COVID-19:Telemedicine Revenue Cycle Readiness · 2020. 8. 2. · services on outpatient CDI, clinical coding, and revenue cycle management to 3M clients. She has 25 years of technical

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A p r i l 2 2 , 2 0 2 0C o l l e e n D e i g h a n , R H I A , C C S , C C D S - O ,

S e n i o r C o n s u l t a n t , 3 M H e a l t h I n f o r m a t i o n S y s t e m s

COVID-19: Telemedicine Revenue Cycle Readiness

2© 2020 Waystar Health. All rights reserved.

About the speaker

Colleen Deighan, RHIA, CCS, CCDS-O, Consultant, 3M Health Information SystemsColleen is a consultant with 3M Health Information Systems where she provides advisory services on outpatient CDI, clinical coding, and revenue cycle management to 3M clients. She has 25 years of technical and managerial experience in coding, clinical documentation, compliance and revenue cycle management. Prior to joining 3M, Colleen served in a series of management roles at a large academic medical institution in Cleveland, Ohio, including Director of Professional coding, Director of CDI, Senior Director of Coding Compliance, and Senior Program Director for ICD-10 implementation. Colleen also served as adjunct faculty for 12 years at Cuyahoga Community College in the Health Information Management program, teaching courses on clinical coding, reimbursement methodologies and medical terminology. Colleen is a graduate of the University of Cincinnati with a bachelor of science degree in Health Information Management. She is a Registered Health Information Administrator (RHIA), a Certified Coding Specialist (CCS) and a Certified Clinical Documentation Specialist for outpatient CDI (CCDS-O).


Learning Objectives

At the end of this presentation attendees will be able to:• Define telemedicine• Explain the changes in CMS’

telemedicine coverage policies due to COVID-19 Public Health Emergency

• List the three types of telemedicine visits and the requirements for furnishing these services


Today’s agenda

• Review the state of telemedicine prior to the COVID-19 pandemic

• Examine telemedicine after Public Health Emergency (PHE) declared including requirements for furnishing telehealth visits

• Addressing FAQs• Summary and take-aways


Waystar Disclaimer

Participants are cautioned that information contained in this presentation is not a substitute for informed judgment. The participant and/or participant’s organization are solely responsible for compliance and reimbursement decisions, including those that may arise in whole or in part from participant’s use of or reliance upon information contained in the presentation. Waystar disclaims all responsibility for any use made of such information. Please note that the telehealth information shared during this presentation pertains to CMS telehealth guidelines.


3M Disclaimer

The information presented herein contains the views of the presenters and does not imply a formal endorsement or consultation engagement on the part of 3M. Participants are cautioned that information contained in this presentation is not a substitute for informed judgment. The participant and/or participant’s organization are solely responsible for compliance and reimbursement decisions, including those that may arise in whole or in part from participant’s use of or reliance upon information contained in the presentation. 3M and the presenters disclaim all responsibility for any use made of such information. Please note that the telehealth information shared during this presentation pertains to CMS telehealth guidelines.


Telemedicine prior to the COVID-19 pandemic


TelemedicineTelemedicine

• The practice of medicine using technology to deliver care at a distance

• World Health Organization (WHO): “healing from a distance”

• Increasing becoming a tool for convenient medical care

CMS definition• Telehealth, telemedicine, and related terms generally refer

to the exchange of medical information from one site to another through electronic communication to improve a patient's health

Common terms• Telemedicine• Virtual visits• Telehealth• e-health


Telemedicine and Medicare

Prior to COVID-19 pandemic• Medicare beneficiary must live in rural area and travel to a local

medical facility and get telehealth services from a doctor in a remote location

• Originating sites• Distant site practitioners• Must use real-time interactive audio and video

telecommunications system• Defined what services could be provided

• Medicare beneficiaries generally could not get telehealth services in their home

• Prior to this waiver, CMS made changes to improve access to virtual care (Virtual Check-Ins)


Telemedicine after PHE declared


COVID-19 Public Health EmergencyCMS broadens access to Medicare telehealth• Temporary and emergency basis under the 1135 waiver authority and

Coronavirus Preparedness and Response Supplemental Appropriations Act• Part of a broader effort by CMS and the White House Task Force • Intent of the waiver is to assure:

• Increased access for Medicare beneficiaries• Keep them safe at home• Avoid travel• Contain the community spread of COVID-19• Without regard to beneficiary’s diagnosis


CMS broadens access to Medicare telehealth• Effective March 1, 2020 and for the duration of the PHE• All beneficiaries across the country can receive Medicare telehealth and other

communications technology-based services wherever they are located• Beneficiaries can get telehealth services in any health care facility as well as from

their home• This change broadens telehealth flexibility without regard to the beneficiary’s

diagnosis (all conditions not just COVID-19)• Providers can furnish these services to new or established patients


Compliance with Medicare telehealth

• Prevent fraud and abuse• Err on the side of caution• Burden of proof is high• Compliance checklist

• Subject Matter Expert review• Educate• Communicate• Policies and procedures• Monitor and audit• Feedback loop


Coding for COVID-19 in the outpatient and office visit settings

1 2 3 4


Requirements for furnishing

Types of telemedicine visits


Types of telemedicine visits

Medicare telehealth visits• Interactive audio

and video telecommunication

• Real-time communication

Virtual check-ins• Brief

communication service

• Typically initiated by patients

E-Visits• Non-face-to-face

patient-initiated communication using online patient portals


Medicare telehealth visits

• Provider must use an interactive audio and video telecommunication, permits real-time communication

• Any technology with audio and video can be used • Will not face HIPAA penalties from HHS Office of Civil Rights

• Considered the same as in-person visits• Paid the same as in-person visits• Can be furnished in any healthcare facility and in the patient’s home• Can be furnished in all areas of the country, in all settings• HHS Office of Inspector General (OIG) allowing providers to reduce or waive

cost-sharing


Medicare telehealth visits

• Who can furnish? • Physicians and certain non-physician

practitioners • Services payable under the Medicare

Physician Fee Schedule • This is not changed by the waiver

• What services are covered?• Office and other outpatient visits• Hospital inpatient• Nursing facility services• ED services• Home services• 80+ services found at:• https://www.cms.gov/Medicare/Medicare-

General-Information/Telehealth/Telehealth-Codes

• For Office and Other outpatient services furnished via telehealth

• Similar to Final Rule regarding this E/M category and changes effective 1/1/2021

• Level of service selection can be based on MDM or time

• Time being defined as all of the time associated with the E/M on the day of the encounter

• Removes the requirement regarding documentation of the history and physical exam in the medical record

• CMS expects providers will document E/M visits as necessary to ensure quality and continuity of care

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes


Coding and billing for telehealth visits

• Assign the E/M Code that describes the service performed (e.g. 99214, Established office visit) along with modifier 95 to identify service was furnished via telehealth

• Place of Service (POS) should identify where the service would have occurred if furnished in person

• Append modifier CS as appropriate E/M service that result in the order or decision to order one of the COVID-19 lab tests

• CS modifier first used in the 2010 Gulf of Mexico oil spill• Repurposed for COVID-19 PHE

• Identifies services subject to cost-sharing waiver• Instructs MAC to reimburse at 100%• Effective for dates of service between March 18, 2020 and the duration of the PHE • Do not add for services unrelated to COVID-19


Virtual check-ins

• Brief communication technology-based service over the phone or exchange of information via video or image

• Initiated by the patient• Can be furnished to new and established patients• Expanded to allow those who do not bill for E/M services to furnish • Patients communicate with their provider, avoids in-person visit• Verbal consent is needed• HCPCS Code: G2012

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, 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; 5-10 minutes of medical discussion

• HCPCS Code: G2010Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, 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.


E-Visits• Non-face-to-face service• Patient must generate initial communication• Patient must have an established relationship

with provider • Patients communicate with their provider,

avoids in-person visit by using telephone or online patient portals

• Verbal consent is needed• Communication can occur over a 7-day period


E-Visit CPT and HCPCS codes

Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

99441: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes99442: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes99443: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes

G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutesG2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutesG2063: Qualified non-physician healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.


Summary of Medicare Telemedicine Services

Source: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet


Questions submitted by listeners


Frequently asked questions

1. What CPT Services are covered by Medicare for telemedicine services?The policy changes to telehealth in response to the COVID-19 pandemic are granted under President Trump’s emergency declaration. Under these policy changes CMS has broadened access to Medicare telehealth services. There are more than 80 services included: office visits, annual wellness visits, observation services, emergency department visits, inpatient care, critical care, nursing facility care, home visits, psychiatric and psychotherapy, ESRD services, PT/OT and ST, medical nutrition, diabetes mgmt., alcohol and substance abuse assessments. Complete list can be found at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

2. Can you clarify what modifier is needed when billing for telehealth services?For Medicare claims use the POS that would have been used had the patient been seen in-person; append modifier 95 to identify the service was telehealth. If the service is COVID-19 related, also append modifier CS.

3. If the telehealth visit is real-time audio only, can this be billed as a telehealth visit?No, telehealth must be real-time audio and visual telecommunication between the patient and the provider.

4. Will Medicare allow NPs and LCSWs to bill for E/M for telephone calls to patients or is the virtual visit, G2012, the only option for them?

To the extent that the practitioner provided these services in person they can be furnished as telehealth services. A telehealth visit is not a phone call, so again want to clarify that telehealth services are real-time audio visual telecommunication services. The definition of the three types of telemedicine visits along with remote monitoring services must be communicated within facility/organization/clinic.



Frequently asked questions5. Can you provide information for billing telehealth visits not related to COVID-19?Furnishing of telehealth services during the PHE is not just for COVID-19. To encourage vulnerable beneficiaries and beneficiaries with mild symptoms to stay at home, limit exposure to other patients and reduce the spread of COVID-19 telehealth services can be furnished for any condition.

6. How often can telehealth visits be furnished, are there any frequency limits?If services are reasonable and necessary there is not frequency limits. Medicare defines services as reasonable and necessary as:Health care services or procedures that a prudent physician would provide to a patient for the purpose of

• Preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:• In accordance with generally accepted standards of medical practice;• Clinically appropriate in terms of type, frequency, extent, site and duration; and• Not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient,

treating physician or other health care provider.”

7. Can you talk about how incident to may work for mid-level providers?Services where direct supervision is required by the physician it can provided virtually using the same technology. Considerthe requirements for direct supervision and the physician being immediately available, the same applies to telehealth services. CMS does expect that the provider billing for the service is the provider who furnished the care.


Frequently asked questions8. What codes can be billed on a UB-04 and what can be submitted on a CMS1500?Telehealth services are professional services. CMS is actively considering the facility side of a hospital-based clinics and services finished by individuals not able to bill on a 1500.

9. What telehealth services are authorized for physical therapy providers and outpatient physical therapy clinics? Can PT/OT bill incident to under the physician’s NPI?

Per CMS “office hours” twice weekly calls the answer to this is “no”. They expect the telehealth practitioner furnishing theservice to bill for the service. However, they did state they understand these services are necessary for the beneficiaries andare being provided; they are actively looking at expanding telehealth services.

10.What telehealth services are RHCs and FQHC’s allowed to provide during the pandemic and what are the billing instructions?

This past Friday, April 17,2020 CMS authorized RHCs and FQHCs to furnish distant site telehealth service to Medicare beneficiaries during the COVID-19 PHE. For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, RHCs and FQHCs must put Modifier 95 on the claim. RHCs will be paid at their all-inclusive rate (AIR), and FQHCs will be paid based on the FQHC Prospective Payment System (PPS) rate. These claims will be automatically reprocessed in July when the Medicare claims processing system is updated with the new payment rate. RHCs and FQHCs do not need to resubmit these claims for the payment adjustment. July 1, 2020 a new G code, G2025 will be used by RHCs and FQHCs will be used to bill for telehealth services between July 1,2020 and the end of the COVID-19 PHE.


Summary and key take-aways


Key take-aways

• Telehealth pre-dates COVID-19 PHE• Waiver is temporary through the duration of the COVID-19 PHE• Expanded access for beneficiaries to telehealth services• Know the guidelines / stay informed• Extremely fluid

• FAQs, Bulletins, email alerts on COVID-19• Check with your commercial payers

• Generally following Medicare’s lead in terms of coverage and policy• Medicare encouraging all plans to promote the use of telehealth and other remote services• However, coding guidance varies from payer to payer and state to state


Access to the Waystar Resource Center Waystar continues to update its COVID-19 Resource Center to ensure our providers are armed with the information they need during this crisis.

Check Back Often ForMore WebinarsLinks to Helpful External ResourcesAccess to Presentations

https://info.waystar.com/WAY-COVID19-Resource-Center.html

https://info.waystar.com/WAY-COVID19-Resource-Center.html

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ReferencesCOVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing

https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Medicare Telemedicine Healthcare Provider Fact Sheet


MLN Telehealth Services

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

New and Expanded Flexibilities for Rural Health Clinics and Federally Qualified Health Centers During the

COVID-19 PHE

https://www.cms.gov/files/document/se20016.pdf

List of CMS Telehealth Services


https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

https://www.cms.gov/files/document/se20016.pdf



Glossary of termsPHE: Public Health EmergencyWHO: World Health OrganizationHHS: Health and Human Services CMS: Centers for Medicare and Medicaid ServicesMAC: Medicare Administrative ContractorOIG: Office of Inspector GeneralHIPAA: Health Insurance Portability and Accountability ActPHI: Protected Health InformationCPT: Current Procedural Terminology HCPCS: Healthcare Common Procedure Coding SystemE/M: Evaluation and ManagementPOS: Place of ServiceNP: Nurse PractitionerPA: Physician AssistantLCSW: Licensed Clinical Social WorkerFQHC: Federally Qualified Health CenterRHC: Rural Health Clinic

Documents

COVID-19:Telemedicine Revenue Cycle Readiness · 2020. 8. 2. · services on outpatient CDI, clinical coding, and revenue cycle management to 3M clients. She has 25 years of technical