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)

Version 3 Basic Cart: Extras: Otoscope Digital Camera Scanner ECG Tympanometer/Audiometer Spirometer Vital Signs Monitor (pulse oximeter, blood pressure, temperature and pulse) VTC Equipment Dental (Intraoral) Camera Version 3 Cart Audiometer Tympanometer Dental (Intraoral) Camera Digital Camera ECG Scanner Spirometer Video Otoscope Vital Signs Monitor

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.

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.

Telehealth and HIPAA http://www.hhs.gov/ocr/privacysummary.pdf#search='summary%20of%20the%20HIPAA%20privacy%20rule'

HIPAA cont. Treatment, Payment, and Health Care Operations; 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: To the Individual (unless required for access or accounting of disclosures); Treatment, Payment, and Health Care Operations; Opportunity to Agree or Object; Incident to an otherwise use and disclosure Public Interest and Benefit Activities

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. Examples: psychiatric assessment or counseling. Photo credit: http://murray.senate.gov

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

Definition of Store & Forward (cont.) Medical Information may include, but is not limited to: Video clips Still images X-rays (not currently on AFHCAN system) EKG’s EEG’s Audio clips

Requesting Provider (sending site-where 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 Required Telemedicine Modifier Appropriate covered procedure code for provider type None required – nothing changes with telemedicine

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. Required Telemedicine Modifier Procedure Code Covered procedure code for Brief/minimal evaluation and Management service for an Established patient GT

Distant Site (Consulting) Provider Evaluates the patient and/or medical data/images using telemedicine mode of delivery upon recommendation of the referring provider Required Telemedicine Modifier Procedure Code GT (Interactive Method) GQ (Store-and-Forward Method) APPROPRIATE COVERED PROCEDURE CODE FOR PROVIDER TYPE

PROVIDER TELEMEDICINE ROLES

Provider Telemedicine Roles Store-and-Forward Mode of Delivery Interactive Mode of Delivery Referring Provider Consulting Provider Digital images, sounds, previously recorded video Referring Provider Presenting Provider (Patient is Here) Consulting Provider Live Interaction with patient using camera, video, or audio conference equipment

Provider Telemedicine Roles EXAMPLE Store-and-Forward Mode of Delivery Interactive Mode of Delivery REMOTE CHA/P HUB CONSULTING PROVIDER Digital images, sounds, This could also be a CHA/P Previously recorded video HUB PROVIDER The patient is here. REMOTE CHA/P Live Interaction with patient ANMC CONSULTING MD Using camera, video, or audio Conference equipment

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

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)

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)

DOCUMENTATION

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)!

TM 4 This is an ongoing email communication between a remote provider and a specialist at ANMC. NO CONSULT!

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.

This statement alone is not sufficient for requesting a consult. TM 1 EXAMPLE This statement alone is not sufficient for requesting a consult. A statement is also required for why they are requesting a consult.

PROBLEMS: EXAMPLE OF WHAT NOT TO DO! Appears that ANMC TM 2 PROBLEMS: Appears that ANMC physician initiated this (no one has requested a consult). There is evidence of a prior communication that coder doesn’t have access to. Each record needs to be a stand alone document. 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). This is more like an ongoing email communication. EXAMPLE OF WHAT NOT TO DO!

EXAMPLE OF WHAT TO DO Assuming this form would be used TM 3 Chances are, this visit will meet the requirements for a 99213, but impossible to code without the PCC or PEF Assuming this form would be used to bill the consult, the documentation provided here meets the criteria for a 99242 Level II Office Consultation: Expanded problem focused history Expanded problem focused exam Straight forward medical decision making EXAMPLE OF WHAT TO DO

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.

New Patient

Established Patient

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.

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.

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.

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.

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.

Three R’s of Consultations Requesting a consult Rendering an opinion Reporting back to the requesting provider

PAYOR SPECIFIC REIMBURSMENT

STATE OF ALASKA MEDICAID

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

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

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

Ineligible Providers 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

STORE & FORWARD EXAMPLES

CHA/P Visit at a Remote Site TM 4 CHA/P Visit at a Remote Site Visit meets the criteria for a 99212- Established Patient OV PF HPI PF Exam Low Comp Dec Making Example of WHAT TO DO Store & Forward Document that this is a store and forward telemedicine case. 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

This is the claim billed to FHSC (MEDICAID) for the CHA/P TM 5 No telemedicine modifier for the face-to-face visit, just use the U1 modifier to signify CHA/P as provider. This is the claim billed to FHSC (MEDICAID) for the CHA/P end of the visit only.

TM 6 Example of WHAT TO DO This is a problem focused exam, so 99241 is the consultation code to bill with a GQ modifier for the telemedicine mode of delivery. The consulting provider at the hub clinic reviews the case.

Example of how to bill FHSC (MEDICAID) for the consult if provider TM 7 Example of how to bill FHSC (MEDICAID) for the consult if provider is in a clinic.

Store and Forward FNP Visit at a Remote Site TM 9 Store and Forward Requesting telemed consult Sending 3 images signifying store and forward.

No modifier required for the face-to-face visit. TM 10 Bill FHSC For Referring Provider FNP No modifier required for the face-to-face visit. 99212 for face-to-face visit

TM 11 Example of WHAT TO DO This is a problem focused exam, so 99241 is the consultation code to bill with a GQ modifier for the telemedicine mode of delivery. The consulting provider at the hub clinic reviews the case.

GQ Modifier for Store and Forward TM 12 Billing FHSC (MEDICAID) for the consult (at ANMC or Hub). GQ Modifier for Store and Forward Consult 99241

INTERACTIVE EXAMPLE

Example of Interactive TM 13 CHA/P is Referring Provider. Pt will be presented in Interactive Session tomorrow. This visit meets guidelines for 99212 Example of Interactive

Visit is coded as a 99212 for the face-to-face visit with patient TM 14 Visit is coded as a 99212 for the face-to-face visit with patient Bill FHSC (MEDICAID) for CHA/P as Referring Provider in Interactive Session No Telemedicine Modifier for the Referring Provider U1 Modifier for CHA/P

It is the next day, the patient returns to the This visit 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.

GT Modifier for Interactive Telemedicine Visit This is how to bill the Presenter to FHSC (MEDICAID). GT Modifier for Interactive Telemedicine Visit U1 Modifier for CHA/P

Consult code with a GT modifier for Interactive Telemedicine Session This is how the Consulting end Is billed to FHSC (MEDICAID)

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.

Multiple Consultation Roles Store-and-Forward Mode of Delivery only Referring Provider Consulting Provider Consulting Provider Example: CHA/P forwards a request for consult to a healthcare provider (audiologist, NP, physician, etc) who then evaluates the information and requests further consultation from another healthcare provider (ENT, specialist, etc) MEDICAID

Multiple Consultation Roles Example Store-and-Forward Mode of Delivery only Referring Provider REMOTE CHA/P Consulting Provider HUB FNP Consulting Provider ANMC MD Example: CHA/P forwards a request for consult to a healthcare provider (audiologist, NP, physician, etc) who then evaluates the information and requests further consultation from another healthcare provider (ENT, specialist, etc) Both Hub FNP and ANMC MD can bill for consults MEDICAID

Multiple Consultations/Referrals Multiple consultations covered (scope of practice is greater than or equal to the referring) Multiple referrals not covered MEDICAID

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 85% Medicaid physician fee schedule for CHA/P services Current year encounter rate published in the Federal Register for services provided under CL_____ or OP Hospital clinic HS__OP Mental health services and all other services under the appropriate published Medicaid fee schedules MEDICAID

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

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

MEDICARE

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

This visit cannot be billed to Medicare CHA/P Visit at a Remote Site TM 18 CHA/P Visit at a Remote Site Visit meets the criteria for a 99212- Established Patient OV This visit cannot be billed to Medicare 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. Important to note provider credentials MEDICAID

HOWEVER….

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-to-face visit.

Consulting MD bills an E/M. In this case 99212. TM 20 Consulting MD bills an E/M. In this case 99212. Use the GQ modifier to document store and forward telemedicine as mode of delivery. Meets criteria for 99212: PF HPI PF Exam DM Low Complex

TELEHEALTH SERVICES INCLUDE: Office Visits Other Outpatient Visits Consultation Individual Psychotherapy Pharmacologic Management Services Gwen will change Medicaid to match this.

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 Per Medicaid – Originating site (MCR) is “Presenting provider” and/or “Referring provider” – this is the face-to-face with the patient. Distant Site (MCR) is Consulting provider with Medicaid

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 Interactive is also “live” with Medicaid

TELECOMMUNICATION SERVICES NOT COVERED Telephones Facsimile Machines Email Text Messages Same w/MCD

Qualified Practitioners Distant Site Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist Nurse-Midwife Clinical Psychologist Clinical Social Worker Nutritionist For Medicaid, UNQUALIFIED – Home & community based waiver svcs Pharmacy svcs. DME Transportation svcs Accommodation svcs Esrd Direct-entry midwife services Private-duty nursing svcs Personal care attendant svcs Visual care dispensing svc or optician svcs Eligible for MCD – services provided by a treating, consulting, presenting or referring* provider for a Medicaid covered service that is provided within the scope of the practitioner’s license.

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) MCD – no limitations on POS for originating or referring

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 MCD 100% of fee schedule Includes: Initial visit F/u visit Confirming consultation Diagnostic, therapeutic or interpretive service Psychiatric or substance abuse assessment Individual psychotherapy or pharmacological mgmt svcs

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 Medi is face-to-face No facility fee

COMMERCIAL PAYORS

Commercial Payors Many private payors are covering telemedicine Make certain the payor is aware that they are paying a telemedicine delivery.

Questions? Cheryl A. Skiffington, CCA cskiffington@anmc.org 907.729.2902