Transcript MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES

REIMBURSEMENT FOR
TELEHEALTH SERVICES
AFHCAN
• Alaska Federal Health Care Access Network
• Began in 1998 to improve access to health care
for federal beneficiaries
• Veterans Administration, Department of
Defense, US Coast Guard, Indian Health Service,
and the Alaska Native Tribal Health Consortium
(managing partner)
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Version 3
•Basic Cart:
•Otoscope
•Digital Camera
•Scanner
•ECG
•Extras:
•Tympanometer/Audiometer
•Spirometer
•Vital Signs Monitor (pulse
oximeter, blood pressure,
temperature and pulse)
•VTC Equipment
•Dental (Intraoral) Camera
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What is Telemedicine?
Telemedicine is a health care delivery method that links
a patient and a provider who are not at the same
location and is identical to a traditional healthcare visit
except for the mode of delivery:
• Via real time video or by
• Sending clinical information or picture images to a
provider for evaluation, consult or treatment via store
and forward.
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What is Telemedicine?
• No telemedicine CPT codes because
telemedicine is not a service provided, it is a
MODE OF DELIVERY.
• There are TM modifiers that alert payers of
telemedicine presentation.
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Telehealth and HIPAA
http://www.hhs.gov/ocr/privacysummary.pdf#search='summary%20of%20the%20HIPAA%20privacy%20rule'
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HIPAA cont.
Permitted Uses and Disclosures.
A covered entity is permitted, but not required, to use and disclose
protected health information, without an individual’s authorization, for
the following purposes or situations:
(1) To the Individual (unless required for access or accounting of
disclosures);
(2) Treatment, Payment, and Health Care Operations;
(3) Opportunity to Agree or Object;
(4) Incident to an otherwise use and disclosure
(5) Public Interest and Benefit Activities
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Definition of Interactive
Two-way, real-time
(live) interactive
communication
between the patient
and the distant site
(consulting)
practitioner via
audio/video
(Polycom or VTC)
equipment.
Photo credit: http://murray.senate.gov
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Definition of Store & Forward
Store and Forward is:
asynchronous (not
live) transmission of
medical information to
be reviewed at a later
time by a health care
provider at the distant
(consulting) site.
Photo credit
http://www.ttuhsc.edu/telemedicine/images/
assited006.jpg
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Definition of Store & Forward (cont.)
Medical Information may include, but is not
limited to:
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Video clips
Still images
X-rays (not currently on AFHCAN system)
EKG’s
EEG’s
Audio clips
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Requesting Provider (sending sitewhere the patient is located)
Face to Face visit. Provider evaluates a
patient, determines the need for a
consultation, and arranges services of a
consulting provider for the purpose of
diagnosis and treatment.
Procedure (CPT)
Code
Appropriate covered
procedure code for
provider type
Required Telemedicine Modifier
None required – nothing
changes with
telemedicine
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Presenting Provider
(Where the Patient is Physically Located)
• Introduces a patient to consulting provider during an
interactive telemedicine session
• This provider type is not required and would only be
billable during a live interactive session.
Procedure Code
Covered procedure code for
Brief/minimal evaluation and
Management service for an
Established patient
Required Telemedicine
Modifier
GT
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Distant Site (Consulting) Provider
Evaluates the patient and/or medical
data/images using telemedicine mode of
delivery upon recommendation of the referring
provider
Procedure Code
APPROPRIATE COVERED
PROCEDURE CODE FOR
PROVIDER TYPE
Required Telemedicine
Modifier
GT (Interactive
Method)
GQ (Store-andForward Method)
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PROVIDER TELEMEDICINE
ROLES
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Provider Telemedicine Roles
Store-and-Forward Mode of Delivery
Referring Provider
Digital images, sounds,
previously recorded video
Consulting
Provider
Interactive Mode of Delivery
Referring Provider
Presenting Provider
(Patient is Here)
Live Interaction with patient
using camera, video, or audio
conference equipment
Consulting
Provider
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Provider Telemedicine Roles
EXAMPLE
Store-and-Forward Mode of Delivery
This
could
also be
a CHA/P
REMOTE
CHA/P
Digital images, sounds,
Previously recorded video
HUB
CONSULTING
PROVIDER
Interactive Mode of Delivery
HUB
PROVIDER
REMOTE
CHA/P
The
patient is
here.
Live Interaction with patient
Using camera, video, or audio
Conference equipment
ANMC
CONSULTING
MD
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Referring Provider Type
(sending site)
• Performs face to face evaluation of patient
• Determines need for further consultation with
another healthcare provider
• Develops media presentation (store and
forward) including complete information of
evaluation
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Presenting Provider
(Where the Patient is Physically
Located)
• Introduces a patient to consulting
provider during an interactive
telemedicine session (example:
CHA/P at a remote site)
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Distant Site (Consulting)
Provider
• Evaluates the patient and/or medical
data/images using telemedicine mode of
delivery upon recommendation of the
referring provider (example: MD at ANMC or
Regional Hub)
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DOCUMENTATION
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Provider Documentation
• Follow same requirements as face to face to meet
CPT standards for coding – remember SOAP
notes!
• Do not utilize the AFHCAN system as email!
Always remember that the information you
send/receive becomes part of the patient’s medical
record!
• As with all medical records, it is important to clarify
the encounter so that coders aren’t making
judgment calls (don’t assume anything)!
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TM 4
This is an ongoing
email
communication
between a
remote provider
and a specialist
at ANMC.
NO CONSULT!
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IMPORTANT!
• When the AFHCAN system is used for
communication between two or more
providers regarding a specific patient, the
AFHCAN form needs to be printed out and
incorporated into the medical record!
• This could mean that a visit would have a
PEF and an AFHCAN form, or a PCC and an
AFHCAN form.
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EXAMPLE
TM 1
This statement
alone is not
sufficient for
requesting a
consult.
A statement is
also required for
why they are
requesting a
consult.
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TM 2
PROBLEMS:
1. Appears that ANMC
physician initiated this
(no one has requested
a consult).
EXAMPLE
OF WHAT
NOT TO
DO!
2. There is evidence of
a prior communication
that coder doesn’t have
access to. Each record
needs to be a stand
alone document.
3. ANMC cannot code as a
consult because there is no
statement about why the remote
site is requesting a consult.
Additionally, the “consulting”
provider is assuming treatment
of the patient, so does not meet
criteria of consult. ANMC also
cannot code an E/M because
patient is not present (no exam).
4. This is more like an ongoing
email communication.
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TM 3
Chances are, this visit
will meet the
requirements for a
99213, but impossible
to code without the
PCC or PEF
EXAMPLE OF
WHAT TO DO
Assuming this form would be used
to bill the consult, the documentation
provided here meets the criteria for a
99242 Level II Office Consultation:
1. Expanded problem focused history
2. Expanded problem focused exam
3. Straight forward medical decision making
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E/M*
Guidelines to
Remember
* Evaluation/Management
New Patient vs.
Established Patient
Definition
• New Patient – A new patient is one who has
not received any professional services from the
provider or another provider of the same
specialty who belongs to the same group
practice, within the past three years.
• Established Patient – An established patient
is one who has received professional services
from the provider or another provider of the
same specialty who belongs to the same group
practice, within the past three years.
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New Patient
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Established Patient
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Consultations
• 99241 Office consultation for a new or
established patient, which requires these
three key components:
• A problem focused history;
• Problem focused examination; and
• Straightforward medical decision making.
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Consultations
• 99242 Office consultation for a new or
established patient, which requires these
three key components:
• An expanded problem focused history;
• An expanded problem focused examination;
and
• Straightforward medical decision making.
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Consultations
• 99243 Office consultation for a new or
established patient, which requires these
three key components:
• A detailed history;
• A detailed examination; and
• Medical decision making of low complexity.
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Consultations
• 99244 Office consultation for a new or
established patient, which requires these
three key components:
• A comprehensive history;
• A comprehensive examination; and
• Medical decision making of moderate
complexity.
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Consultations
• 99245 Office consultation for a new or
established patient, which requires these
three key components:
• A comprehensive history;
• A comprehensive examination; and
• Medical decision making of high complexity.
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Three R’s of Consultations
1. Requesting a consult
2. Rendering an opinion
3. Reporting back to the requesting
provider
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PAYOR SPECIFIC
REIMBURSMENT
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STATE OF ALASKA
MEDICAID
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Service Requirements
• Telehealth services must
– Be within the scope of Medicaid’s coverage
provisions
– Be within the scope of the practitioner’s license
– Be a service that is appropriate for using a
telemedicine method
MEDICAID
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Service Requirements cont.
• Provider must ensure telemedicine
transmission meets all federal and state
privacy regulations and requirements
• Alaska Medical Assistance does not cover
medical services provided by telephone or
fax machine
MEDICAID
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Medicaid Providers
• Most healthcare practitioners who are
currently eligible for reimbursement by
Alaska Medical Assistance may participate in
telemedicine. However, the following
provider types cannot be reimbursed for
telemedicine delivery:
MEDICAID
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Ineligible Providers
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Home and Community-based Waiver
Pharmacy
Durable Medical Equipment (DME)
Transportation
Accommodation
End-stage Renal Disease
Private Duty Nursing
Personal Care Attendant
Vision (includes visual care, dispensing, or optician
services)
MEDICAID
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STORE & FORWARD
EXAMPLES
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TM 4
CHA/P Visit at a Remote Site
Visit meets
the criteria
for a 99212Established
Patient OV
•PF HPI
•PF Exam
•Low Comp
Dec Making
Document
that this is a
store and
forward
telemedicine
case.
Example of
WHAT TO DO
Store & Forward
CHA/P at a
remote
site sees
patient in a
face-to-face visit
and requests
consult from a
hub provider.
Important to
note provider
credentials
MEDICAID
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TM 5
This is the claim
billed to
FHSC
(MEDICAID)
for the CHA/P
end of the visit
only.
No telemedicine
modifier for the
face-to-face
visit, just use the
U1 modifier to
signify CHA/P as
provider.
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TM 6
Example of
WHAT TO DO
The consulting
provider at the
hub clinic reviews
the case.
This is a problem focused
exam, so 99241 is the
consultation code to bill with
a GQ modifier for the
telemedicine mode of
delivery.
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TM 7
Example of how to bill
FHSC
(MEDICAID) for the
consult if provider
is in a
clinic.
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FNP Visit at a Remote Site
TM 9
Store and
Forward
Requesting
telemed
consult
Sending 3
images
signifying
store and
forward.
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TM 10
Bill FHSC
For Referring
Provider FNP
No modifier
required for
the face-toface visit.
99212 for
face-toface visit
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TM 11
Example of
WHAT TO DO
The consulting
provider at the
hub clinic reviews
the case.
This is a problem focused
exam, so 99241 is the
consultation code to bill with
a GQ modifier for the
telemedicine mode of
delivery.
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TM 12
Billing FHSC
(MEDICAID) for
the consult (at
ANMC or Hub).
Consult
99241
GQ
Modifier
for Store
and
Forward
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INTERACTIVE EXAMPLE
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TM 13
Example of
Interactive
CHA/P is
Referring
Provider.
Pt will be
presented
in
Interactive
Session
tomorrow.
This visit
meets
guidelines
for 99212
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TM 14
Bill FHSC
(MEDICAID) for
CHA/P as
Referring
Provider in
Interactive
Session
Visit is
coded as a
99212 for
the face-toface visit
with patient
No
Telemedicine
Modifier for
the Referring
Provider
U1 Modifier
for CHA/P
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TM 15
It is the next
day, the patient
returns to the
clinic and is
presented by
the same CHA/P
for interactive
telemedicine
session with
Dr. Ortho at
Hub. The CHA/P
now is the
Presenter.
This visit
meets the
criteria for
99211.
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TM 16
This is how to
bill the Presenter
to FHSC
(MEDICAID).
U1
Modifier
for CHA/P
GT
Modifier
for
Interactive
Telemedici
ne Visit
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TM 17
This is how the
Consulting end
Is billed to FHSC
(MEDICAID)
Consult code
with a GT
modifier for
Interactive
Telemedicine
Session
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What if the CHA/P refers and
presents on the same day?
• FHSC (State of Alaska Medicaid) will only
pay on one of the bills, the second will most
likely be denied as “incident to” the first visit.
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Multiple Consultation Roles
• Store-and-Forward Mode of Delivery only
Referring
Provider
Consulting
Provider
MEDICAID
Consulting
Provider
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Multiple Consultation Roles
Example
• Store-and-Forward Mode of Delivery only
Referring
Provider
REMOTE CHA/P
Consulting
Provider
HUB FNP
Consulting
Provider
ANMC MD
Both Hub FNP and ANMC MD
can bill for consults
MEDICAID
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Multiple
Consultations/Referrals
• Multiple consultations covered
(scope of practice is greater than or equal to
the referring)
• Multiple referrals not covered
MEDICAID
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BILLING AND
REIMBURSEMENT
• Billed on 1500 for professional services
provided in a tribal free-standing clinic setting
• Billed on UB for professional services
provided in tribal outpatient hospital clinic
• Services are reimbursed at the regular
Medicaid rate
MEDICAID
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Exclusions to Required
Modifiers
• Currently accepted practices within an
industry not affected
• Example: teleradiology consults will not need to use
telemedicine modifiers GT and GQ; these providers
should continue to use modifiers -26 (Professional
Component)
MEDICAID
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Telemedicine for Dental
Providers - Medicaid
• Store and Forward Application (sending x-ray
image) to a Dentist for interpretation is currently
reimbursed
• Live (interactive) consults by the distant site dentist
can be reimbursed as if face to face
• Presenting providers use CDT-4 code D0140 –
Limited Exam for reimbursement
• Use your standard dental claim form
• There are NO telemedicine dental modifiers
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MEDICARE
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Medicare Reimbursement
• Tribal sites permitted to bill store and forward
consultations due to participation in federal
demonstration project – AFHCAN
• CHA/P originating site referrals not billable
(Medicare does not recognize CHA/P as a provider)
• Originating site can NOT bill a facility fee with
CHA/P referral since Medicare does not recognize
CHA/P as a provider)
• Consulting Provider has to bill as an office visit, not
consult with CHA/P referral
MEDICARE
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TM 18
CHA/P Visit at a Remote Site
Visit meets
the criteria
for a 99212Established
Patient OV
Document
that this is a
telemedicine
visit.
CHA/P at a
remote
site sees
patient in a
face-to-face visit
and requests
consult from a
hub provider.
MEDICAID
Important to
note
provider
credentials
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HOWEVER….
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TM 19
Medicare can be billed for the consulting side,
although an E/M code will be used instead of a
consult code. Since Medicare does not recognize
CHA/P’s as providers, there is no request for
consult. The consulting provider bills as a face-toface visit.
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TM 20
Consulting MD
bills an E/M. In
this case
99212.
Meets criteria
for
99212:
PF HPI
PF Exam
DM Low
Complex
Use the GQ
modifier to
document
store and
forward
telemedicine
as mode of
delivery.
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TELEHEALTH SERVICES
INCLUDE:
•
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•
•
Office Visits
Other Outpatient Visits
Consultation
Individual Psychotherapy
Pharmacologic Management Services
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DEFINITIONS
• Distant Site – where the person delivering
the service is located at the time
telecommunications service is provided
• Originating Site – where the eligible
Medicare beneficiary is located at the time
telecommunications services are furnished
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DEFINITIONS, cont.
• Asynchronous Store & Forward Technologies –
patient’s information is transmitted from an
originating site to a practitioner at a distant site for
review without patient’s presence
• Interactive Technologies – involve audio and video
multimedia communication equipment for two-way,
real-time interactive communication between the
patient and the distant site practitioner
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TELECOMMUNICATION
SERVICES NOT COVERED
•
•
•
•
Telephones
Facsimile Machines
Email
Text Messages
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Qualified Practitioners
• Distant Site
– Physician
– Physician Assistant
– Nurse Practitioner
– Clinical Nurse Specialist
– Nurse-Midwife
– Clinical Psychologist
– Clinical Social Worker
– Nutritionist
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QUALIFIED ORIGINATING
SITE (where the patient is located)
•
•
•
•
•
•
Practitioner’s Office
Critical Access Hospital
Rural Health Clinic
Federally Qualified Health Center
Hospital
(Does NOT include a CHA/P clinic)
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REIMBURSEMENT – DISTANT
SITE (where the consulting provider is located)
• Payment to the distant site practitioner is equal to
the current fee schedule amount paid for such
services without telecommunications
• Distant site practitioner should choose from the
following CPT codes:
•
•
•
•
99241 through 99275
99201 through 99215
90804 through 90809
And 90862
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REIMBURSEMENT –
ORIGINATING SITE
• The originating site receives a facility fee equal to
80% of the lesser of the actual charge or $22.94
(2007) unless CHA/P
• HCPCS code Q3014 – Telehealth Originating Site
Facility Fee
• Payments made to a distant site practitioner
(including deductible and coinsurance) may not be
shared with the originating site.
• Type of Service 9 – other items and services
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COMMERCIAL PAYORS
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Commercial Payors
• Many private payors are covering
telemedicine
• Make certain the payor is aware that they are
paying a telemedicine delivery.
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Questions?
• Cheryl A. Skiffington, CCA
• [email protected]
• 907.729.2902
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