emergency department telemedicine reimbursement covid-19 ...€¦ · during covid surge acuity...
TRANSCRIPT
Emergency Department Telemedicine Reimbursement COVID-19 Update
May 12th from 12-12:30 p.m. EST
A Discussion with Michael Granovsky, M.D., FACEP, CPC and Elijah Berg, M.D., FACEP
Adam Delmolino
Director of State Government Advocacy,
Massachusetts Health & Hospital Association
Michael Granovsky, M.D., FACEP, CPC
President, LogixHealth
Dr. Mark P. Jarrett, MD, MBA, MS
Elijah Berg, M.D., FACEP
CEO, LogixHealthAssoc. Chairman, Dept. Emergency Medicine,
Melrose Wakefield Healthcare
Emergency Department Telemedicine Reimbursement COVID-19 Update
Elijah Berg MD, FACEPCEO, LogixHealthAssociate Chair Department of Emergency Medicine, Melrose Wakefield Healthcare
Michael Granovsky MD, CPC, FACEPPresident, LogixHealth
▪ Elijah Berg MD, FACEP
CEO, LogixHealth – National ED Coding and Billing Company
▪ Michael Granovsky MD, CPC, FACEP
President, LogixHealth – National ED Coding and Billing Company
Disclosures
May, 2020 COVID Statistics:Comparisons to January, 2020
National Volume Data
▪ ED: Maximum decrease was 50% nationwide from Jan, 2020 baseline
‒ Volume slowly improving
‒ Positive trend and now -42% from Jan, 2020 baseline
▪ Urgent Care: Maximum decrease was 79% from Jan, 2020 baseline
‒ Significant return towards Jan, 2020 baseline now -52%
▪ Peds ED: Maximum decrease was 73% from Jan, 2020 baseline
‒ Stabilizing and slight trend up now to -70% from Jan, 2020 baseline
▪ Tents: Contributing to expanded access
‒ ED visit
‒ Urgent Care visit
‒ Swab only visit
COVID Related ED Visits in April and May
▪ Month of April: 25%-30% of nationwide ED visits were COVID related
▪ Late April and early May: COVID visits as a percent are trending down
▪ Surge case studies:
‒ Surge sites peaked at 60% COVID now 40%
‒ Surge site ED volume has stabilized @ -55%
• Select Surge sites 5% - 10% improvement compared to nadir
• Worrisome delay in care: some staying home
▪ During COVID surge acuity changes drastically
‒ Informs staffing needs
▪ May, 2020 acuity:
‒ Admission rate for typical surge ED is 40%
‒ Critical care rate doubles
‒ May, 2020 surge RVU per patient increase of 20% compared to pre COVID
▪ Low acuity presentations
‒ 99281- 99283 virtually disappear
‒ Contributes to need for acute care telemedicine services
Surge Site Acuity Shifts April/May
Patients Are Delaying/Avoiding ED care
Who Is Staying Home?Clinical Presentations Compared with January, 2020 Baseline
May, 2020 data: slight reversal in CP & MI
Life altering decisions
Massachusetts Expansion of Telemedicine
Regulatory Expansion of Covered Services:Medicaid Expands Access to Telehealth
▪ All provider bulletins 289/291
March 15th Executive Order:Expanding Access to Telehealth
Telemedicine Acute Care Reimbursement Update
▪ Telemedicine refers to two-way real time audio-video interaction
between a provider and a patient
‒ Historically these services were limited by:
• Geographic restrictions
– Health Professional Shortage Area
• Location restrictions: OK for nursing home, physician’s office
but NOT a patient’s home
• Established patients only
▪ Telemedicine has undergone multiple updates since the Public
Health Emergency declaration
‒ Under Waivers (section 1135 of the Social Security Act)
‒ CMS-1744-IFC and CMS-5531-IFC
Pre-Covid Telemedicine ServicesOverview
‒ Patient geographic limitations waived
‒ Patient location limitations waived
• Patient may now be at home
‒ Existing patient relationship requirement waived
‒ Patient cost sharing is allowed to be waived
‒ Technology standards relaxed
• May use most two way audio-video devices
– Facetime, Skype or Zoom
– Not public platforms - Facebook Live
General Post COVID Telemedicine Waivers
FACETIME
SKYPE
Pre COVID: ED services were Not on the CMS list of covered telehealth
services
Telehealth ED/Inpatient consult codes- Tele Stroke
G0425-G0427
For specialty consultations into the ED
Telemedicine originating site facility fee
Q3014 ($26.65)
CMS POS #2 (telemedicine)for a qualified service
CPT had its own modifier -95
Emergency Medicine Telemedicine Service Billing
▪ Expanded eligible telehealth services to include ED and Observation
“We are adding the following codes to the existing list of telehealth services.
CPT codes 99281-99285, 99217-99220, 99224-99226, 99234-99236.” CMS-1744- IFC page 19/221
▪ ED Telehealth should use ED specific POS #23 rather than POS #2
“We are instructing physicians and practitioners who bill for Medicare telehealth
services to report the POS code that would have been reported had the service been
furnished in person.” CMS-1744-IFC page 15/221
CMS-1744-IFC Big ED Telemedicine Changes
Modifier 95 should be applied
“We are finalizing the use of the CPT telehealth modifier, modifier 95, which should
be applied to claim lines that describe services furnished via telehealth.”CMS-1744-IFC page 15/221
Telemedicine paid at the same rate as in person services
“It would be appropriate to assume that the relative resource costs of services
furnished through telehealth should be reflected in the payment as if they
furnished the services in person, and to assign the payment rate that ordinarily
would have been paid under the PFS were the services furnished in-person.” CMS-1744-IFC page 14/221
CMS-1744-IFC Big ED Telemedicine Changes
Telemedicine Provider Documentation Process
▪ Document in the same manner as face-to-face
▪ HPI, Past/Family/Social Hx
▪ Visual Physical Exam
▪ Medical Decision making such as differential (including COVID concern), any
prescriptions, testing or self monitoring instructions
▪ Medical record should reflect the location of the provider as a best practice
Do not confuse telemedicine with telephone (99441-99443)
▪ Starting January 1, 2021 CMS had already waived Hx and PE
requirements for Office/Urgent Care codes
‒ 99201-99215
▪ Now accelerating the 2021 changes
“We are revising our policy to specify that the office/outpatient E/M
level selection when furnished via telehealth can be based on MDM or
time; and to remove any requirements regarding documentation of
history and/or physical exam in the medical record. This policy is similar
to the policy that will apply to all office/outpatient E/Ms beginning in
2021.”March 30th CMS IFR page 136/221
Office Telehealth Hx and PE Requirements Waived
.
Teaching Physician Pre COVID Overview
▪ Teaching Physicians may now meet the supervisory requirements to bill using
telehealth
▪ Does not need to be in person
“The requirement for the presence of a teaching physician can be met,
through direct supervision by interactive telecommunications technology…
the teaching physician must provide supervision either with physical presence
or be present through interactive telecommunications technology during the
key portion of the service.” March 30th CMS IFR page 103/221
Teaching Physician Oversight via Telehealth
EMTALA
▪ Q: Can emergency physicians and other health care practitioners conduct
medical screening exams (MSEs) under EMTALA via telehealth?
▪ A: Yes
‒ QMPs (Qualified Medical Personnel), including emergency physicians, can
perform MSEs using telehealth
‒ The QMP may be on-campus and using technology to self-contain or offsite
due to staffing shortages
‒ The MSE may be performed solely via telehealth if clinically appropriate
‒ QMP must be performing within the scope of his/her state practice act and
approved by the hospital’s governing body to perform MSEs
Can EMTALA Be Satisfied Using Telemedicine?
https://www.cms.gov/files/document/frequently-asked-questions-and-answers-emtala-part-ii.pdf
▪ Q: Can Emergency physicians perform medical screening exams outside of the
ED, such as in tents in the parking lot, under EMTALA?
▪ A: Yes.
‒ A hospital may set up alternative sites on its campus to perform MSEs.
Individuals may be redirected to these sites.
‒ Whether the individual is seen at the alternate on-campus site or in the ED,
they should be logged in where they are seen.
‒ Individuals do not need to present to the ED, first, and if they do present to
the ED, they may still be redirected to the on-campus alternative screening
location for logging and subsequent screening.
Can EMTALA Be Satisfied In A Tent or Parking Lot ?
▪ Q: Hospitals may consider providing telehealth appointments for
patients at home as emergency medicine providers; what obligation
does this create?
▪ A: The use of telehealth to provide evaluation of individuals who have
not physically presented to the hospital for treatment does NOT create
an EMTALA obligation.
Does A Patient Presenting Via Telemedicine Invoke EMTALA
https://www.cms.gov/files/document/frequently-asked-questions-and-answers-emtala-part-ii.pdf
April 30th New Code C9803: Swab Only
Code for specimen acquisition
“We believe this code is necessary to address the resource
requirements hospitals face in establishing broad community
diagnostic testing for COVID-19, including significant specimen
collection.”
April 30 CMS-5531-IFC page 189/279
Swab Only (No Provider Evaluation): Medicare Reporting
▪ On a hospital campus: CMS has created a new code to report
facility component of COVID-19 testing
‒ HCPCS code C9803 (Hospital outpatient clinic visit
specimen collection for sars-cov-2)
‒ Maps to APC 5731 Level 1 minor procedure ($22.98)
‒ Status Indicator Q1
▪ Report E/M code if there is an E/M encounter by a provider
Swab Only (No Provider Evaluation):Private Payer Reporting
New Ways To Interact With Patients
▪ Telephone Services Requirements
‒ The service is initiated by the patient
‒ The service is not related to an E/M services in
the past 7 days – may not fit for ED lab call backs
‒ Bundled with a visit that occurs within next 24
hours
Telephone Services Pre and Post-Covid
Telephone Services Reimbursement DetailUpdated April 30th
CPT Code Time Work RVUs
99441 5-10 minutes .25 .48
99442 11-20 minutes .50 .97
99443 21-30 minutes .75 1.50
CMS started to cover the telephone codes during the
PHE and on April 30th increased the RVUs substantially
“Specifically, we are cross walking CPT codes”
99441 99212
99442 99213
99443 99214 April 30 CMS-5531-IFC page 139/279
Conclusion
▪ ED Volume is starting to return
▪ Must message that patients with concerning symptom
should come to the ED
▪ Telemedicine has a big role to play in acute care
▪ The regulatory environment is complex , fluid, and changing rapidly
▪ Stay tuned!
Michael Granovsky, MD, CPC, FACEP
President, LogixHealth
www.logixhealth.com
781.280.1575
Elijah Berg, MD, FACEP
CEO, LogixHealth
www.logixhealth.com
781.280.1520
Educational Appendix
Does Requesting A Swab Only Off Site Invoke EMTALA?
▪ Q: If a hospital set up a COVID-19 testing location offsite, and patients only
present to the hospital for testing without requesting additional services, do
those patients need an MSE before we refer them offsite?
▪ A: Those patients would not be subject to an MSE in this case unless they are
requesting examination or treatment for a medical condition or demonstrate a
medical condition for which a MSE is necessary. EMTALA requires that all
persons who present to the hospital or ED for a medical condition be provided
an MSE to determine whether they have an EMC.
Can EMTALA Be Satisfied In A Car?
▪ Q: Can a hospital conduct an MSE if the patient remains in an automobile and
meet its EMTALA obligations?
▪ A: It depends. The MSE does not have to take place in the ED to satisfy
EMTALA. The content of the MSE varies according to the individual’s presenting
signs and symptoms, and it can be as simple or as complex, as needed, to
determine if an emergency medical condition exists. MSEs must be conducted
by qualified personnel, which may include physicians, nurse practitioners,
physician’s assistants, or RNs trained to perform MSEs and acting within the
scope of their state practice act. If a clinically-appropriate MSE can be
performed in an automobile to determine whether or not an emergency
medical condition exists, that MSE would be permissible under EMTALA.
▪ 99091 Collection and interpretation of physiologic data (ECG, blood pressure,
glucose monitoring) digitally stored and/or transmitted by the patient a
minimum of 30 minutes of time, each 30 days
‒ Not restricted based on product used
• May be digitally stored or transmitted
‒ Example: home glucose monitor that stores data or smart thermometer or
pulse ox that stores data
‒ No restrictions if related to previous E/M (not same DOS)
‒ Requires 30 minutes or more of dedicated time in a 30 day period by a
physician or qualified health care provider
‒ RVUs 1.64
Digitally Stored Data Services
▪ Must be a medical device as defined by the FDA
‒ So far the FDA has not defined an inclusive list of devices
▪ Service must be ordered by a physician or other qualified
healthcare provider
▪ Example of potential remote monitoring device
‒ CPAP machine with real time monitoring and outbound
cellular (like a house alarm system) capability to transmit
data for remote monitoring
Possible Future ED Use?Remote Physiological Monitoring:
▪ 99453 Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure,
pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of
equipment
‒ 0.52 RVU
▪ 99454; device(s) supply with daily recording(s) or programmed alert(s) transmission,
each 30 days
‒ 1.73 RVU
▪ 99457: Remote physiologic monitoring treatment management services, 20 minutes or
more of clinical staff/physician/other qualified healthcare professional time in
a calendar month requiring interactive communication with the patient/caregiver
during the month. 1.43 RVUs
Remote Physiological MonitoringPossible Future ED Use?
Michael Granovsky, MD, CPC, FACEP
President, LogixHealth
www.logixhealth.com
781.280.1575
Elijah Berg, MD, FACEP
CEO, LogixHealth
www.logixhealth.com
781.280.1520
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