Embed Size (px)
Citation preview
Telehealth Reimbursement During COVID-19:
FQHC/RHC BillingRebecca Picasso, Program Director
The California Telehealth Resource Center (CTRC) and all resources and activities produced or supported by the CTRC are made possible by grant number G22RH30349 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS. This information or content and conclusions are those of the CTRC and should not be construed as the official
position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Reimbursement information is constantly changing during the COVID-19 Public Health Emergency. The information
contained in this slide deck is current as of May 1, 2020 at 5pm.
Please check your local, state, and federal health plan pages for the most current information.
1. The patient was seen from an “originating site” as defined by CMS.
- Physician and practitioner offices - Hospitals- Critical Access Hospitals (CAHs) - Rural Health Clinics- Federally Qualified Health Centers - Community Mental Health Centers (CMHCs)- Mobile Stroke Units - Renal Dialysis Facilities- Hospital-based Renal Dialysis Centers (including satellites) - Patient Homes w/ End-Stage Renal Disease (ESRD) getting home dialysis
2. The originating site must be located in one of the following geographic areas:
Outside of an MSA -or-
In a Primary or Behavioral Health HPSA inside a rural census tract
Traditional Medicare Telehealth Services
1. The patient was seen from an “originating site” as defined by CMS.
- Physician and practitioner offices - Hospitals- Critical Access Hospitals (CAHs) - Rural Health Clinics- Federally Qualified Health Centers - Community Mental Health Centers (CMHCs)- Mobile Stroke Units - Renal Dialysis Facilities- Hospital-based Renal Dialysis Centers (including satellites) - Patient Homes w/ End-Stage Renal Disease (ESRD) getting home dialysis
2. The originating site must be located in one of the following geographic areas:
Outside of an MSA -or-
In a Primary or Behavioral Health HPSA inside a rural census tract
TEMPORARILY WAIVED
During COVID-19
Traditional Medicare Telehealth Services
3. The encounter was performed at the “distant site” by an eligible practitioner. Eligible distant site practitioners are as follows:
*RHCs and FQHCs cannot provide services as a distant site for Medicare reimbursement. This includes bringing the specialist in to the 4 walls virtually
4. The patient must be present and the encounter must involve interactive audio and video telecommunications that provides real-time communication between the practitioner and the Medicare beneficiary.
5. Type of Service provided must fall within the Medicare Eligible Services table. You can find the current CPT and HCPC codes in the Telehealth Services fact sheet. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
- Physicians - Nurse practitioners (NPs)- Physician assistants (PAs) - Nurse-midwives- Certified registered nurse anesthetists - Clinical nurse specialists (CNSs)- Clinical psychologists (CPs) - Clinical social workers (CSWs)- Registered dietitians or nutrition professionals - Opioid Treatment Programs (OTPs)
Traditional Medicare Telehealth Services
3. The encounter was performed at the “distant site” by an eligible practitioner. Eligible distant site practitioners are as follows:
*RHCs and FQHCs cannot provide services as a distant site for Medicare reimbursement. This includes bringing the specialist in to the 4 walls virtually
4. The patient must be present and the encounter must involve interactive audio and video telecommunications that provides real-time communication between the practitioner and the Medicare beneficiary.
5. Type of Service provided must fall within the Medicare Eligible Services table. You can find the current CPT and HCPC codes in the Telehealth Services fact sheet. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
- Physicians - Nurse practitioners (NPs)- Physician assistants (PAs) - Nurse-midwives- Certified registered nurse anesthetists - Clinical nurse specialists (CNSs)- Clinical psychologists (CPs) - Clinical social workers (CSWs)- Registered dietitians or nutrition professionals - Opioid Treatment Programs (OTPs)
For the duration of the PHE, FQHCs/RHCs CAN act as a distant site
Traditional Medicare Telehealth Services
CMS has added 80 additional codes to the existing list of eligible telehealth (audiovisual) serviceshttps://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
PT, OT and SLP have been added for the duration of the PHE
Services can be audio only for the duration of the PHE.
Originating Site Fee – Q3014
The home is not eligible for an originating site fee. If your patient is physically present in your FQHC/RHC, and receiving telehealth services on site, you may still bill for a Q3014.
If the patient is in their home, and an FQHC/RHC providing is seeing them via video or telephone, you cannot bill a Q3014.
Traditional Medicare Telehealth Billing
COVID-19 Medicare Telehealth BillingWhat We Know For FQHC/RHC Billing as a Distant Site
CMS originally released MLN SE20016 on April 17, 2020 detailing payment for FQHCs/RHCs during the public health emergency. On April 30, 2020, CMS updated the previously mentioned MLN.
An FQHC/RHC will not be paid their PPS/AIR rate for telehealth services. Instead, they will be paid $92.03 per visit.
Distant site telehealth services can be furnished by any health care practitioner working for the clinic within their scope of practice. The practitioners can furnish the telehealth services from any distant site location, including their homes, duringthe time they are working for the RHC or FQHC.
Effective March 6, 2020, patients may be at any site, including their home.
For claims January 27, 2020 through June 30, 2020: Clinics will be paid their PPS/AIR rate. HOWEVER, CMS will be reprocessing claims in July 2020 and adjusting these payments back down to $92.03.
What does this mean: If a clinics PPS/AIR rate is less than $92.03 per visit, Medicare will pay an amount equal to the number of telehealth visits the clinic conducted between January 27, 2020 and June 30, 2020 multiplied by the difference between the PPS/AIR rate and $92.03
OR
If PPS/AIR is more than $92.03 per visit, Medicare will recoup an amount equal to the number of telehealth visits the clinic conducted between January 27, 2020 and June 30, 2020 multiplied by the difference between the PPS/AIR and $92.03.
COVID-19 Medicare Telehealth Billing
Example:
PPS or AIR rate is $200.00Between 1/27/2020 and 6/30/2020, clinic provides 450 telehealth visitsClinic was entitled to $92.03 for each telehealth visitCMS will RECOUP $38,869.20 from the clinic in July 2020
$200.00 -$92.03 = $107.97 x 450 = $48,586.50 X 80%= $38,869.20
For RHC telehealth distant site services furnished from January 27, 2020 through June 30, 2020:
• Bill using HCPC code G2025• Must append modifier CG. Modifier 95 is optional.• POS is equivalent to where the service would have been rendered in person
For RHC telehealth distant site services starting July 1, 2020 through the end of the public health emergency:
• Telehealth services will be billed with G2025• Modifier 95 is optional
COVID-19 Medicare Telehealth Billing
For FQHC qualifying visits done via telehealth distant site services furnished from January 27, 2020 through June 30, 2020:
• Bill using the FQHC PPS specific payment code (GO466, G0467, G0468, G0469, or G0470) and;• The HCPCS/CPT code that describes the services furnished via telehealth with modifier 95 and;• G2025 with modifier 95• POS is equivalent to where the service would have been rendered in person
When furnishing services via telehealth that are not FQHC qualifying visits, FQHCs should hold these claims until July 1, 2020
COVID-19 Medicare Telehealth Billing
For FQHC telehealth distant site services starting July 1, 2020 through the end of the public health emergency:
• Telehealth services will be billed with G2025• Modifier 95 is optional
COVID-19 Medicare Telehealth Billing
Only distant site telehealth services furnished during the COVID-19 PHE are authorized for payment to RHCs and FQHCs. If the COVID-19 PHE is in effect after December 31, 2020, this rate will be updated based on the 2021 PFS average payment rate for these services, weighted by volume for those services reported under the PFS.
Medicare Advantage Wrap Payments: Since telehealth distant site services are not paid under the RHC AIR or the FQHC PPS, the Medicare Advantage (MA) wrap-around payment does not apply to these services. Wrap-around payment for distant site telehealth services will be adjusted by the MA plans.
COVID-19 Medicare Telehealth Billing
Audio Only billing for RHCs/FQHCs
Effective March 1, 2020 RHCs and FQHCs can furnish and bill for the audio-only telephone E/M services.
Bill these services using HCPCS code G2025.
To bill for these services, at least 5 minutes of telephone E/M service by a physician or other qualified health care professional who may report E/M services must be provided to an established patient, parent, or guardian. These services cannot be billed if they originate from a related E/M service provided within the previous 7 days or lead to an E/M service or procedure within the next 24 hours or soonest available appointment.
Retroactive to March 18, 2020, CMS will pay all of the reasonable costs for specified categories of E/M services, if they result in an order for, or administration of, a COVID-19 test and relate to the furnishing, or administration of, such test or to the evaluation of an individual for purposes of determining the need for such test. This would include applicable telehealth services.
For visits and services related to COVID-19 testing, clinics must waive the collection of co-insurance from beneficiaries. Clinics have the option to waive cost sharing for all telehealth services.
For all visits and services in which the coinsurance is waived, RHCs/FQHCs must append modifier CS on the service line.
Claims with the CS modifier will initially be paid with the coinsurance applied, HOWEVER, the MAC will automatically reprocess these claims beginning on July 1, 2020.
Coinsurance should not be collected from beneficiaries if the coinsurance is waived.
COVID-19 Medicare Telehealth Billing
Recap: Waivers for Traditional Medicare Telehealth Services During COVID-19
No restrictions on originating site or location of patient at the time of the visit.
FQHC/RHC provider does not need to be located at the clinic. They can be in their home and NOT have to register their home office with Medicare during the emergency.
Patient home has been added as an eligible originating site effective March 6, 2020
Patient may be located anywhere, not just MSA, HPSA or nonurban
Patient may present to an eligible health care site, e.g., hospital, clinic, RHC, FQHC or be located in their own home
Service can be audio-only
Medicare Virtual Visits
Virtual Check-InsVirtual Check-Ins are billed with code G0071
These interactions are patient initiated telephone or live videointeractions. They involve a physician or non-physician practitioner having a brief, at least 5 minute, check-in with an established patient to assess whether the patient needs to come in for an office visit. The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.
The virtual check-in must be for a condition not related to an E/M service provided within the previous 7 days and does not lead to an E/M service or procedure within the next 24 hours or soonest available appointment.
There are no frequency limitations at this time.
Billable providers are physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers. If the discussion could be conducted by a nurse, health educator, or other clinical personnel, it would not be billable as a virtual communication service.
POS is equivalent to where the service would have been reported for in person (e.g. POS 11)
E-VisitsE-Visits are billed with code G0071
E-Visits are patient-initiated digital communications via an online patient portal that requires a clinical decision that otherwise typically would have been provided in the office.
Billable provider spends at least five or more minutes over the course of seven days providing online E/M services. Seven days must lapse before you bill G0071 again for the same condition.
Includes multiple digital visits over the course of seven days if for related signs/symptoms/conditions
CPT Digital visit codes 99421, 99422 & 99423 were added as part of the care options outlined in the Interim Final Rule for the emergency period, BUT are not eligible to separately report in the RHC or FQHC setting for primary Medicare
POS is equivalent to where the service would have been reported for in person (e.g. POS 11)
Remote Evaluation Services – Store & ForwardRemote Evaluation Services are billed with code G0071
Remote evaluation services are patient initiated and consist of a practitioner evaluating a patient’s transmitted information via pre-recorded video or image. The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.
The services can only be billed if the condition is not related to a service provided within the previous 7 days and does not lead to a service provided within the next 24 hours or soonest available appointment.
There are no frequency limitations at this time.
Billable by physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers. If the discussion could be conducted by a nurse, health educator, or other clinical personnel, it would not be billable as a virtual communication service.
Billing the G0071
Use a UB 04 claim form
• RHC Type Of Bill 711• FQHC Type Of Bill 771
Assign revenue code 0521
No modifier is required
For the emergency period effective March 1, 2020, CMS will pay $24.76 (normally these payments are around $14)
Consent for Medicare Services
A verbal patient consent is required for all Virtual Visits (Virtual Check-Ins, E-Visits, and
Remote Evaluation)
Consent can be obtained at the time that the service is furnished or prior to the service
being furnished during the emergency period.
Consent may be obtained by ancillary staff under the general supervision of the RHC or
FQHC provider
A Note About Video Platforms
The federal Office of Civil Rights (OCR) has temporarily relaxed its enforcement standards during this national emergency to allow covered health care providers to use video technologies that do not fully comply with HIPAA rules. These include non-public facing “popular” video products such FaceTime or Skype.
Health care providers choosing to use these products a required to inform patients that there may be privacy risks and obtain consent.
Health care providers seeking more privacy for patients should consider products that use encryption and tools such as passcodes to restrict the session, and vendors that will sign HIPAA Business Associates Agreements (BAAs) in connection with their video solutions.
CMS COVID-19 Resources
• CMS Current Emergencies page• CMS Newsroom• CMS MLN Connects Newsletters
FFS Medi-Cal Billing Requirements for Virtual/Telephonic Communications
On April 30, 2020, DHCS updated their Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus (COVID-19) document
FQHCs/RHCs are able to bill their PPS rate, as applicable, for live video telehealth and telephone services.
Patients do NOT have to be HHMS to be seen in their home during the public health emergency.
Below is a chart that outlines the associated HCPCS or CPT codes for billing either the Medi-Cal FFS rate or PPS rate.
Please note: DHCS is aware that FQHCs, RHCs, and Tribal 638 Clinics do not include CPT codes as part of traditional claim submission. That said, for purposes of the temporary flexibilities under this policy and to allow DHCS to track that services were provided via virtual/telephonic communication modalities, DHCS is requesting this modified billing structure relative to the Section III guidance, i.e., including the CPT codes on the “information line” of the claim form. The selected CPT codes will also allow DHCS to also track the level of complexity (low, medium, high, etc.) of the visit and whether it is a new or established patient
Medi-Cal FFS: For the PPS rate, FQHCs/RHCs would need to list HCPCS code T1015 in the “payable” claim line in conjunction with one of the appropriate corresponding CPT codes (i.e., 99201-99203 for “new” patients, and 99212-99214 for “established patients) on the “informational” line relative to the complexity of the virtual/telephonic communication. Please note that the corresponding CPT codes are not separately reimbursed, but instead will be used to identify the virtual/telephonic communication visit. as well as by DHCS for tracking and reporting purposes related to COVID-19.
For the Medi-Cal FFS rate when billing with the HCPCS code G0071, clinics should only list the HCPCS code on the “payable” claim line and should not include a corresponding CPT code.
Medi-Cal Managed Care: FQHCs/RHCs will receive their PPS rate, as applicable, for rendering a Medi-Cal covered benefits or services – whether provided through telehealth or virtual/telephonic communication – if they meet the criteria/guidance.
DHCS will ensure the FQHCs/RHCs are made whole with an appropriate wrap payment, consistent with existing DHCS policy.
Q: Can physicians/health care practitioners in a FQHC provide covered services via a virtual/telephonic communication and receive the Medi-Cal fee-for-service (FFS) rate for HCPCS code G0071?
A: Yes, the billing/reimbursement policy for HCPCS code G0071 applies to Medi-Cal FFS. For the Medi-Cal FFS rate when billing with HCPCS code G0071, FQHC, RHC, and Tribal 638 Clinic should only list the HCPCS code on the “payable” claim line and should not include a corresponding CPT code.
Q: Are Registered Nurses (RNs) or Licensed Vocational Nurses (LVNs) able to provide Medi-Cal covered benefits or services via a virtual/telephonic communication modality and bill the Medi-Cal FFS rate?
A: No. Virtual/telephonic communication modalities are billable by FQHCs/RHCs only when the discussion requires the skill level of an FQHC/RHC practitioner, which includes physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, clinical social workers, and marriage and family therapist. Medi-Cal has not changed its policies on billable providers/practitioners.
Q: Do FQHCs/RHCs bill covered services provided via a virtual/telephonic communication modality the same as if it was in-person?
A: Yes, providers will submit claims using the applicable Revenue Code, HCPCS T1015 or T1015 SE (managed care patient only), and appropriate CPT code for reimbursement at the PPS rate.
Q: Where can I find information specific to Specialty Mental Health Services (SMHS), i.e. those contracted with county Mental Health Plans, and the Drug Medi-Cal Organized Delivery System (DMC-ODS)?
A: For information specific to SMHS and DMC-ODS, please see Behavioral Health Information Notice 20-009 and FAQs on the DHCS COVID-19 Response website.
https://www.dhcs.ca.gov/Documents/COVID-19/Telehealth_Other_Virtual_Telephonic_Communications_V4.0.pdf
Medi-Cal Fee-For-Service
Informed Consent
Health care providers must inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services.
If a health care provider, whether at the originating site or distant site, maintains a general consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file.
The consent shall be documented in the patient’s medical file DHCS upon request.
Consent shall including the following:• A description of the risks, benefits and consequences of telemedicine• The patient retains the right to withdraw at any time• All existing confidentiality protections apply• The patient has access to all transmitted medical information• No dissemination of any patient images or information to other entities
without further written consent
Medi-Cal Fee-For-Service
Informed Consent
Health care providers must inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services.
If a health care provider, whether at the originating site or distant site, maintains a general consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file.
The consent shall be documented in the patient’s medical file DHCS upon request.
Consent shall including the following:• A description of the risks, benefits and consequences of telemedicine• The patient retains the right to withdraw at any time• All existing confidentiality protections apply• The patient has access to all transmitted medical information• No dissemination of any patient images or information to other entities
without further written consent
CA Executive Order N-43-20 (4.3.2020)
Telehealth consent requirement is
suspended during PHE
Documentation
All health care practitioners providing covered benefits or services must maintain appropriate documentation to substantiate the corresponding technical and professional components of billed CPT or HCPCS codes.
Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service.
Medi-Cal Fee-For-Service
Resources
Providers may email questions about Medi-Cal telehealth policy to: [email protected]
California Department of Health Care Services Medi-Cal Program Telehealth Webpage:
http://www.dhcs.ca.gov/provgovpart/Pages/Telehealth.aspx
DHCS COVID-19 Resource Pagehttps://www.dhcs.ca.gov/Pages/DHCS-COVID-19-Response.aspx
DMHC COVID-19 Resource Pagehttp://www.dmhc.ca.gov/COVID-19.aspx
Private Payers, Managed Care, and IPA
All Health plans should be reimbursing for telehealth and telephone during the public health emergency.
The reimbursement rates should be equal to the rate for in person services
Modifiers could be different – Some use 95 and some still use GT
POS could be 02 or they could ask you use your normal POS
Listen to your health plans, even if they want you to bill in a way that you are not used to.
Private Payers, Managed Care, and IPA
DMHC APL 20-009 from March 18, 2020 states:
Pursuant to the authority granted in the California Emergency Services Act (Gov. Code sections 8566, et seq.), all health plans shall, effective immediately, comply with the following:
1. Health plans shall reimburse providers at the same rate, whether a service is provided in-person or through telehealth, if the service is the same regardless of the modality of delivery, as determined by the provider’s description of the service on the claim. For example, if a health plan reimburses a mental health provider $100 for a 50-minute therapy session conducted in-person, the health plan shall reimburse the provider $100 for a 50-minute therapy session done via telehealth.
2. For services provided via telehealth, a health plan may not subject enrollees to cost-sharing greater than the same cost-sharing if the service were provided in person.
3. Health plans shall provide the same amount of reimbursement for a service rendered via telephone as they would if the service is rendered via video, provided the modality by which the service is rendered (telephone versus video) is medically appropriate for the enrollee.
Private Payers, Managed Care, and IPA
DMHC APL 20-013 from April 7, 2020 states:
A health plan may not exclude coverage for certain types of services or categories of services simply because the services are rendered via telehealth, if the enrollee’s provider, in his/her professional judgment, determines the services can be effectively delivered via telehealth. For example, a health plan may not categorically exclude coverage for Applied Behavioral Analysis services delivered via telehealth (video or telephone) during the State of Emergency.
Likewise, during the COVID-19 State of Emergency a health plan may not place limits on covered services simply because the services are provided via telehealth if such limits would not apply if the services were provided in-person. For example, if a health plan allows an enrollee to receive a particular covered service up to three times per week if the enrollee receives the service in-person, the health plan may not limit the service to only once per week if the service is delivered via telehealth.
The Department has heard from providers and enrollees that health plans are requiring their enrollees to access services through the plans’ contracted telehealth vendor (e.g., Teledoc) rather than covering telehealth services delivered by providers who have typically delivered services to the enrollees in person. During the COVID-19 State of Emergency, a health plan may not require enrollees to use the plan’s telehealth vendor, or a different provider from the one the enrollee typically sees, if the enrollee’s provider is willing to deliver services to the enrollee via telehealth and the enrollee consents to receiving services via telehealth.
