Telehealth in USA

A lot of federal funds and financial stimulus packs have been released in the wake of COVID-19. Two such measures have been game changers for the telehealth sector, namely the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Together, these measures have enabled CMS to make telehealth more accessible than ever before during this period of public health emergency. They are temporary however, designed to be an response to this pandemic. We review the changes in this post, but also go over the whole gamut of telehealth options for physicians which had existed prior to the enactment of the new measures.

What Has Changed?

During this period, coverage for telehealth reimbursement is extended where physicians can be contacted by patients from any location, waiving the originating site requirement. To understand how big of a deal this is, see the following originating sites where a patient had to be to receive care via telehealth prior to COVID-19: 

• Physician and practitioner offices  
• Hospitals  
• Critical Access Hospitals (CAHs)  
• Rural Health Clinics  
• Federally Qualified Health Centers  
• Hospital-based or CAH-based Renal Dialysis Centers (including satellites)  
• Skilled Nursing Facilities (SNFs)  
• Community Mental Health Centers (CMHCs)  
• Renal Dialysis Facilities  
• Mobile Stroke Units 

Only instances where the patient was allowed to be in home while receiving care was for End Stage Renal Dialysis (ESDR), substance use disorder or a co-occurring mental health disorder.

Apart from the patient being in one of the above sites, the patient would have had to reside in a county outside of a Metropolitan Statistical Area (MSA) or in a rural health professional shortage are (HPSA).

The Changes

Beginning from March 6th, a patient does not have to be outside of MSA, in a rural HPSA or in any of the originating sites above. They can avail the care they need right from the safety and privacy of their own homes. Not only for ESDR, substance abuse or co-occurring mental disorder, but for any care service. 

Furthermore, there will be payment parity for these services. Providers will be able to bill for telehealth services at the same rate as in-person visits. 

A patient must initiate services, but physicians will be allowed to inform their patients on the availability of telehealth services.  HHS (Health and Human Services) has said that it will not conduct audits to confirm prior patient-physician relationships for claims submission. 

What Was Always There

So we see that more than any other time in history, telehealth is being treated like real health. As everyone practices social distancing and self-isolation, the line between the two has been greatly blurred, where any form of care starts out as virtual care to minimize unnecessary visits outside. Therefore, it has garnered a lot of attention from physicians who want to use the system, encouraged by the waiving of originating sites and payment parity. But from a financial or coding perspective, how do you begin to account for patient visits? 

The movement to switch to telehealth for initial contact or at least encourage more use of it, had started years back. Codes had been enacted with their own reimbursement rates which could be billed by physicians irrespective of the patient’s location.  Only early adopters of the relevant codes would know. But worry not, this post makes sure you catch up to speed. The reimbursement rates for the codes are also included. 

Virtual Check-In 

HCPCS 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. 

Notice  the before and after time stipulations in the code. CMS is big on non-duplication, where you cannot code twice for treating the same condition within a certain time span. So the purpose of the virtual check-in code, is just that, it is just a quick consultation. If it is related to an E/M service from the last week, or if it will lead to an E/M service or procedure anytime soon, then you would be better off not coding it. The purpose of this code is to clearly keep the patient out of the facility for the time being, and for them to bring forth new concerns that requires the physician’s attention.  The virtual check in is for established patients.

National non-facility payment: $14.80.     National facility payment: $13.35 

Note: There are  no frequency limitations. 

Requirements: Need advance consent from a patient who is established. Physician must be on the call. Cannot only be clinical staff. 

Allowed Technology: Real time audio only synchronous two-way audio interactions that are enhanced with video, or just telephonic communication.  

Remote Evaluation of Pre-recorded Patient Information 

HCPCS G2010- Remote 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 

National non-facility payment: $12.61.     National facility payment: $13.35 

Requirements: Need advance consent from a patient who is established. 

Allowed technology: May involve prerecorded use of patient generated still or video images. Follow up with patient can be done over a phone call, audio/visual communication, secure text messaging, email, or patient portal communication. 

Interprofessional Internet Consultation 

The purpose of these codes to enhance care coordination. 

For Consultative Physician

CPT  99446- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review  

Amount Reimbursed: $18.38 

CPT 99447- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review  

Amount Reimbursed: $36.40 

 CPT 99448- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review  

Amount Reimbursed: $54.78 

 CPT 99449- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review  

Amount Reimbursed: $73.16 

 CPT 99451-Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time. 

Amount Reimbursed: $37.48 

Requirements: Need advance patient content. The consultative physician must be a qualified healthcare professional. Has a frequency limitation of once every 7 days for the same patient. The time reports are based on cumulative time spent. Not reported if the patient was seen by the consultant in the past 14 days, or if a transfer of care or a request for face-to-face consult occurs over the next 14 days.

For Requesting Physician

CPT 99452- Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes). 

Amount Reimbursed: $37.48 

 Requirements: Need advance patient content. The requesting physician must be a qualified healthcare professional.  The non face-to-face consult for medical advice or opinion that is requested must not be for a transfer of care. It requires a minimum of 16 minutes, which can include time preparing for the referral and and/or communicating with the consultant.  It has a frequency limitation of one every 14 days for a patient.

The Online Digital Evaluation Service (e-Visit) 

These codes are used when the purpose of the video call is not to determine if an office E/M service is necessary. If that was the case, a Virtual Check-in would have been used. Rather an e-visit is an online E/M visit, and so is treated just like an in person visit, but conducted online. It is for established patients.  Medicare describes it as patient initiated digital communications that require a clinical decision that would have been otherwise typically been provided in the office. 

Acknowledging non-physician healthcare practioners who will be conducting e-visits, Medicare is using HCPCS codes for on-line digital evaluation performed by these professionals who can’t bill E/M services. Notice, that instead of “evaluation and management” the definitions use the word “assessment.” 

For Non-physicians

HCPCS G2061- Qualified nonphysician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes 

Reimbursement Amount: $12.27.      

 HCPCS code G2062- Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes 

Reimbursement Amount: $21.65     

 HCPCS code G2063- Qualified nonphysician qualified 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 

Reimbursement Amount: $33.92   

 For Physicians and Other Qualified Healthcare Professionals that may bill Medicare E/M Codes

CPT 99421- Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes 

National non-facility payment: $15.52     National facility payment: $13.35 

 CPT 99422-Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11—20 minutes 

National non-facility payment: $31.04   National facility payment: $27.43 

 CPT 99423- 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 

National non-facility payment: $50.16    National facility payment: $43.67 

Notice how all e-visits have a time frame of 7 days, if any evaluation or assessment extend beyond this 7 day period, then they may be billed under remote patient monitoring. We cover remote patient monitoring reimbursement details in other posts, such as this one. It has its own set of conditions, as does chronic care. Remote Patient Monitoring and Chronic Care codes are two other examples besides Virtual Check In and e visits which were never considered telehealth to begin with, and thus were not restricted by the originating site requirement. 

Medicare Telehealth Visits

(The Real Beneficiary of The Changes)

For a complete list of telehealth services covered by Medicare, refer to this list. We’ll cover the common ones which can help you intake patients and begin a care plan for them so they get the treatment that they need. The Medicare Telehealth Visits are different from the virtual check ins and the -visits, in that the patient need not be established. HHS has said it won’t audit for existing relationship during this emergency period. Also, the originating site waiver applies to these codes, as everything else covered previously never had site restrictions to begin with. 

 In addition, the following codes can also be used to intake new patients, by means of telehealth consultations.

Conclusion 

Thus we can see that whether it is for established patients whose care may have been disrupted, or for first time patients who need care, there are telehealth codes in the books available to manage them. From March 6th, the traditional Medicare telehealth codes have temporarily joined the ranks of e-visits and virtual check ins, where the patient does not have to be in an originating site. So it must be said, that audio visual technology is an essential for any private practice, let alone a hospital. If you are at the stage of comparing features to determine what’s best for you, do get in touch with us. We can point you to the right direction. If you want to set up your telehealth program for the future, complete with care coordination features and remote patient monitoring capabilities, then we would love to learn more about your use case. Get in touch with us. 

 References

https://www.aappublications.org/news/2019/01/04/coding010419

https://www.aafp.org/journals/fpm/blogs/inpractice/entry/telehealth_algorithm.html

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

https://www.gottransition.org/resourceGet.cfm?id=352