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Telehealth Reimbursement: What You Don’t Know Could Hurt You!

Telemedicine reimbursement is always a hot topic but even hotter with the new CMS regulations.  On February 7, 2019, Jordana Bernard the Director for Policy and Public Affairs at InTouch Health, was the guest presenter for the Southwest Telehealth Resource Center and the Arizona Telemedicine Program webinar series.  The webinar reached over 500 individuals across the US and a few international folks joined in too! Jordana provided a concise and informative overview of all the latest changes in telehealth reimbursement. It was recorded and archived on our website along with her slide deck and a couple of useful handouts (e.g., the list of 98 CPTs that are reimbursed), so if you missed it think about taking the time to view it. These, along with all our previous webinars, can be found at https://telemedicine.arizona.edu/webinars/previous .

The presentation has lots of incredibly valuable information and as you might suspect we received lots of questions! We were able to get through a good number in the Q&A period but ran out of time to answer them all. Below we summarize some of the key question themes and provide answers that hopefully will help you in your reimbursement efforts.

Home Health and Remote Patient Monitoring

- Are there new codes for remote monitoring billing by home health?

Yes, CMS finalized 3 new payment codes for “remote physiologic monitoring” (RPM) in 2019:  99453, 99454, and 99457.  The first two define payment for the technical components of RPM and the third pays for the professional fee.

- Do RPM codes require daily monitoring (or can it be weekly, etc.) using technology or can it be self-reported (lo-tech?)

CMS does not set a frequency limitation or type of technology for RPM, however, the physiologic data must be transmitted electronically.  The RPM payment codes are based on cumulative time spent by the practitioner delivering RPM treatment management services: CPT 99457 requires at least 20 minutes time spent by physicians, QHPs or clinical staff in a calendar month and CPT 99091 requires at least 30 minutes time spent by physicians and QHPs over a 30-day period.

- Who bills for review of RPM data?

The healthcare practitioner who reviews the physiologic data would bill the professional fee for RPM either using 99091 or 99457.  The home health agency or responsible entity providing the technology could bill the technical components for setting up the equipment, etc. using codes 99453 and 99454.

Clinically Related

- Is telebehavioral health (TBH) only applicable for substance use disorders or can we use for treating geriatric population with depression?

Starting July 1, 2019, the new TBH rules remove the rural geographic requirement and allow services into the patient’s home for substance use disorder treatment and co-occurring mental health disorders only. There are other TBH approved services/payment codes (see Medicare list), however, these services – except where otherwise exempted such as for telestroke - would be subject to Medicare’s telehealth restrictions.

- Are you saying that this new telestroke provision is not good for the hospital that does telestroke, just a mobile stroke unit?

Effective January 1, CMS finalized nationwide payment for telestroke consultations to patients presenting with acute stroke in hospitals, CAHs and mobile stroke units.  The new G0 (zero) modifier must be used when billing any telestroke encounter, regardless of geographic location or facility type.

- How can CMS pay for genetic counseling services when Medicare does not recognize GCs as a licensed provider type?

Currently CMS does not pay for genetic counseling.  Congress recognizes this important area and introduced H.R. 7083 Access to Genetic Counselor Services Act of 2018 that aims to establish coverage for these services through telehealth.  Hopefully this bill will be reintroduced in the current Congress.

-My understanding is that only hospital-based dialysis centers are authorized as originating sites per the BBA, not independent dialysis facilities. Is this correct?

The BBA expanded the list of approved originating sites to include independent dialysis facilities and the home for purposes of the monthly clinical assessment for ESRD home dialysis patients. For this use case, any approved originating sites are not subject to the rural requirement.

Logistics

- How do you properly bill for Q3014?

This facility fee payment code is billed by the originating site (patient location).

- Consent requirement for interprofessional consultations - is it written consent or verbal? 

Verbal or written consent is required and must be documented in the medical record for each encounter.

- How is reimbursement in the US territories (e.g., Virgin Islands, Puerto Rico)?

Medicare covers telehealth services in the U.S. territories. Payment for services would be subject to the telehealth requirements (i.e., rural, etc.)  Other payment sources - such as through commercial payers - could be explored.

- Besides time spent by the providers, what are the differences between the new virtual care interprofessional consult codes?

CPT codes 99446-49 define services provided by a consulting physician by telephone or internet service including a verbal and written report to the requesting/treating physician or QHP.  CPT code 99452 is a service provided by the requesting/treating provider via telephone, internet or EHR referral. CPT code 99451 requires only a written report by the consulting physician to the requesting/treating provider.

- Are the virtual visits only paid for patients that are not seen 7 days prior or 24 hours after the virtual visit?

CMS will only pay for the new brief check-in and remote evaluation (S&F) visits when

not originating from a related E/M service provided “within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.”  See the full descriptors in the 2019 Physician Fee Schedule.

- Will Medicare let us bill originating site and distant site bundled?

No, CMS does not allow this, however, these can be put on the same claim form.

- Recently heard that all of our contracts with payors will need to be amended to include payment for telehealth, is this true?

We are not aware of this, however, it is good practice to add specifying language regarding telehealth at the time of payer contract renewal.

The Future

- What is the outlook of Medicaid support of telehealth, with the understanding that reimbursement, etc. is dictated by the states?

The outlook is bright!  States are trending toward enacting more progressive laws focused on expanding coverage and reimbursement policies for telehealth.

- What are the best resources for reimbursement changes and models for Medicaid and private payers? Your Telehealth Resources Centers and the Center for Connected Health Policy!

About the Author

Elizabeth Krupinski, Ph.D. is a Professor at Emory University in the Department of Radiology & Imaging Sciences and is Vice-chair of Research.. She is Associate Director of Evaluation for the Arizona Telemedicine Program and Director of the SWTRC. She has published extensively in these areas, and has presented at conferences nationally and internationally. She is Past Chair of the SPIE Medical Imaging Conference, Past President of the American Telemedicine Association, President of the Medical Image Perception Society, and Past Chair of the Society for Imaging Informatics in Medicine. She serves on a number of editorial boards for both radiology and telemedicine journals and is the Co-Editor of the Journal of Telemedicine & Telecare.

Jordana Bernard is Director, Policy and Public Affairs with InTouch Health. Jordana has over 30 years of healthcare industry experience with twenty years in telehealth. At InTouch Health, Jordana leads regulatory and legislative initiatives to advance policy priorities and advance remedies to top telehealth policy barriers and challenges.  She provides leadership on policy issues and serves as a policy resource for stakeholders across the industry.

 

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