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Show Telemedicine: Does It Pay To Play? Billing, Coding, and Reimbursement Kevin E. Lai, M.D. Circle City Neuro-Ophthalmology / Midwest Eye Institute Assistant Professor of Clinical Ophthalmology Indiana University School of Medicine Richard L. Roudebush VA Medical Center Relevant Financial Disclosures • None Telemedicine Around The World https://telehealthandmedicinetoday.com/index.php/journal Models of Reimbursement Research Grants Third-party (Medicare/Medicaid, commercial Insurance) Self-Pay/Concierge Research Grants https://www.telehealthresourcecenter.org/wp-content/uploads/2019/01/Funding-Jan.-2019.pdf • Grant funding is available from many resources • Not meant for perpetual funding of projects • Not a good long-term plan for reimbursement Self-Pay (Concierge) • Still need to meet state and institutional regulations for licensure, etc. • Overall fewer regulations • Increased price transparency • Requires patient "buy-in" Medicare/Medicaid/Commercial Insurance Before You Bill Medicare… • Are you compliant with state laws (your state and the patient's state)? Before You Bill Medicare… • Are you compliant with state laws (your state and the patient's state)? • Have you obtained (and documented) patient consent? Before You Bill Medicare… • Are you compliant with state laws (your state and the patient's state)? • Have you obtained (and documented) patient consent? • Is your patient located in a Health Professional Shortage Area? Before You Bill Medicare… • Are you compliant with state laws (your state and the patient's state)? • Have you obtained (and documented) patient consent? • Is your patient located in a Health Professional Shortage Area? • Is the patient at a qualified facility? Before You Bill Medicare… • Are you compliant with state laws (your state and the patient's state)? • Have you obtained (and documented) patient consent? • Is your patient located in a Health Professional Shortage Area? • Is the patient at a qualified facility? • Are you credentialed at the patient's facility? • "Privileging by proxy" rule Telehealth Services most likely used In NeuroOphthalmology Face-to-Face Non-Face-to-Face Patient phone calls Synchronous complete consult ("live video") Patient-sent photos/videos Provider-to-provider consults How does CMS define live video telemedicine? https://www.bqwchc.com/sites/bqwchc.co m/files/img/hero/telemedicine_0.jpg Who? MD/DO, NP, PA, etc. What? ED consult Inpatient consult Office/outpatient visit Where? Eligible patient at eligible facility (HPSA, etc.) Health Professional Shortage Area (HPSA) http://hpsafind.hrsa.gov/ Eligible Facilities • Physician office • Hospitals • Critical Access Hospitals (CAH) • Rural Health Clinics (RHC) • Federally Qualified Health Centers (FQHC) • Hospital or CAH-based Renal Dialysis Centers • Skilled nursing facilities (SNF) • Community Mental Health Centers (CMHC) Coding For Face-To-Face, Synchronous Teleconsults CPT Code • • • • Outpatient E/M (99201-99205) ER consult (99211-99215) Inpatient consult (99231-99233) Prolonged services (99354-99357) Modifiers, etc. Change Place of Service to 02 (Telemedicine) -GT modifier no longer needed Sample Documentation real time telehealth video connection I obtained verbal consent from the patient Approximately *** minutes were spent with the patient, of which more than 50% of the time was spent in counseling and/or coordinating care on ***. Courtesy of Allison Liu, M.D., Ph.D. "New" Codes G2012 Brief communication technology-based service, e.g. virtual check-in G2010 Remote evaluation of recorded video and/or images submitted by an established patient 99446-99449 99451-99452 Interprofessional telephone/internet consult ("E-consult") Considerations When Billing Medicare Who performs the service? • Must be a physician/practitioner • Cannot be performed by technicians or office staff When is the service performed? • Cannot be related to an E/M service before or after service (depends on service) Does the patient consent to billing? • Patients are responsible for co-pay • Verbal or written consent should be documented Considerations When Billing Medicare Who performs the service? • Must be a physician/practitioner • Cannot be performed by technicians or office staff When is the service performed? • Cannot be related to an E/M service before or after service (depends on service) Does the patient consent to billing? • Patients are responsible for co-pay • Verbal or written consent should be documented Considerations When Billing Medicare Who performs the service? • Must be a physician/practitioner • Cannot be performed by technicians or office staff When is the service performed? • Cannot be related to an E/M service before or after service (depends on service) Does the patient consent to billing? • Patients are responsible for co-pay • Verbal or written consent should be documented Considerations When Billing Medicare Who performs the service? • Must be a physician/practitioner • Cannot be performed by technicians or office staff When is the service performed? • Cannot be related to an E/M service before or after service (depends on service) Does the patient consent to billing? • Patients are responsible for co-pay • Verbal or written consent should be documented Example: "Virtual check-In" 1/4/2020: New visit (in-person) 1 month later: • Date of service: 2/5/2020 • Reason for call: Patient reports double vision and ptosis improved, no systemic weakness • Medical decision making: Continue pyridostigmine at present dose • Follow-up: As previously scheduled in 5 months • Consent to bill for services: Patient verbally agreed Code submitted: G2012 2/5/2020: Phone call G2012: Brief communication technologybased service ("virtual check-in") Type of patient Established Nonqualified communications Real-time, audio-only telephone Real-time, two-way audio + video Unrelated to E/M service in prior 7 days Unrelated to E/M service 24 hours in future Test result notification Conversation prompts office visit CMS Fee Schedule $14.78 Modalities Timing Example: Remote Evaluation of Pre-recorded Patient Information 10/16/2019: New visit (in-person) 3 months later: • Date of service: 1/20/2020 • Interpretation: Orthotropic, resolution of ptosis • Medical decision making: Observation • Follow-up: No return appointment needed • Notified patient: Discussed 1/20/2020 • Consent to bill for services: Patient verbally agreed 1/20/2020: Remote image Code submitted: G2010 G2010: Remote evaluation of pre-recorded patient information Type of patient Modalities Timing Established Photo or video submitted securely by patient and added to patient's medical record Unrelated to E/M service in prior 7 days Unrelated to E/M service 24 hours in future Nonqualified communications Conversation prompts office visit CMS Fee Schedule $12.61 Example: Interprofessional Consults ("E-Consults") Consultant Report • Date of service: 2/18/2020 • Referring doctor: Dr. X • Reason for E-consult: Papilledema • Verbal report: 26 yo female with headaches, suspected papilledema; MRI normal, MRV normal, LP OP 36 cmH2O, CSF normal Consultant Report • Record review: • 2/14/2020: Clinic note from Dr. X: VA 20/20 OU, papilledema OU • 2/14/2020: HVF 24-2: normal OU • 2/14/2020: MRI brain w/wo contrast: partially empty sella • 2/14/2020: MRV brain wo contrast: no venous thrombosis, occlusion, or stenosis • 2/17/2020: LP opening pressure: 36 cmH2O Consultant Report • Recommendations: • Start acetazolamide 500 mg BID, titrate to maximally tolerated • Weight loss • Recheck visual function and optic nerves periodically; once papilledema resolves, taper based on symptoms and optic nerve appearance • Patient wishes to follow locally, no visit with consultant scheduled Consultant Report • Consent to bill for services: Patient verbally agreed • Total time spent in consult: 13 minutes Codes submitted: 99451 (neuro-ophthalmologist) 99452 (ophthalmologist) 99451-99452, 99446-99449: Interprofessional Consultation Type of patient Modalities Timing Nonqualified communications New or established with NEW medical problem Written request for consult Phone or 2-way video communication Patient cannot be in referring doctor's office 1 E-consult allowed per 7 days Consultant cannot have seen patient within past 14 days Conversation prompts transfer of care or office visit within 14 days Referring Providers • Referring provider can bill 99452 for initiating the consult (CMS fee schedule: $37.48) Records/Data Review • To bill 99446-99449: >50% of the time spent must be in consultation and not time used to review data • Otherwise, use 99451 CPT Code Time Required CMS Fee Schedule 99446 5-10 minutes $18.38 99447 11-20 minutes $36.40 99448 21-30 minutes $54.78 99449 ≥ 31 minutes $72.80 > 50% spent in data review? No Yes 99451: CPT Minutes Fee 99446 5-10 $18.38 99447 11-20 $36.40 99448 21-30 $54.78 99449 ≥ 31 $72.80 $37.48 > 30 min 99451 + 99358: $151.00 > 74 min 99451 + 99358 + 99359: $205.78 http://legacy.americantelemed.org/policy-page/state-policy-resource-center Type of Visit CPT code(s) Reimbursement* 7:45a - 8:30a Chart review 99451 $37.48 $0.00 8:30a - 8:45a Established visit 99213, 92060 92133 99214, 92083, $213.35 $140.91 8:45a - 9:15a New visit 99205, 92083 $274.98 9:15a - 9:30a Phone consult 99451 $0.00 $37.48 9:30a - 10:00a New visit 99204, 92060 $232.45 10:00a - 10:30a New visit 99205, 92083, 92133 $312.82 10:30a - 10:45a Established visit 99214, 92083, 99213 92133 $213.35 $75.32 10:45a - 11:15a New visit 99204 $166.86 11:15a - 11:30a Established visit Chart reviews, Chart reviews, phone calls phone calls 99212 G2012 x 2, G2010, 99451 $45.77 $79.65 $0.00 11:30a-12:00p $1,249.11 $1,286.59 $1,359.03 $1,396.51 $1,568.42 $1,534.54 *CMS Physician Fee Schedule 2019 Summary • Telemedicine reimbursement is still changing, hopefully for the better Summary • Telemedicine reimbursement is still changing, hopefully for the better • New codes and rules now exist to potentially aid payment for services we are already doing for free now • G2012: "Virtual Check-In" • G2010: Remote interpretation of photos or images submitted by the patient • 99451, 99456-99459: Interprofessional consult ("E-consult") Summary • Telemedicine reimbursement is still changing, hopefully for the better • New codes and rules now exist to potentially aid payment for services we are already doing for free now • G2012: "Virtual Check-In" • G2010: Remote interpretation of photos or images submitted by the patient • 99451, 99456-99459: Interprofessional consult ("E-consult") • These codes are not meant to replace in-office visits; however, when appropriate, they can free up our schedule to see more new consults |
