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Part of the KDHE Rural Resources Webinar Series, this provides an update on telehealth development, Best Practices and available resources within the State of Kansas through 2013, plus an update of Medicare reimbursement codes effective 01/01/14
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TELEHEALTH TODAY
Successful Applications and Valuable Resources in Kansas
TELEHEALTH
This way to Successful Applications and Valuable Resources. . .
Phone (toll-free): 877- 643 – HTRC(4872)
Email: [email protected]
IP: 169.147.3.125 ext.7010109
WWW: HeartlandTRC.org
Gordon AllowayProject Director, HTRC
The Telehealth Resource CenterGrant Program
www.telehealthresourcecenter.org
Technical assistance forstarting or expanding telehealth services.
What is Telemedicine?
Telemedicine:… delivery of health care when distance separates a physician from the patient.
Telehealth: … broader form of telemedicine that includes additional technologies, providers and health education.
What is Telehealth?
How does it work?
Telemedicine is NOT a new techniqueVillemard, 1910 Correspondance Cinéma - Phono - Télégraphique Chromolithographie Paris, BNF, Estampes http://expositions.bnf.fr/utopie/grand/3_95b2.htm
Hugo Gernsback - 1924
Telemedicine has been
around long time.
Now. . .New Forms of Communication =
New Delivery Options
New Forms of Communication =
New Application Opportunities.
Telemedicine in the 1990s
• Very few telemedicine programs• Expensive, bulky equipment• Expensive telephone lines• Minimal insurance reimbursement (In Kansas,
Medicare and Blue Cross/Blue Shield)• Limited research
Telemedicine in the 1990’s
Telemedicine in Kansas: 1991
Hays AHEC Kansas City
Telemedicine in KansasClinical Consults: 1993-2001
1993 1994 1995
19961997
19981999
2000
2001
0
500
1000
1500
2000
2500
3000
Telemedicine Today
• Smaller, less expensive equipment• High quality, high definition (HD) technology• Less expensive internet connectivity• Mobile, wireless capability• Improved insurance reimbursement• More extensive research
Telemedicine Today
• In 2013:– KUCTT
• Over 60 sites interacted with KUCTT• More than 4,000 clinical visits conducted
– Total KS activity unknown
Group Sessions and Educational Events
Specialty Consultation via ITV
Telestroke / Physician-to-Physician
School-Based Programs
Intra-Oral Scope (Tele-Sleep Study)
What Tele-Sleep Presenter Sees
Oncology Care (Hospital Exam Room)
Disease Management – Home Monitoring
Clinical Models• Level and frequency of telemedicine use can vary,
based on comfort of provider and specialty needs– TelePsychiatry – completely by telemedicine, no in-
person
– TeleOncology – hybrid model of some in-person (often 1st appt.) and some telemedicine follow-up
– TeleRehabMedicine – more in-person, less telemedicine
Kansas Best Practices – Telehealth / Telemedicine
Telemedicine Services at Goodland Regional Medical Center
Kansas Best Practice - Telehealth / Telemedicine
Kansas Best Practice - Telehealth / Telemedicine
Hays Daily NewsBy KALEY CONNER
10/25/2013
Kansas Best Practice - Telehealth / Telemedicine
South Central Kansas Special Education CooperativeSchool-Based Telemedicine• Behavioral Clinics
Psychology
Psychiatry
• Mental Health Clinic
CCHD Autism Diagnostics
• Healthy Hawks Clinic
Weight ManagementShelly Brensing, RN(With her Polycom HDX 7000)
Historical Challenges for Telemedicine
1. Limited adoption by providers– Federal & State reimbursement slow to expand
• Medicare - Adding CPT/HCPCS codes annually• Medicaid – Varies by state
– Private reimbursement not standardized– Seemingly not integrated in clinic flow– Technology concerns
• Initial investment of equipment• Ongoing support• Lack of standardization• Inconsistent broadband internet service
2. Privacy / confidentiality
3. Liability / Licensure
Good News! There Is Reimbursement
• Medicare (2001)• Medicaid varies by state, but generally follows
Medicare guidelines– Kansas (2004)
• Reimbursement available from all health insurance providers (no need for KS legislative mandate)
• Also, Federal grants & loans available
2014Medicare
Benefit Policy –
Telehealth Services
Telehealth Service CPT / HCPCS Codes
Emergency department or initial inpatient consultations HCPCS codes G0425 – G0427
Follow-up inpatient consultations (hospitals or SNFs) HCPCS codes G0406 – G0408
Subsequent hospital care services, limitation 1 telehealth visit every 3 days CPT codes 99231 - 99233
Subsequent nursing facility care services, limitation 1 telehealth visit every 30 days CPT codes 99307 - 99310
Office or other outpatient visits CPT codes 99201 -- 99215
Individual and group diabetes outpatient self-management training (DSMT) services, with a minimum of 1-hr. of in-person instruction to be furnished in the initial year training period to ensure effective injection training
HCPCS codes G0108 and G0109
Individual and group Kidney Disease Education (KDE) services HCPCS codes G0420 and G0421
End Stage Renal Disease (ESRD) related services CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961
Individual and group Medical Nutrition Therapy HCPCS code G0270 and CPT codes 97802 -- 97804Individual and group health and behavior assessment and intervention (HBAI) services CPT codes 96150 - 96154
Psychiatric diagnostic interview examination CPT code 90791 and 90792Individual psychotherapy CPT codes 90832 -- 90834 and 90836 -- 90838Pharmacologic management CPT code 90862Neurobehavioral Status Exam CPT codes 96116
Smoking cessation services HCPCS codes G0436 and G0437, andCPT codes 99406 and 99407
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS codes G0396 and G0397
Annual alcohol misuse screening, 15 minutes HCPCS code G0442Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS code G0443
Annual depression screening, 15 minutes HCPCS code G0444
High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes
HCPCS code G0445
Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS code G0446
Face-to-face behavioral counseling for obesity, 15 minutes HCPCS code G0447
Transitional care management services CPT code 994951 and 994962
Telehealth originating site facility fee (short description: “telehealth facility fee”) Q03014
Medicare Benefit Policy – Telehealth ServicesNEW for 2014
(Effective 01/01/14)
Transitional care management services CPT code 994951 and 994962
1. Communication with patient and/or caregiver within 2 business days of discharge; face-to-face visit within 14 calendar days of discharge and moderate complexity of medical decision-making during service period
2. Communication with patient and/or caregiver within 2 business days of discharge, face-to-face visit within 7 calendar days of discharge and high complexity of medical decision-making during service period
Email: [email protected]
Telehealth Guidelines
• Patient location:– Physician/Practitioner’s office– Hospital (inpatient or outpatient)– Critical Access Hospital (CAH)– Rural Health Clinic (RHC)– Federally Qualified Health Center (FQHC)– Skilled Nursing Facility (SNF)– Hospital-based or CAH-based Renal Dialysis Centers– Community mental health center (CMHC)– HPSA county outside metro area
Telehealth Guidelines• Physician/Provider location (“distant site”)
– No limitation on location– Must be licensed in state where patient is located
• Who may receive payment– Physician, PA, Nurse practitioner, Nurse midwife, Clinical
nurse specialist, Clinical Psychologist, Clinical social worker, Registered dietitian / nutrition professional
• Telepresenters– Not required– Unique to event/specialty
Telehealth Guidelines
• Interactive audio and video telecommunication must be used in real-time communication– Patient must be present and participating
• Payment is equal to the current Physician Fee Schedule amount
• Telehealth Facility Fee (for originating site)– Billable separately under Part B
Telemedicine in U.S.Multiple Federal Funding Resources
– HRSA – Network Planning and Network Development
• Grant assistance for upfront planning and initial development
– http://www.grants.gov/web/grants/search-grants.html
– USAC – Rural Health Care Support
• Will pay for % of Internet access cost
– http://wireless.fcc.gov/outreach/index.htm?job=funding
– Dept. of Commerce – National Telecomm. and Information Admin.
• Expanding broadband Internet access
• State Broadband Initiative & Tech Opp. Pgm.
• http://www.ntia.doc.gov/grants-combined
Telemedicine in U.S.Multiple Federal Funding Resources
– USDA – Rural Development (RD) – Grants & Loans
• Community Facilities (CF) Program - $70 million Direct Loans / $10 million Grants
– Areas/towns up to 20,000 pop.
– Construction or renovation of hosp., NF, Clinic (inc. necessary equipment)
– Purchase of specific equipment (new CT scanner), technology, software
• Application is once a year (end of May/early June)
• Announced 60 days in advance of due date
• RD staff assistance available for application process
• http://www.rurdev.usda.gov
Telemedicine in U.S.Federal Funding Support - Kansas
USDA – Rural Development (RD) – CF Program
Onaga, KSArea: 410 acresPop: 707 (2012)
$5 million CF Direct Loan
Bundled variety of needs:
• EMR hardware/software in hosp. & clinics
• Renovations/enhancements to existing hospital
• Purchased diagnostic equipment
• Refinanced existing debt
USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc
Telemedicine in U.S.Federal Funding Support - Kansas
USDA – Rural Development (RD) – CF Program
WHO: Great Plains Health Alliance, Inc.
WHAT: 24-Hospital NetworkWHERE: Phillipsburg, KS
$2.2 million bank loan guarantee
$3 million CF Direct Loan
Acted as borrower for hospital network:
• EHR hardware/software for 22 CAHs
• Enabled them to provide telemedicine services, virtual consults, diagnostic exams and imaging, and remote monitoring of patients.
USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc
Telemedicine in U.S.Multiple Federal Funding Resources
– USDA – Rural Development (RD) – Grants & Loans
• Distance Learning and Telemedicine (DLT) Program - $15 million
– Areas/towns up to 20,000 pop.
– 15% matching requirement
– Minimum grant award: $50,000; maximum: $500,000
– Purchase of computer hardware/software, computer network components, terminal equip., inside wiring, and inside equip. warranties
• Application is once a year (end of May/early June)
• Announced 60 days in advance of due date
• RD staff assistance available for application process
• http://www.rurdev.usda.gov
Insurance & Licensure
• Standard malpractice insurance covers telehealth
• Very low risk service to date– 3-4 known cases (2 were online
prescribing)
– 2 New Mexico cases bring up telehealth use – If available and not used, there may be liability
• No national physician license– A few states require telemedicine license
• Supplemental licensing
Credentialing & Privileging
• Where patient is located is place of service
• Providers need to be credentialed / privileged/ licensed at each place of service
Effective July 2011 – hospital’s governing body still responsible for all privileging decisions, but can accept credentials from distant-site Medicare hospital for telemedicine providers. CMS
Privacy/Security Issues
• Generally, all current videoconferencing systems include encryption technology.
• Security Rule does not require encryption (“Live” events are not ePHI), but technology easily encripts
• Privacy rule DOES apply• Telemedicine room should be private just like any other
clinic room• Use private connections when possible
HIPAA Security Rule• “The standards and specifications of the Security Rule are
specific to electronic protected health information (e-PHI). . . E-PHI does not include paper-to-paper faxes or video teleconferencing or messages left on voice mail, because the information being exchanged did not exist in electronic form before the transmission. In contrast, the requirements of the Privacy Rule apply to all forms of PHI, including written and oral.”US Dept. of Health & Human Serviceshttp://www.hhs.gov/ocr/privacy/hipaa/faq/securityrule/2010.html
Connectivity in Kansas Hospitals*
• 66% - Have videoconferencing equipment• 31% - Using telemedicine (2010)
– Daily 55%– Weekly 20%
• 23% - Receiving reimbursement for telemedicine (25% - Not sure)
• 50% used same equipment for education and training
* Kan-ed Telemedicine Capacity and Readiness Survey, KS Office of Edu. Innovation & Evaluation / Kan-ed , 2010
Connectivity in Kansas
• Internet access via Internet Service Provider (ISP) is available throughout Kansas
• ISP Internet connectivity is adequate for high-quality videoconferencing
• Multiple Internet-based videoconferencing services now available via ISP connectivity
Source: Kansas Board of Regents: Evaluating the Effects of Eliminating the Kan-ed Program, Legislative Post Audit Committee, Legislative Division of Post Audit, State of Kansas, January 2012.
Interactive Tele-Video (ITV)Putting technology concerns into the past.
PROVIDER’S OFFICEw/ Desk Top Computer
TABLET
SMARTPHONE
Telemedicine on Smaller Scale
Telehealth Peripherals
http://www.telehealthtac.org/toolkits/patient-exam-cameras-technology-overview#Patient_Exam_Cameras
Digital Stethoscopes
Electronic Otoscope for Pediatrics
What the provider or practitioner sees.
(Actual otoscope image)
Technology Specific to Health Care
• Peripheral devices– Otoscope– Stethoscope– Dermascope– Ophthalmascope– General exam camera– Handheld retina camera
Telehealth Peripherals
http://www.telehealthtac.org/toolkits/patient-exam-cameras-technology-overview#Patient_Exam_Cameras
Total Exam Camera
AdvantagesSame FeaturesLess expensiveEasily Available
Digital Camera/Camcorders
FeaturesDigital
Records imageHas own lighting
HD
VS
Technical Advances
• Smaller, less expensive equipment
• From analog to digital
• From telephone lines to internet lines
• Wireless
• Encryption
• Integration
Technical Advances
• Next generation:
The Wireless World of Hospitals
Telemedicine Today
How ToLearn More.
1-877-643-HTRC (4872)
www.HeartlandTRC.org
[email protected] a fan:
www.facebook.com/HeartlandTRC.org
The Telehealth Resource CenterGrant Program
www.telehealthresourcecenter.org
Technical assistance forstarting or expanding telehealth services.
Who do the TRCs serve? Rural Clinics Federally-Qualified Health
Centers (FQHC) Critical Access Hospitals (CAH) Community & Urban Hospitals Primary Care Clinics Providers Health Care Organizations Ambulatory Care Centers Nursing Homes and others…
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http://www.telehealthresourcecenter.org
How TRCs can help. . .• Proven resources
- Legislation/Regulations- Forms & Protocols- Toolkits- Event Announcements
• Staff training- Onsite - Basic Protocols Telepresenters
• Peer-to-peer connections- Learn from other’s mistakes- Tele-All (Stroke, ICU, etc.)- No regional limitations
http://www.telehealthresourcecenter.org
How TRCs can help. . .• Technical Assistance
- Assessmentso Market Conditionso Needs & Prioritizationo Organizational Readinesso Technologyo Peer Comparison
- Basic strategic planningo Sources for revenue generationo Expense reductionso Cost Center/Residual benefitso Start Up / Replacement funding
http://www.telehealthresourcecenter.org
How TRCs can help. . .
• Technical Assistance (cont’d.)- Business Model Development
o Equipment Selectiono Program developmento Operational supporto Education on Insuranceo Reimbursemento Quality Assessment
http://www.telehealthresourcecenter.org
The National Telehealth Resource Center Webinar Series
www.telehealthresourcecenters.org
Key telehealth topics from experts!• 3rd Thursday of Every Month• 1:00 PM Central Time
Phone: 1.877.643.HTRC (4872)
Email: [email protected]
Video IP: 169.147.3.125 ext. 7010109
Gordon AllowayProject Director, HTRC