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

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afhcan
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:

    • 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
what is telemedicine
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 telemedicine5
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
Telehealth and HIPAA

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

hipaa cont
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:

  • 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
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

definition of store forward
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
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
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
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
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 roles15
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
Provider Telemedicine RolesEXAMPLE

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.

Live Interaction with patient

REMOTE

CHA/P

ANMC

CONSULTING

MD

Using camera, video, or audio

Conference equipment

referring provider type sending site
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 located18
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 provider19
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)
provider 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)!
slide22

TM 4

This is an ongoing email communication between a remote provider and a specialist at ANMC.

NO CONSULT!

important
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.
slide24

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.

slide25

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!

slide26

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

slide27

E/M*

Guidelines to

Remember

* Evaluation/Management

definition
Definition
  • New Patient – A new patient is one whohas not receivedany 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 whohas receivedprofessional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.
consultations
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.
consultations33
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.
consultations34
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.
consultations35
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.
consultations36
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
Three R’s of Consultations
  • Requesting a consult
  • Rendering an opinion
  • Reporting back to the requesting provider
service requirements
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
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
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
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

slide45

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

slide46

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.

slide47

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.

slide48

TM 7

Example of how to bill

FHSC

(MEDICAID) for the

consult if provider

is in a

clinic.

slide49

FNP Visit at a Remote Site

TM 9

Store and

Forward

Requesting telemed consult

Sending 3 images signifying store and forward.

slide50

TM 10

Bill FHSC

For Referring

Provider FNP

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

99212 for face-to-face visit

slide51

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.

slide52

TM 12

Billing FHSC

(MEDICAID) for

the consult (at

ANMC or Hub).

GQ Modifier for Store and Forward

Consult 99241

slide54

TM 13

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

Example of

Interactive

slide55

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

slide56

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.

slide57

TM 16

This is how to

bill the Presenter

to FHSC

(MEDICAID).

GT Modifier for Interactive Telemedicine Visit

U1 Modifier for CHA/P

slide58

TM 17

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

Referring

Provider

Consulting

Provider

Consulting

Provider

MEDICAID

multiple consultation roles example
Multiple Consultation RolesExample
  • 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

multiple consultations referrals
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
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

exclusions to required modifiers
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
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 reimbursement
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

slide68

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

slide70

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.

slide71

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
TELEHEALTH SERVICES INCLUDE:
  • Office Visits
  • Other Outpatient Visits
  • Consultation
  • Individual Psychotherapy
  • Pharmacologic Management Services
definitions
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
definitions cont
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
telecommunication services not covered
TELECOMMUNICATION SERVICES NOT COVERED
  • Telephones
  • Facsimile Machines
  • Email
  • Text Messages
qualified practitioners
Qualified Practitioners
  • Distant Site
    • Physician
    • Physician Assistant
    • Nurse Practitioner
    • Clinical Nurse Specialist
    • Nurse-Midwife
    • Clinical Psychologist
    • Clinical Social Worker
    • Nutritionist
qualified originating site where the patient is located
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)
reimbursement distant site where the consulting provider is located
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
reimbursement originating site
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
commercial payors81
Commercial Payors
  • Many private payors are covering telemedicine
  • Make certain the payor is aware that they are paying a telemedicine delivery.
questions
Questions?
  • Cheryl A. Skiffington, CCA
  • cskiffington@anmc.org
  • 907.729.2902