REIMBURSEMENT FOR TELEHEALTH SERVICES

1. REIMBURSEMENT FOR TELEHEALTH SERVICES

2. 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)

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

4. 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.

5. 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.

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. PROVIDER TELEMEDICINE ROLES

15. 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

16. 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

17. 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

18. 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)

19. 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)

20. DOCUMENTATION

21. 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)!

22. TM 4 This is an ongoing email communication between a remote provider and a specialist at ANMC. NO CONSULT!

23. 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.

24. 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.

25. 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!

26. 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

27. E/M* Guidelines to Remember * Evaluation/Management

28. New Patient vs. Established Patient

29. 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.

30. New Patient

31. Established Patient

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. Three R’s of Consultations • Requesting a consult • Rendering an opinion • Reporting back to the requesting provider

38. PAYOR SPECIFIC REIMBURSMENT

39. STATE OF ALASKA 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) MEDICAID

44. STORE & FORWARDEXAMPLES

45. 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

46. 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.

47. 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.

48. TM 7 Example of how to bill FHSC (MEDICAID) for the consult if provider is in a clinic.

49. FNP Visit at a Remote Site TM 9 Store and Forward Requesting telemed consult Sending 3 images signifying store and forward.

50. TM 10 Bill FHSC For Referring Provider FNP No modifier required for the face-to-face visit. 99212 for face-to-face visit