursement of the bedside ICU physician. It is unlikely that CMS would pay two physicians for the same service. Would CPT codes 99291, 99292 (critical care, evaluation and management) be devalued because some of the preservice and postservice work is being done by the tele-ICU physician? How would the overlap between the on-site physician arriving at bedside while the tele-ICU physician is writing a note and accruing minutes be determined and assigned. Additionally, this potentially produces a disincentive for on-the-ground physicians in rural or underserved areas to provide any bedside care—just let the remote “doc-in-the-box” do it. Under the current fee-for-service model, this will become a competing code set/relative value unit for real critical care time and real face-to-face critical care services, potentially exacerbating the access that patients in rural areas have to critical care physicians. Fourth, it is clear that there are a limited number of dollars to pay for health care. Every new service that is created and paid for requires that either new dollars be added to the system or that the current dollars be redistributed (budget neutrality adjustment factor). Although there are rules about how this is done, it is clear that there is an effort not to add more money to the Medicare Part B system. In fact, there are regular last-minute efforts to avoid the sustainable growth rate cuts to physician reimbursement. The addition of a new service (tele-ICU monitoring) would likely go into direct competition for bedside critical care services leading to the possible or probable devaluation of face-to-face critical care services. Although each individual tele-ICU encounter that is billed will likely produce minimal reimbursement (which is still subject to the practice management overhead of the physician's practice and the whims of CMS and Congress), the potential volume of all claims could reduce the payment received for face-to-face critical care time. At the same time, it is unlikely that individually, a single tele-ICU physician will generate enough professional fee billing to justify time spent at night “in the box” as well as the effort of submitting individual bills. Ultimately, the facility still must bear most, if not all, of the cost of the physician associated with the tele-ICU. The professional fee received by the tele-ICU physician only subsidizes a service provided by the hospital out of the limited Part B professional fee pool. In summary, I believe that there are number of good reasons to continue to expand tele-ICU services. However, there are a number of reasons that professional fee billing is not appropriate for tele-ICU monitoring. First, this service is of uncertain benefit, and additional studies to determine the efficacy of tele-ICU monitoring are necessary before a CPT category 1 code should be created. Second, this service is provided by a physician to a facility and currently is being reimbursed by a facility. Third, it is a complicated service to integrate with current and ongoing services and potentially offers a disincentive to actual face-to-face services that should provide superior patient care. Finally, billing for tele-ICU services has great potential to devalue actual face-to-face service and yet be insufficient to cover the physician cost of the tele-ICU service." @default.
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• W2011211457 title "Counterpoint: Should Tele-ICU Services Be Eligible for Professional Fee Billing? No" @default.
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