REIMBURSEMENT FOR TELEHEALTH SERVICES. 2 AFHCAN Alaska Federal Health Care Access Network Began in 1998 to improve access to health care for federal beneficiaries.

REIMBURSEMENT FOR TELEHEALTH SERVICES

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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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•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

Version 3

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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:

•Video clips•Still images•X-rays (not currently on AFHCAN system)•EKG’s•EEG’s•Audio clips

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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) Procedure (CPT) CodeCode

Appropriate coveredprocedure code for

provider type

Required Telemedicine ModifierRequired 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.

Covered procedure code forBrief/minimal evaluation andManagement service for an

Established patient

Procedure CodeProcedure Code

GT

Required Telemedicine Required Telemedicine ModifierModifier

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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 CodeProcedure CodeRequired Telemedicine Required Telemedicine

ModifierModifier

APPROPRIATE COVERED PROCEDURE CODE FOR

PROVIDER TYPE

GT (Interactive Method)

GQ (Store-and-Forward Method)

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PROVIDER TELEMEDICINE ROLES

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Provider Telemedicine Roles

Store-and-Forward Mode of Delivery

Interactive Mode of Delivery

Referring ProviderConsulting

Provider

Presenting Provider(Patient is Here)

Consulting Provider

Referring Provider

Digital images, sounds,

previously recorded video

Live Interaction with patientusing camera, video, or audio

conference equipment

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Provider Telemedicine RolesEXAMPLE

Store-and-Forward Mode of Delivery

Interactive Mode of Delivery

REMOTE CHA/P

HUB CONSULTING

PROVIDER

REMOTE CHA/P

ANMC CONSULTING

MD

HUBPROVIDER

Digital images, sounds,

Previously recorded video

Live Interaction with patient

Using camera, video, or audioConference equipment

The patient is

here.

This could

also be a CHA/P

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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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This is an ongoing

email communication between a

remote provider and a specialist at

ANMC.

NO CONSULT!

TM 4

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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

This statement alone is not sufficient for requesting a

consult.

A statement is also required for

why they are requesting a

consult.

TM 1

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EXAMPLEOF WHATNOT TODO!

PROBLEMS:

1. Appears that ANMCphysician initiated this(no one has requesteda consult).

2. There is evidence ofa prior communicationthat coder doesn’t haveaccess to. Each recordneeds to be a stand alone document.

3. ANMC cannot code as a consult because there is no statement about why the remotesite is requesting a consult. Additionally, the “consulting” provider is assuming treatment of the patient, so does not meet criteria of consult. ANMC alsocannot code an E/M becausepatient is not present (no exam).

4. This is more like an ongoingemail communication.

TM 2

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EXAMPLE OF WHAT TO DO

TM 3

Assuming this form would be usedto bill the consult, the documentationprovided here meets the criteria for a99242 Level II Office Consultation:1. Expanded problem focused history2. Expanded problem focused exam3. Straight forward medical decision making

Chances are, this visit will meet the

requirements for a 99213, but impossible

to code without the PCC or PEF

E/M*

Guidelines to

Remember

* Evaluation/Management

New Patient vs. Established Patient

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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

MEDICAID 40

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 41

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 42

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 43

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)

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STORE & FORWARDEXAMPLES

MEDICAID 45

Example of WHAT TO DOStore & Forward

CHA/P Visit at a Remote Site

CHA/P at a remotesite seespatient in a face-to-face visit and requests consult from ahub provider.

Visit meetsthe criteriafor a 99212-EstablishedPatient OV•PF HPI•PF Exam•Low CompDec MakingDocument

that this is a store and forward

telemedicine case.

Important to note provider credentials

TM 4

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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 toFHSC (MEDICAID)for the CHA/Pend of the visit only.

TM 5

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Example ofWHAT TO DO

The consultingprovider at the hub clinic reviewsthe 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.

TM 6

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Example of how to billFHSC(MEDICAID) for theconsult if provideris in a clinic.

TM 7

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FNP Visit at a Remote Site

Requesting telemed consult

Sending 3 images

signifying store and forward.

Store and Forward

TM 9

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No modifier required for the face-to-face visit.

Bill FHSCFor ReferringProvider FNP

99212 for face-to-face visit

TM 10

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Example ofWHAT TO DO

The consultingprovider at the hub clinic reviewsthe 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.

TM 11

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Billing FHSC (MEDICAID) forthe consult (atANMC or Hub).

Consult 99241

GQ Modifier for Store

and Forward

TM 12

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INTERACTIVE EXAMPLE

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Example ofInteractive

CHA/P is Referring Provider. Pt will be presented

in Interactive Session

tomorrow. This visit

meets guidelines for 99212

TM 13

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Bill FHSC(MEDICAID) forCHA/P as ReferringProvider inInteractiveSession

U1 Modifier for CHA/P

No Telemedicine Modifier for

the Referring Provider

Visit is coded as a 99212 for

the face-to-face visit

with patient

TM 14

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It is the nextday, the patientreturns to the clinic and is presented bythe same CHA/Pfor interactivetelemedicine session with Dr. Ortho atHub. The CHA/Pnow is the Presenter.

This visitmeets the criteria for99211.

TM 15

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This is how tobill the Presenterto FHSC (MEDICAID).

U1 Modifier

for CHA/P

GT Modifier

for Interactive Telemedici

ne Visit

TM 16

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This is how theConsulting endIs billed to FHSC(MEDICAID)

Consult code with a GT

modifier for Interactive

Telemedicine Session

TM 17

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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.

MEDICAID 60

Multiple Consultation Roles• Store-and-Forward Mode of Delivery only

ReferringProvider

ConsultingProvider

ConsultingProvider

MEDICAID 61

Multiple Consultation RolesExample

• Store-and-Forward Mode of Delivery only

ReferringProvider

REMOTE CHA/P

ConsultingProvider

HUB FNP

ConsultingProvider

ANMC MD

Both Hub FNP and ANMC MDcan bill for consults

MEDICAID 62

Multiple Consultations/Referrals

• Multiple consultations covered

(scope of practice is greater than or equal to the referring)

• Multiple referrals not covered

MEDICAID 63

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 64

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)

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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

MEDICARE 67

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

MEDICAID 68

CHA/P Visit at a Remote Site

CHA/P at a remotesite seespatient in a face-to-face visit and requests consult from ahub provider.

Visit meetsthe criteriafor a 99212-EstablishedPatient OV

Document that this is a telemedicine

visit.

Important to note

provider credentials

TM 18

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HOWEVER….

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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.

TM 19

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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 for99212:PF HPIPF ExamDM Low Complex

TM 20

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TELEHEALTH SERVICES INCLUDE:

• 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