Hospitals Saw Substantial Underbilling for Medicare Telestroke Services


One-third of hospitals across the country offered telestroke services, but less than 40 percent submitted Medicare telestroke claims in the year before the COVID-19 pandemic.

Following the Furthering Access to Stroke Telemedicine (FAST) Act, Medicare claims for telestroke services increased in rural and urban emergency departments. However, there was still substantial underbilling from hospitals with known telestroke capabilities, according to a Health Affairs study sent to journalists.

During the COVID-19 pandemic, Medicare temporarily expanded reimbursement for telemedicine for beneficiaries in rural and urban areas. As the public health emergency nears its end, policymakers are considering the future of Medicare telemedicine reimbursement.

One option is to continue the temporary expansions for a couple of years and reassess the impact on spending and care quality. Another option would be to make Medicare telemedicine reimbursement permanent in urban areas for selected services only, while other services would revert to pre-pandemic restrictions.

Medicare has had experience with selective telemedicine reimbursement, as Congress passed the FAST Act in 2018, which expanded reimbursement for telestroke services to urban areas. Previously, Medicare only reimbursed for telestroke services in some rural regions.

Telestroke care was the first virtual service that Medicare offered reimbursement for both urban and rural residents. Following the FAST Act, billing for this service increased, but there was still substantial underbilling among hospitals with telestroke capabilities.

Researchers gathered Medicare fee-for-service inpatient and outpatient claims from acute care and critical access hospitals between January 2016 and March 2021. They focused on 1,166 rural and urban hospitals with telestroke capacities as of January 2018, one year before the FAST Act.

Following FAST Act implementation, the percent of stroke episodes with a telestroke claim more than doubled. In December 2018, 1.1 percent of stroke episodes had a telestroke claim compared to 2.8 percent in December 2019. Relative to the pre-FAST Act period, telestroke claims increase by 476 percent.

After the start of the COVID-19 pandemic, stroke episodes with accompanying Medicare telemedicine claims increased. Between February 2020 and April 2020, episodes with telestroke claims increased 3.6 percentage points, indicating a more than 100 percent increase, the study noted.

However, some of these billing claims were inconsistent with Medicare requirements.

After the FAST Act implementation, Medicare stated that providers must use the new G0 modifier code for telestroke consultations. Only half of the telestroke claims submitted during the pandemic used the code. The remaining claims used combinations of inpatient telemedicine HCPCS and CPT codes, the GT modifier code, the place-of-service code for telehealth, and the 95 modifier code—which indicated synchronous telemedicine service.

Out of the 1,166 hospitals that had telestroke capabilities, 27 percent had Medicare telestroke claims in the year before FAST Act implementation. This measure rose to 39 percent after one year of FAST Act implementation. Finally, by the end of 2020, 60 percent of hospitals submitted Medicare telestroke claims.

The FAST Act increased Medicare billing for telestroke services at rural and urban hospitals, perhaps due to the more straightforward reimbursement rules.

“The act eliminated the need to establish whether the delivery site was rural,” the study stated. “It is also possible that with broader reimbursement, telestroke networks saw greater value in setting up their infrastructure to submit claims.”

The results also highlighted substantial underbilling for telestroke services. Data indicated that hospitals were providing telestroke consultations in the years before and after the FAST Act went into effect, but few hospitals submitted corresponding Medicare claims.

“We believe that this was largely because of the complexity of telemedicine billing for hospital-based services, including administrative and contractual barriers,” researchers wrote.

Submitting a claim would have required the remote specialist to gather patient health plan information and complete other regulatory processes. Providers also frequently used the wrong codes for telestroke services.

Once Medicare expanded telemedicine reimbursement during the pandemic, more hospitals submitted claims for telestroke services.

“Although increased clinical need for telemedicine certainly played an important role in this growth, we hypothesize that it was also facilitated by the removal of many administrative barriers, such as condition-specific telemedicine rules, state licensure requirements, and waiving of privacy requirements for technology,” researchers stated.

Simplifying Medicare payment rules for telemedicine and establishing universal coverage may help avoid underbilling for telehealth services, the study concluded.

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