Adella Cordova, Expert Billing ConsultantTeresa Iafolla, eVisit

How to Get Reimbursed for Telemedicine

Sept 2015

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Who We Are

Teresa IafollaContent Marketing Manager, eVisittiafolla@evisit.com

Adella CordovaMedical Billing & Practice Administration Consultant

Host

Speaker

Your Speaker

Adella CordovaMedical Billing & Practice Administration ConsultantDr.’s Choice Medical Billing Practice Administration 1990 - 2000Medical Billing Consultant 2000 - present

• Telemedicine is healthcare delivered from a distance

• Telemedicine allows the patient to talk to a physician and or specialist on video without having to wait 2-3 days for an in-office visit.

• Telemedicine delivers rapid, accurate, real-time advice allowing the physicians to catch, treat and intervene in the patient’s care much earlier than ever before.

• Telemedicine has entered the mainstream and is transforming the way we experience the medical system today.

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Telemedicine Reimbursement

MedicareMedicare reimburses for telemedicine nationwide.

Medicaid48 state Medicaid programs cover telemedicine (CT & RI do not).

PrivatePrivate commercial payers such as BCBS, United Healthcare, Aetna, Cigna, Humana, BCBS are required by law to cover telemedicine, but coverage is policy-dependent.

The 3 Types of Payers - Overview

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Navigating Medicare

• Medicare is a national federal program run by CMS to provide government-funded healthcare for Americans 65 and older (and younger adults with disabilities)

• Medicare lags behind the other payers for telemedicine reimbursement

• Medicare guidelines are still mostly based on the traditional model of telemedicine, where the patient would come into a small, rural health clinic to do an online visit with a far away specialist

• This is where the terms “originating site” and “distant site” come in

• Legislation is in the works to further expand Medicare coverage of telemedicine and will be done in 3 phases.

Main Points

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Navigating Medicare

• Originating Site • The location of the patient at the time of the telemedicine visit • The patient must be located either in a Heath Professional Shortage Area (HPSA), located outside a

Metropolitan Statistical Area (MSA) or in a rural census tract.• The originating site may bill an originating site facility, fee HCPS Code Q3014

• The originating sites authorized by law are:

• The offices of physicians or practitioners;�• Hospitals;�• Critical Access Hospitals (CAH);�• Rural Health Clinics;�• Federally Qualified Health Centers;�• Hospital-based or CAH-based Renal Dialysis�• Centers (including satellites);• Skilled Nursing Facilities (SNF); and�• Community Mental Health Centers (CMHC)�

Terms you need to know

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Navigating Medicare

• Distant site – location of the provider at the time of the telemedicine visit

• the distant site is the site that furnishes and bills for the consultation

• Eligible providers or practitioners - providers eligible to bill and receive reimbursement under Medicare

• Physicians;• Nurse practitioners (NP)�• Physician assistants (PA)�• Nurse-midwives�• Clinical nurse specialists (CNS)�• Certified registered nurse anesthetists�• Clinical psychologists (CP) �• Clinical social workers (CSW)

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Navigating Medicare

• Facility fee – fee that can be charged by the originating site as payment for “hosting” the patient for the telemedicine visit

• HPSA– Health Professional Shortage Area The criteria for these related yet distinct designations rely heavily on measures of physician supply relative to the size of a local population to assess geographically available care.

• MUA - Medically Underserved Area

• http://www.cms.gov/Medicare/Medicare-General-Information/telemedicine

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Navigating Medicare1. The patient was seen from one of the following Originating Sites:

In order to bill Medicare for professional fees for telemedicine encounters or consultations:

• Physicians or practitioner offices

• Hospitals• Critical Access Hospitals

(CAH)• Rural Health Clinics• Federally Qualified Health

Centers

• Hospital-based or CAH-based Renal Dialysis Centers

• Skilled Nursing Facilities (SNF)

• Community Mental Health Centers (CMHC)

2. The encounter was performed at the distant site by one of the following physicians or practitioners:

• Physicians;• Nurse practitioners (NP)• Physician assistants (PA)• Nurse-midwives• Clinical nurse specialists (CNS)• Certified registered nurse anesthetists• Clinical psychologists (CP) • Clinical social workers (CSW)

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Navigating Medicare3. You must be doing live video telemedicine

• Medicare only covers telemedicine via live video

• Live video telemedicine means you can see and hear the patient in real-time, like an in-person visit ( live video technology)

• Store-and-forward (also called asynchronous) telemedicine is where you’re sending medical data or diagnosis remotely and not talking to the patient in real-time. Example, x-ray imaging forward to physician for review and diagnosis.

• The only exception is for AK and HI, where store-and-forward is covered as well

In order to bill Medicare for professional fees for telemedicine encounters or consultations:

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In order to bill Medicare for professional fees for telemedicine encounters or consultations:

Navigating Medicare4. Medicare beneficiary resides in, or utilizes the telemedicine system in federally designated HPSA, MSA, or demonstration project.

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http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

Navigating Medicare

• July 7th, 2015 - House representatives introduced the Medicare telemedicine Parity Act of 2015

• If passed, the bill will get rid of some of the limitations on what qualifies as an originating site

When will Medicare recognize the patient home as an eligible site?

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Navigating Medicare

• Set-up a partnership with an eligible originating site that’s close to your patients

• Talk to your patients at the face to face encounter and educate them where to go for the telemedicine visit and have a coordinator/telepresenter there who can orient the patient

• Remember new Medicare phasing information and stay connected!

Ok, so how can I do telemedicine through Medicare for now, if the patient can’t do it from their own home?

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Medicare Example

- Originating Site- Hospital - bills facility fee Q3014- Separately billable Part B payment

- Distant Site Physicians and Practitioners- Physician- bills appropriate CPT or HCPCS code along with GT modifier- e.g., 99243 GT

- Live Video Telemedicine- Live Video Technology- (using live video)

- HPSA/MSAhttp://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx(located in a HPSA)

Case scenario example

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Navigating Medicare

The medical procedure needs to be on the list of covered services and meet all the requirements of CPT codes.

• Here’s the complete list of medical services eligible for telemedicine reimbursement

Medicare Telehealth Services Rural Health Fact Sheet

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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdftelemedicine services

Navigating Medicare

• Choose the appropriate CPT or Medicare HCPCS codes

• Add the “GT” modifier to show the service was delivered via telemedicine

• If you’re an originating site, use HCPCS code Q3014 to bill a facility fee as payment for hosting the visit

Reimbursement Codes

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Navigating Medicare

• Medicare reimburses telemedicine at the same rate as in-person visits

• Check the current year Medicare physician fee schedule for the appropriate CPT/HCPCS code to see rate

• You can also get a 10% bonus for delivering services to a HPSA• https://www.cms.gov/Medicare/Medicare-Fee-for-Service payment/HPSAPSAPhysicianBonuses/index.html?redirect

=/hpsapsaphysicianbonuses/01_overview.asp

Reimbursement Rates

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Billing and Payment for Professional Services Furnished

via Telemedicine1. Examples1. 99213-GT This set states that an evaluation and management consultation provided by a “physician or other qualified health care professional” was done (99213) via telemedicine (GT modifier). The GT modifier simply states that the service was performed online rather than face to face.

2. 99444 This codes also states that an online electronic medical evaluation service was provided by a “physician or other qualified health care professional,” however, this code is specific to “online evaluation and management service.” Specific code not covered by Medicare, use E&M coding.

CPT® is registered trademark of the American Medical Association. 19

Billing and payment for professional services furnished via telemedicine

2. Examples3. 99446 – 99449 Interprofessional internet assessment and management service provided by a “consultative physician.”

4. 98969Online assessment and management service provided by a qualified “nonphysician health care professional”

CPT® is registered trademark of the American Medical Association.

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Medicare Billing Tips• BILLING AND PAYMENT FOR PROFESSIONAL SERVICES FURNISHED VIA telemedicine You

should submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service along with the telemedicine modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT).

• By coding and billing the GT modifier with a covered telemedicine procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telemedicine service.

• By coding and billing the GT modifier with a covered ESRD-related service telemedicine code, you are certifying that you furnished one “hands on” visit per month to examine the vascular access site.

• For Federal telemedicine demonstration programs conducted in Alaska or Hawaii, you should submit claims using the appropriate CPT or HCPCS code for the professional service along with the telemedicine modifier GQ if you performed telemedicine services “via an asynchronous telecommunications system” (for example, 99201 GQ). By using the GQ modifier, you are certifying that the asynchronous medical file was collected and transmitted to you at the distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii.

• . BILLING AND PAYMENT FOR THE ORIGINATING SITE FACILITY FEE Originating sites are paid an originating site facility fee for telemedicine services as described by HCPCS.

Next payer up…..

Navigating Medicaid

• Originating (Spoke) Site – the location of the patient at the time of the telemedicine visit

• Distant (Hub) site – location of the provider at the time of the telemedicine visit

• Eligible providers – healthcare providers that can get reimbursed for telemedicine under Medicare

• Facility fee – fee that can be charged by the originating site as payment for “hosting” the patient for the telemedicine visit

• Referring provider – the healthcare provider at the originating or spoke site. This provider is acting as the host.

• Consulting provider – the healthcare provider at the distant or hub site. This is the provider who’s actually delivering the medical service.

• Telepresenter– professional at the originating (or spoke) site who helps patient get set-up for the telemedicine visit.

Terms you need to know

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Navigating Medicaid

• Since every state has its own Medicaid program, every Medicaid program has different rules for telemedicine

Always read your state Medicaid telemedicine guide• Go to your Medicaid website• Search for your provider manual on telemedicine• For instance, here’s Georgia’s telemedicine manual

And talk to your state Medicaid department• You can also get help from your

regional telemedicine resource center.

Main Points

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Navigating Medicaid

• 48 state Medicaid programs offer some form of coverage for telemedicine (except CT & RI)• 24 states cover telemedicine under their state employee plans• 24 states plus DC don’t require a specific patient location as a condition for

coverage• 25 states recognize the home as an originating site• 82% of U.S. states cover telemedicine state-wide, with no restrictions on distance

between provider and patient• 15 states plus DC don’t specify type of healthcare provider as condition of payment• 28 states plus DC don’t require a telepresenter

*based on recent report by the American Telemedicine Association (ATA)

Medicaid Telemedicine Trends

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Navigating Medicaid

1. Lookup the Medicaid telemedicine reimbursement rules for your state

• The National telemedicine Policy Resource Center has an interactive map of telemedicine policy, state-by-state

• Visit your state Medicaid agency website & read your Medicaid handbook

• Read this policy analysis from American Telemedicine Association

How to Get Reimbursed Through Medicaid

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Navigating Medicaid

2.Know what to researchHere are some of the common restrictions and guidelines that may affect your telemedicine reimbursement through your state Medicaid program:

How to Get Reimbursed Through Medicaid

• Type of Telemedicine (Live video, store-and-forward, remote patient monitoring)

• Health Services covered & Applicable CPT Codes

• Eligible providers (Physicians, NPs, PAs etc)

• Distance or Geographic restrictions (Does patient need to be located in certain region, or distance from provider)

• Is a Pre-existing relationship with patient required?

• Location restrictions on patient or provider

(what defines an eligible originating site? Eligible distant site?)

• Informed Patient consent (do you need to get patient’s consent before the visit?)

• Type of fee reimbursed (transmission, facility, or both)

• GT Modifier (do you to use the GT modifier when coding?)

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Navigating Medicaid

3. Record your research and think about how it affects your use case• Get our Medicaid state policy worksheet (contact Teresa for this)

4. Contact your Medicaid department or Rep with questions

How to Get Reimbursed Through Medicaid

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Billing and Payment for Professional Services Furnished

Via telemedicine1. Examples1. 99213-GT This set states that an evaluation and management consultation provided by a “physician or other qualified health care professional” was done (99213) via telemedicine (GT modifier). The GT modifier simply states that the service was performed online rather than face to face.

2. 99444 This codes also states that an online electronic medical evaluation service was provided by a “physician or other qualified health care professional,” however, this code is specific to “online evaluation and management service.” Specific code not covered by Medicare, use E&M coding.

CPT® is registered trademark of the American Medical Association. 29

Billing and payment for professional services furnished via telemedicine

1. Examples3. 99446 – 99449 Interprofessional internet assessment and management service provided by a “consultative physician.”

4. 98969Online assessment and management service provided by a qualified “nonphysician health care professional”

CPT® is registered trademark of the American Medical Association.

30

Next Payer up…..

Private Payers

Navigating Private Payers

Telemedicine Parity Laws• State telemedicine parity laws require private payers to reimburse for telemedicine

the same way they would for in-person medical services• 29 States + DC currently have parity laws (9/2015)• Check if your state is covered here

Things to Know

Map created by the American Telemedicine Association2015 Source

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Navigating Private Payers

• The commercial insurance carriers cover telemedicine

• BCBS• Aetna• Cigna• United Healthcare,• Humana

BUT……• Coverage by private payers is policy-

dependent • A patient with a BCBS gold policy in North

Carolina might have telemedicine listed as a covered service for their policy

• A patient in same state with BCBS silver, may not have it

Things to Know

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Navigating Private Payers

• So how to you ensure a patient’s private insurance will reimburse for telemedicine?

• You have to verify before the visit• Verify insurance coverage for each patient• ALWAYS record that call with a verification

form• Use our example verification form

Things to Know

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Navigating Private Payers

• Like with Medicaid, private payers in your state are influenced by state policy

• Plus, each private payer has their • own telemedicine guidelines

• The best way to check their telemedicine reimbursement requirement? Call them and ask questions

Check with your payers

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Navigating Private Payers

• Pick your top 3-5 private payers and call their eligibility & verification department

• Ask the right questions:• Which CPT and HCPCS codes can be completed via telemedicine?• Do I need to use the GT modifier?• Do I need prior authorization?• Are there any restrictions on the location of the patient or provider?• Does the reimbursement rate match the in-person rate?• Which providers are eligible (physician, NP, PA)?• Are there any specific notes that need to be included in the visit documentation?• Do you have a handout or guide you could send me on your telemedicine guidelines?

Calling your private payers

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Navigating Private Payers

Billing Trends

• Private payers tend to follow Medicare on billing

• Generally you would use the appropriate E/M CPT code plus the GT modifier

• But, some payers accept the telemedicine-specific code 99444

• Again, always check coding guidelines with your payers. These are just trends we’ve seen for context.

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Our Recommendations• Consider starting with one payer, or one use case

• For instance, offer telemedicine only to patients with a Medicaid plan• Or, only offer telemedicine visits to patients with a chronic condition• Once you figure out the workflow for that payer or use case, grow from there

• Always call your private payers and verify their guidelines

• Connect with your state Medicaid department and your regional telemedicine resource center to verify guidelines and get questions answered

• Always verify a patient’s insurance covers telemedicine using the example verification form we provided

• Yes, you’ll need to do it for each patient, but only for the first visit!

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If all else fails…

• Patients love the convenience of telemedicine

• Many of our clients simply charge a convenience fee (expect when billing insurance company)

• You can charge a fee in place of reimbursement, or on top of

• Self Pay fees can range anywhere from $30 to $300 per visit depending on the specialty, duration, and provider fee schedule.

Charge Your Patients Directly!

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Billing and Payment for Professional Services Furnished

Via telemedicine1. Examples1. 99213-GT This set states that an evaluation and management consultation provided by a “physician or other qualified health care professional” was done (99213) via telemedicine (GT modifier). The GT modifier simply states that the service was performed online rather than face to face.

2. 99444 This codes also states that an online electronic medical evaluation service was provided by a “physician or other qualified health care professional,” however, this code is specific to “online evaluation and management service.” Specific code not covered by Medicare, use E&M coding.

CPT® is registered trademark of the American Medical Association. 40

Billing and payment for professional services furnished via telemedicine

1. Examples3. 99446 – 99449 Interprofessional internet assessment and management service provided by a “consultative physician.”

4. 98969Online assessment and management service provided by a qualified “nonphysician health care professional”

CPT® is registered trademark of the American Medical Association.

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Other Reimbursement Resources

• List of state Medicaid websites• Medicare Telemedicine Guide• List of Medicare telemedicine CPT codes• ATA state policy matrix• telemedicine Resource Center State Policy Map

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Things to Remember

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• Original Medicare has limited coverage but is also expanding in 2016

• Medicare Advantage Members have complete flexibility to use Telemedicine

• Commercial Private Payers already cover Telemedicine

• Telemedicine has been around for about the last 40 years

• Telemedicine is growing, evolving and more widely used than ever before

Questions?Teresa IafollaContent Marketing Manager, eVisittiafolla@evisit.com

Adella CordovaExpert Medical Billing Consultant

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Sept 2015