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.