telemedicine: trends, strategies and payments · 2019. 8. 19. · 8/19/2019 1 telemedicine: trends,...
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Telemedicine: Trends, Strategies and PaymentsFriday, August 23, 2019
HEALTH LAW IS OUR BUSINESS.
Scott J. Geboy, Esq.
Hall, Render, Killian, Heath & Lyman, P.C.
111 East Kilbourn Avenue, Suite 1300
Milwaukee, WI 53202
(414) 721-0451
Jeffrey J Bramschreiber, CPA |
Health Care PartnerWipfli LLP
469 Security Blvd
Green Bay, WI 54313
(920) 662-2822
www.wipfli.com
Telemedicine Trends Use of telemedicine to deliver care continues to expand
The use of telemedicine in “traditional” care settings remains a slow process
Various new and alternative care delivery models are evolving
Telemedicine kiosks
Direct to consumer
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Telemedicine: The basics Medicare
No coverage for patients in urban areas – now with growing exceptions covering patients in urban areas
Specific originating site (patient end) requirement and limited set of covered services
Each year, incremental coverage expansion can occur For 2018, CMS finalized additional codes for telehealth services, including but not
limited to Health Risk Assessments, Care Planning for Chronic Care Management, and Psychotherapy for Crisis.
For 2019, CMS finalized additional codes for Prolonged Preventative Services.
For complete list, see CMS Telehealth Factsheet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf
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Telemedicine: Recent Changes1. 2019: Removal of geographic condition for treatment of
end stage renal disease (ESRD) and acute stroke. Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act removed the geographic limitations for treatment of substance use disorder and co-occurring mental health disorders.
2. 2019: Category of non-telehealth telemedicine established.
3. 2020: Expansion of MA plans' ability to provide “additional telehealth benefits” beyond what is currently allowable under Medicare telehealth services.
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Patient
Medical Staff
PresenterProvider
Distant
Site
Originating Site
Recent Changes: Removal of Geographic Limitations for ESRD, Acute Stroke, and Substance Use Disorder Effective 2019, CMS removed the geographic condition for originating
sites for treatment of end stage renal disease (ESRD) and acute stroke.
End Stage Renal Disease (ESRD)
Originating sites expanded to include renal dialysis facilities and the home for monthly ESRD-related clinical assessments.
Acute Stroke
Treatment for acute stroke via telehealth allowed in any hospital, critical access hospital, mobile stoke unit, and other sites determined appropriate by the Secretary without needing to meet the geographic limitation.
Beginning July 1, 2019, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act removed the geographic condition for treatment of substance use disorder and co-occurring mental health disorders.
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Opioid Treatment Issues For all telemedicine arrangements, other legal issues
are present to resolve: e.g. Licensure, accreditation, Registration
For medication assisted therapy (MAT) outside of an opioid treatment program, telehealth arrangements must also meet DEA requirements
The DEA rules have their own definition and requirements for the use of telemedicine with controlled substances: https://www.hhs.gov/opioids/sites/default/files/2018-09/hhs-telemedicine-dea-final-508compliant.pdf
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Opioid Treatment Issues Medicare coverage for treatment of substance abuse
disorders and co-occurring mental health disorders is broader than what is allowed under the DEA rules for prescribing controlled substances, including buprenorphine
HHS guidance attempts to resolve some issues, but remains incomplete: https://www.hhs.gov/opioids/sites/default/files/2018-09/hhs-telemedicine-hhs-statement-final-508compliant.pdf
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Recent Changes: Non-Telehealth Telemedicine
CMS interpretation of Section 1834(m) in effect created a category of Non-Telehealth Telemedicine not subject to telehealth restrictions
Examples of services not considered Medicare telehealth services:
Brief Communication Technology-Based Service (HCPCS G2012)
Remote Evaluation of Pre-Recorded Patient Information (HCPCS G2010)
Interprofessional Internet Consultation (CPT 99451, 99452, 99446, 99447, 99448, 99449)
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Recent Changes: Medicare Advantage Plans Starting in 2020, Medicare Advantage (“MA”) plans will be able to offer
“additional telehealth benefits” to enrollees as an original Medicare benefit.
To qualify, MA plans must:
provide in-person access to specified Part B services upon request
provide additional telehealth benefits through contracted providers
advise enrollee that he/she may receive the specified Part B service through an in-person visit
comply with the provider selection and credentialing requirements at 42 C.F.R. Section 422.204 and applicable state licensing laws
make information available about additional telehealth benefits to CMS upon request
ensure that any differential in cost sharing must parallel the actual cost of administering the service and not steer enrollees or inhibit access
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Wisconsin Medicaid Telehealth Policy Audiologists are allowable providers
Not covered as telehealth services:
Telephone conversations
Written electronic communications (e.g., email, texts)
Store and forward services
Services that are not covered when delivered face-to-face
Smaller list of telehealth covered services than under Medicare
More restricted list of authorized originating sites: only hospital, office/clinic, SNF
Telestroke coverage different than Medicare
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Telehealth For Medicare Beneficiaries in Non-Covered Settings Section 1848 of the Social Security Act requires
enrolled providers to submit reassigned claims to Medicare: the “mandatory claims submission” rule
“Opt-out” practitioners, who fully “opt-out” of Medicare, need not submit claims
Opt-out periods 2 years long, with no exceptions
Opt-out practitioners may still enroll under 855O, for ordered items and drugs to be covered by Medicare
Can an enrolled provider use an ABN?
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Telehealth For Medicare Beneficiaries in Non-Covered Settings No current CMS guidance on topic
In 2015, Noridian included the following Q&A on its website, which has since been removed:
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Telemedicine Credentialing:Medicare Conditions of Participation
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Relying on a Distant Site Hospital/Entity
Written agreement between hospitals
Agreement specifies responsibility of distant site to meet credentialing/privileging CoPs
Agreement specifies distant site furnishes contracted service to hospital in a manner that permits receiving hospital to comply with CoPs for contracted services
Distant site must be Medicare-participating hospital
Provider is privileged at distant site, which provides current list of Provider's privileges
Provider holds a license issued or recognized by the state of receiving hospital
Receiving hospital conducts and shares internal reviews of Provider's performance with distant site hospital (at a minimum, all adverse events and complaints)
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Medicare and Medicaid billing and reimbursement for Telehealth Services
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Telehealth in RHCs and CAHs
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Provider Type
Medicare Wisconsin Medicaid
Allowable Originating
Site?
Allowable Distant Site
location?
Allowable Originating
Site?
Allowable Distant Site
location?
RHC Yes(technical fee
schedule)
No Yes (cost, no visit)
Yes(cost, billable
visit)
CAH Yes(technical fee)
Yes(professional fee schedule)
Yes(technical fee)
Yes(professional fee schedule)
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Telehealth Originating Site in RHCs (Medicare)
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Medicare Billing/Reimbursement
Telehealth services (originating site) are non-RHC services. Originating site will receive separate payment. Coinsurance and deductible apply.
RHC (originating site)
• This is one of the few services that may be included on an RHC bill (bill type 71X) with another RHC service (e.g., Rev. Code 521)
• Bill Telehealth service under Rev. Code 0780 with HCPCS Q3014
• Requires HCPCS code Q3014 (Reimbursement ~ $25.00)
Telehealth Originating Site in RHCs (Wisconsin Medicaid)
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Wisconsin Medicaid Billing/Reimbursement
Telehealth services (originating site) are considered RHC services for cost reporting purposes. However, the originating site will not receive separate RHC payment since this is not a billable encounter.
• If separate fee-for-service reimbursement is received by the RHC, this payment “must be reported as a deductive value on the cost report”.
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Telehealth Distant Site in RHCs (Medicare)
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Medicare Billing/Reimbursement
Currently only professional practitioner services can be billed for distant site telehealth services.
Rural health clinic services are not considered professional practitioner services and are excluded from the list of billable distant site providers.
Telehealth Distant Site in RHCs (Wisconsin Medicaid)
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Wisconsin Medicaid Billing/Reimbursement
“RHCs may report services provided via telehealth on the cost settlement report when the RHC served as the distant site and the member is an established patient of the RHC at the time of the telehealth service.”
“Claims for services provided via telehealth by distant site providers must be billed with the same procedure code as would be used for a face-to-face encounter along with HCPCS modifier GT”.
Claims must also include POS code 02 (Telehealth).
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Telehealth Originating Site in CAHs (Medicare)
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Medicare Billing/Reimbursement
Telehealth services (originating site) are not eligible for cost-based CAH reimbursement. Originating site will receive separate Medicare fee schedule payment. Coinsurance and deductible apply.
RHC (originating site)
• Submit claims to the Part A MAC on bill type 85X.
• Bill Telehealth service under Rev. Code 0780 with HCPCS Q3014
• Requires HCPCS code Q3014 (Reimbursement ~ $25.00)
Telehealth Originating Site in CAHs (Wisconsin Medicaid)
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Wisconsin Medicaid Billing/Reimbursement
Telehealth services (originating site) are considered hospital outpatient services. Originating site will receive separate Medicaid payment.
CAH (originating site)
• Bill Telehealth service under Rev. Code 0780 with HCPCS Q3014 as a separate line item.
• Reimbursed under CAH outpatient reimbursement methodology.
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Telehealth Distant Site in CAHs (Medicare)
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Medicare Billing/Reimbursement
Services of a professional practitioner can be billed by a CAH for distant site telehealth services.
CAH (distant site)
• Using Option 2 Billing Method, submit claims to the Part A MAC on institutional claim form (CMS 1450).
• Requires modifier GT.
Telehealth Distant Site in CAHs (Wisconsin Medicaid)
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Wisconsin Medicaid Billing/Reimbursement
“Claims for services provided via telehealth by distant site providers must be billed with the same procedure code as would be used for a face-to-face encounter along with HCPCS modifier GT”.
Claims must also include POS code 02 (Telehealth).
Reimbursement for the professional service is based on the Wisconsin Medicare fee schedule.
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Scott J. Geboy, Esq.
Hall, Render, Killian, Heath & Lyman, P.C.
111 East Kilbourn Avenue, Suite 1300
Milwaukee, WI 53202
(414) 721-0451
Special Thanks to Jenny C. Kumosz,
Law Clerk, Hall Render, for preparation
of slides
Jeffrey J Bramschreiber, CPA |
Health Care PartnerWipfli LLP
469 Security Blvd
Green Bay, WI 54313
(920) 662-2822
www.wipfli.com