Medicare Coverage of Telehealth Services: Presentation to Florida Telehealth Advisory Council

Transcription

1 Medicare Coverage of Telehealth Services: Presentation to Florida Telehealth Advisory Council January 17, 2017 Nathaniel Lacktman Partner, Foley & Lardner, LLP Chair of Telemedicine and Virtual Care Practice Foley & Lardner LLP Attorney 2017 Advertisement Foley & Lardner Prior results LLP 321 do not North guarantee Clark Street, a similar Chicago, outcome IL North Clark Street, Chicago, IL

2 Table of Contents Report to Florida Telehealth Advisory Council. Page 1 Medicare Telehealth Fact Sheet.. Page 4 Foley Blog Page 10 Medicare Covered Telehealth Codes. Page 14 MM9726. Page 17 Medicare Coverage of Telehealth Services PowerPoint. Page 20 Nathaniel M. Lacktman Resume.. Page 27

3 Report to Florida Telehealth Advisory Council Medicare Coverage of Telehealth Services Medicare does cover telehealth services, but is currently very limited, and the definitions and restrictions are established in statute by Congress. 1 For eligible telehealth services, the use of a telecommunications system is a substitute for an inperson encounter (e.g., it satisfies the face-to-face element of an E/M service). In general, Medicare imposes five conditions of coverage on telehealth services: 1. The beneficiary is located in a qualifying rural area at the time of the consult; 2. The beneficiary is located at one of eight qualifying facilities ( originating sites ) at the time of the consult; 3. The telehealth services are provided by one of ten professionals eligible to furnish and receive Medicare payment for telehealth services ( distant site practitioners ); 4. The beneficiary and distant site practitioner communicate via an interactive audio and video telecommunications system that permits real-time communication between the beneficiary and the distant site provider; and 5. The CPT/HCPCS (Current Procedural Terminology/Healthcare Common Procedure Coding System) code for the service itself is named on the CY2016 (or current year) list of covered Medicare telehealth services. In order to bill Medicare for telehealth services, the provider must fully comply with each of the telehealth requirements. If the telehealth arrangement does not meet each of these above requirements, the service is statutorily non-covered, and the Medicare program will 1 See Section 1834(m)(4)(F) of the Social Security Act; 42 CFR (f); CMS Pub , Medicare Benefit Policy Manual, Ch. 15 section 270.2; CMS Pub , Medicare Claims Processing Manual, Ch. 12 section not pay for the service. 2 To certify each of these elements have been met, the distant site practitioner must add the GT modifier when billing the claim (the practitioner adds the GQ modifier for asynchronous services in Alaska and Hawaii). 1. Rural Geographic Restrictions Under the Medicare conditions of payment for telehealth services, the patient must be located at a qualifying originating site (in a rural Health Care Professional Shortage Area (HPSA) outside a Metropolitan Statistical Area (MSA) or in a rural census tract, or a county outside of a MSA). This effectively renders facilities located in urban areas unable to qualify as an originating site and therefore ineligible for Medicare coverage of services to beneficiaries via telehealth. Entities participating in a Federal telehealth demonstration project approved by or receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Such entities are not required to be in a rural HPSA or non MSA. Recognizing the confusion and limitation this restriction has generated, HHS created a website where a beneficiary or provider can enter a zip code and determine whether or not the geographic location is potentially eligible for Medicare coverage of telehealth services. It is called the Medicare Telehealth Payment Eligibility Analyzer Originating Site Restrictions Not only must the beneficiary be located in a qualifying rural area at the time of the consult, the beneficiary must be located at one of eight qualifying originating sites. Eligible originating sites are: 2 See Section 1834(m)(4)(F) of the Social Security Act; 42 CFR (f); CMS Pub , Medicare Benefit Policy Manual, Ch. 15 section 270.2; CMS Pub , Medicare Claims Processing Manual, Ch. 12 section Available at px. Presentation to Florida Telehealth Advisory Council (Page 1)

4 » Offices of a Physician or Practitioner;» Hospitals;» Critical Access Hospitals;» Community Mental Health Centers;» Skilled Nursing Facilities;» Rural Health Clinics;» Federally Qualified Health Centers; and» Hospital-Based or Critical Access Hospital (CAH)- Based Renal Dialysis Centers (including satellites). 4 If a beneficiary receives telehealth services while at his or her home, those telehealth services are not covered by Medicare. 5 Many patients choose telehealth services for the convenience and access it offers as an alternative to driving to a practitioner s office and sitting in the waiting room. Accordingly, many telehealth offerings are built around making the services available to patients on-demand at their home, workplace, or in the evenings. These services would not be covered by Medicare because a beneficiary located at home is not at one of the eight qualifying originating sites. Note, effective January 1, 2017, providers must now use POS code 02 on Medicare claims to designate the service was delivered via telehealth. This code is required in addition to the GT modifier, and the beneficiary must still be located in a qualifying rural area and at a qualifying originating site Eligible Distant Site Practitioners Even if the first two requirements are met, and the beneficiary is located at an eligible rural area and a qualifying originating site, the services themselves must be provided by a qualified distant site practitioner eligible to furnish and receive Medicare payment for telehealth services. Eligible distant site practitioners are:» Physicians;» Nurse practitioners (NPs);» Physician assistants (PAs);» Nurse-midwives;» Clinical nurse specialists (CNSs);» Certified registered nurse anesthetists; 4 See CMS MLN Telehealth Services for CY 2016 (Dec 2015). 5 Id.; see also, e.g., Noridian Telehealth Services Q&A No. 6 (rev. May 29, 2015) (noting that POS Code 12: home is ineligible for payment). 6 See MLN Matters MM9726; Change Request 9726 (Aug 12, 2016)» Clinical psychologists (CPs) and clinical social workers (CSWs) (although CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare); and» Registered dietitians or nutrition professionals. 7 This list of ten eligible practitioners is defined by statute. 8 If a beneficiary receives telehealth services from a practitioner other than those listed above, the service is not covered by Medicare. Many patients enjoy telehealth services from other practitioners or specialty providers (e.g., RNs, occupational therapists, physical therapists). Currently, services provided by such professionals would not be covered by Medicare because that distant site practitioner is not among the ten listed types. 4. Eligible Telecommunications Technology The Medicare coverage rules require the beneficiary and distant site practitioner to communicate via an interactive audio and video telecommunications system that permits real-time communication between the beneficiary and the distant site provider. 9 This means the practitioner may not use audio-only, store and forward, or other message-based communications if the services are to be covered by Medicare. There is a minor exception allowing asynchronous store and forward technology in Federal telehealth demonstration programs in Alaska or Hawaii. 5. Eligible CPT/HCPCS Codes Finally, the service itself must be listed among the eligible CPT/HCPCS codes CMS publishes each year as covered telehealth services. In CY 2016, there were approximately 37 covered services (with approximately 50 associated codes). Unless a service is listed among the approved service codes for telehealth services, Medicare will not cover the service if provided via telehealth. 10 The result of Medicare s restrictive telehealth law has been narrow coverage and few claims submitted. For 7 See CMS MLN Telehealth Services for CY 2016 (Dec 2015). 8 See Section 1834(m)(4)(E) of the Social Security Act. 9 See 42 CFR (a)(3). 10 See Section 1834(m)(4)(F) of the Social Security Act; 42 CFR (f); CMS Pub , Medicare Benefit Policy Manual, Ch. 15 section 270.2; Medicare Claims Processing Manual, Ch. 12 section Presentation to Florida Telehealth Advisory Council (Page 2)

5 example, in CY 2015, Medicare paid a total of $17.6 million for telehealth service claims, compared to an overall $600 billion Medicare program budget. At the same time, patient demand for the convenience and access to care offered by telehealth services has created a willingness for patients (including Medicare beneficiaries) to self-pay out of pocket to enjoy the benefits of these new technologies Note: coverage rules for Medicare Advantage plans and Medicaid Managed Care organizations are notably more flexible than traditional Medicare. These plans are encouraged to develop new and innovative ways to provide care, and are generally subject to fewer restrictions on coverage of telehealth services. Presentation to Florida Telehealth Advisory Council (Page 3)

6 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services To Print a Text-Only Version Telehealth Services RURAL HEALTH SERIES Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare). This publication provides the following information on calendar year (CY) 2016 Medicare telehealth services: Originating sites; Distant site practitioners; Telehealth services; Billing and payment for professional services furnished via telehealth; Billing and payment for the originating site facility fee; Resources; and Lists of helpful websites and Regional Office Rural Health Coordinators. When you is used in this publication, we are referring to physicians or practitioners at the distant site. Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. ORIGINATING SITES An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in: A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or A county outside of a MSA. CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. ICN December 2015 Presentation to Florida Telehealth Advisory Council (Page 4)

7 The Health Resources and Services Administration (HRSA) determines HPSAs, and the United States (U.S.) Census Bureau determines MSAs. You can access HRSA s Medicare Telehealth Payment Eligibility Analyzer to determine a potential originating site s eligibility for Medicare telehealth payment at telehealtheligibility.aspx on the HRSA website. Entities that participate in a Federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of the U.S. Department of Health & Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Each CY, the geographic eligibility of an originating site is established based on the status of the area as of December 31st of the prior CY. Such eligibility continues for the full CY. The originating sites authorized by law are: The offices of physicians or practitioners; 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); and Community Mental Health Centers (CMHCs). Note: Independent Renal Dialysis Facilities are not eligible originating sites. DISTANT SITE PRACTITIONERS Practitioners at the distant site who may furnish and receive payment for covered telehealth services (subject to State law) are: Physicians; Nurse practitioners (NPs); Physician assistants (PAs); Nurse-midwives; Clinical nurse specialists (CNSs); Certified registered nurse anesthetists; Clinical psychologists (CPs) and clinical social workers (CSWs). CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838; and Registered dietitians or nutrition professionals. TELEHEALTH SERVICES As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site. Asynchronous store and forward technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii. The chart on pages 3 4 provides the CY 2016 list of Medicare telehealth services. CPT only copyright 2015 American Medical Association. All rights reserved. 2 Telehealth Services Presentation to Florida Telehealth Advisory Council (Page 5)

8 CY 2016 Medicare Telehealth Services Service Healthcare Common Procedure Coding System (HCPCS)/CPT Code Telehealth consultations, emergency department or initial inpatient Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS codes G0425 G0427 HCPCS codes G0406 G0408 Office or other outpatient visits CPT codes Subsequent hospital care services, with the limitation of 1 telehealth CPT codes visit every 3 days Subsequent nursing facility care services, with the limitation of CPT codes telehealth visit every 30 days Individual and group kidney disease education services HCPCS codes G0420 and G0421 Individual and group diabetes self-management training services, with a HCPCS codes G0108 and G0109 minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training Individual and group health and behavior assessment and intervention CPT codes Individual psychotherapy CPT codes and Telehealth Pharmacologic Management HCPCS code G0459 Psychiatric diagnostic interview examination CPT codes and End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older (effective for services furnished on and after January 1, 2016) CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and CPT code CPT code CPT code CPT code Individual and group medical nutrition therapy HCPCS code G0270 and CPT codes Neurobehavioral status examination CPT code Smoking cessation services HCPCS codes G0436 and G0437 and CPT codes and Alcohol and/or substance (other than tobacco) abuse structured HCPCS codes G0396 and G0397 assessment and intervention services Annual alcohol misuse screening, 15 minutes HCPCS code G0442 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS code G0443 CPT only copyright 2015 American Medical Association. All rights reserved. 3 Telehealth Services Presentation to Florida Telehealth Advisory Council (Page 6)

9 CY 2016 Medicare Telehealth Services (cont.) Service Healthcare Common Procedure Coding System (HCPCS)/CPT Code Annual depression screening, 15 minutes 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 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Face-to-face behavioral counseling for obesity, 15 minutes Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) HCPCS code G0444 HCPCS code G0445 HCPCS code G0446 HCPCS code G0447 CPT code CPT code Psychoanalysis CPT codes Family psychotherapy (without the patient present) CPT code Family psychotherapy (conjoint psychotherapy) (with patient present) CPT code Prolonged service in the office or other outpatient setting requiring CPT code direct patient contact beyond the usual service; first hour Prolonged service in the office or other outpatient setting requiring direct CPT code patient contact beyond the usual service; each additional 30 minutes Prolonged service in the inpatient or observation setting requiring CPT code unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service) (effective for services furnished on and after January 1, 2016) Prolonged service in the inpatient or observation setting requiring CPT code unit/floor time beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service) (effective for services furnished on and after January 1, 2016) Annual Wellness Visit, includes a personalized prevention plan of HCPCS code G0438 service (PPPS) first visit Annual Wellness Visit, includes a personalized prevention plan of HCPCS code G0439 service (PPPS) subsequent visit For ESRD-related services, a physician, NP, PA, or CNS must furnish at least one hands on visit (not telehealth) each month to examine the vascular access site. BILLING AND PAYMENT FOR PROFESSIONAL SERVICES FURNISHED VIA TELEHEALTH Submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, via interactive audio and video telecommunications systems (for example, GT). By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth service. By coding and billing the GT modifier with a covered ESRD-related service telehealth code, you are certifying that you furnished one hands on visit per month to examine the vascular access site. CPT only copyright 2015 American Medical Association. All rights reserved. 4 Telehealth Services Presentation to Florida Telehealth Advisory Council (Page 7)

10 For Federal telemedicine demonstration programs in Alaska or Hawaii, submit claims using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GQ if you performed telehealth services via an asynchronous telecommunications system (for example, GQ). By coding and billing the GQ modifier, you are certifying that the asynchronous medical file was collected and transmitted to you at the distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii. You should bill the Medicare Administrative Contractor (MAC) for covered telehealth services. Medicare pays you the appropriate amount under the Medicare Physician Fee Schedule (PFS) for telehealth services. When you are located in a CAH and reassigned your billing rights to a CAH that elected the Optional Payment Method, the CAH bills the MAC for telehealth services and the payment amount is 80 percent of the Medicare PFS for telehealth services. BILLING AND PAYMENT FOR THE ORIGINATING SITE FACILITY FEE Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. Bill the MAC for the originating site facility fee, which is a separately billable Part B payment. Note: When a CMHC serves as an originating site, the originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services. RESOURCES The chart below provides telehealth services resource information. Telehealth Services Resources For More Information About Telehealth Services Health Professional Shortage Areas All Available MLN Products Provider-Specific Medicare Information Medicare Information for Beneficiaries Resource on the Centers for Medicare & Medicaid Services (CMS) website Chapter 15 of the Medicare Benefit Policy Manual (Publication ) on the CMS website Chapter 12 of the Medicare Claims Processing Manual (Publication ) on the CMS website Medicare Learning Network (MLN) publication titled Health Professional Shortage Area (HPSA) Physician Bonus, HPSA Surgical Incentive Payment, and Primary Care Incentive Payment Programs on the CMS website MLN Catalog on the CMS website MLN publication titled MLN Guided Pathways: Provider Specific Medicare Resources on the CMS website on the CMS website CPT only copyright 2015 American Medical Association. All rights reserved. 5 Telehealth Services Presentation to Florida Telehealth Advisory Council (Page 8)

11 HELPFUL WEBSITES American Hospital Association Rural Health Care Critical Access Hospitals Center Hospitals-Center.html Disproportionate Share Hospitals Payment/AcuteInpatientPPS/dsh.html Federally Qualified Health Centers Center Qualified-Health-Centers-FQHC-Center.html Health Resources and Services Administration Hospital Center Center.html Medicare Learning Network National Association of Rural Health Clinics National Rural Health Association Rural Health Clinics Center Clinics-Center.html Rural Health Information Hub Swing Bed Providers Payment/SNFPPS/SwingBed.html Telehealth Information/Telehealth U.S. Census Bureau National Association of Community Health Centers REGIONAL OFFICE RURAL HEALTH COORDINATORS To find contact information for CMS Regional Office Rural Health Coordinators who provide technical, policy, and operational assistance on rural health issues, refer to DoorForums/Downloads/CMSRuralHealthCoordinators.pdf on the CMS website. The Medicare Learning Network Disclaimers are available at on the CMS website. The Medicare Learning Network, MLN Connects, and MLN Matters are registered trademarks of the U.S. Department of Health & Human Services (HHS). Check out CMS on: 6 Telehealth Services Presentation to Florida Telehealth Advisory Council (Page 9)

12 1/ :FOLEY FOLEY&. LARDNt:R LLP Medicare Payments for Telehealth Increased 25% in 2015: What You Need to Know I Health Care Law Today Health Care Law Today Medicare Payments for Telehealth Increased 25% in 2015: What You Need to Know POSTED BY NATHANIEL M. LACKTMAN ON 3 MARCH 2016 POSTED IN REIMBURSEMENTS; TELEMEDICINE More good news on the telehealth reimbursement front: CMS reported its total 2015 payments for telehealth services under the Medicare program and it was a 25% increase over last year. This reflects how providers are successfully integrating telehealth services into their traditional health care delivery approaches, and are better realizing payment opportunities both within the Medicare FFS program and in other sources of revenue. We have written and advocated extensively on ways providers can (and should) look beyond solely Medicare to drive the financial growth of their telehealth offerings. It is encouraging to see more providers taking the time to understand the reimbursement opportunities and submit covered claims for payment. Let's break down the numbers. In CY 2015, Medicare paid a total of $17,601,996 for telehealth services, spread across a total of 271,877 claims. This includes payments to distant site providers and originating site payments. Compare this to last year, in which Medicare paid a total of $13,934,430 for telehealth services, spread across a total of 214,346 claims. The result: 2015 saw a 27% increase in the number of Medicare FFS telehealth services claims submitted and a 25% increase in total payments. And this uptick in total payments is not attributable to reimbursement increases, but rather to more providers using telehealth services with their traditional Medicare FFS beneficiaries. This is particularly true with claims for professional services by distant site providers, which has seen the largest uptick in claims volume. Presentation to Florida Telehealth Advisory Council (Page 10).,

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16 CY 2016 COVERED TELEHEALTH SERVICES CY 2017 COVERED TELEHEALTH SERVICES Code Short Descriptor Code Short Descriptor Psych diagnostic evaluation Psych diagnostic evaluation Psych diag eval w/med srvcs Psych diag eval w/med srvcs Psytx pt&/family 30 minutes Psytx pt&/family 30 minutes Psytx pt&/fam w/e&m 30 min Psytx pt&/fam w/e&m 30 min Psytx pt&/family 45 minutes Psytx pt&/family 45 minutes Psytx pt&/fam w/e&m 45 min Psytx pt&/fam w/e&m 45 min Psytx pt&/family 60 minutes Psytx pt&/family 60 minutes Psytx pt&/fam w/e&m 60 min Psytx pt&/fam w/e&m 60 min Psychoanalysis Psychoanalysis Family psytx w/o patient Family psytx w/o patient Family psytx w/patient Family psytx w/patient Esrd serv 4 visits p mo <2yr Esrd serv 4 visits p mo <2yr Esrd serv 2-3 vsts p mo <2yr Esrd serv 2-3 vsts p mo <2yr Esrd serv 4 vsts p mo Esrd serv 4 vsts p mo Esrd srv 2-3 vsts p mo Esrd srv 2-3 vsts p mo Esrd srv 4 vsts p mo Esrd srv 4 vsts p mo Esrd srv 2-3 vsts p mo Esrd srv 2-3 vsts p mo Esrd srv 4 visits p mo Esrd srv 4 visits p mo Esrd srv 2-3 vsts p mo Esrd srv 2-3 vsts p mo Esrd home pt serv p mo <2yrs Esrd home pt serv p mo <2yrs Esrd home pt serv p mo Esrd home pt serv p mo Esrd home pt serv p mo Esrd home pt serv p mo Esrd home pt serv p mo Esrd home pt serv p mo Neurobehavioral status exam Esrd home pt serv p day < Assess hlth/behave init Esrd home pt serv p day Assess hlth/behave subseq Esrd home pt serv p day Intervene hlth/behave indiv Esrd home pt serv p day Intervene hlth/behave group Neurobehavioral status exam Interv hlth/behav fam w/pt Assess hlth/behave init Medical nutrition indiv in Assess hlth/behave subseq Med nutrition indiv subseq Intervene hlth/behave indiv Presentation to Florida Telehealth Advisory Council (Page 14)

17 97804 Medical nutrition group Intervene hlth/behave group Office/outpatient visit new Interv hlth/behav fam w/pt Office/outpatient visit new Medical nutrition indiv in Office/outpatient visit new Med nutrition indiv subseq Office/outpatient visit new Medical nutrition group Office/outpatient visit new Office/outpatient visit new Office/outpatient visit est Office/outpatient visit new Office/outpatient visit est Office/outpatient visit new Office/outpatient visit est Office/outpatient visit new Office/outpatient visit est Office/outpatient visit new Office/outpatient visit est Office/outpatient visit est Subsequent hospital care Office/outpatient visit est Subsequent hospital care Office/outpatient visit est Subsequent hospital care Office/outpatient visit est Nursing fac care subseq Office/outpatient visit est Nursing fac care subseq Subsequent hospital care Nursing fac care subseq Subsequent hospital care Nursing fac care subseq Subsequent hospital care Prolonged service office Nursing fac care subseq Prolonged service office Nursing fac care subseq Prolonged service inpatient Nursing fac care subseq Prolonged service inpatient Nursing fac care subseq Behav chng smoking 3-10 min Prolonged service office Behav chng smoking > 10 min Prolonged service office Trans care mgmt 14 day disch Prolonged service inpatient Trans care mgmt 7 day disch Prolonged service inpatient G0108 Diab manage trn per indiv Behav chng smoking 3-10 min G0109 Diab manage trn ind/group Behav chng smoking > 10 min G0270 Mnt subs tx for change dx Trans care mgmt 14 day disch G0396 Alcohol/subs interv 15-30mn Trans care mgmt 7 day disch G0397 Alcohol/subs interv >30 min Advncd care plan 30 min G0406 Inpt/tele follow up Advncd are plan addl 30 min G0407 Inpt/tele follow up 25 G0108 Diab manage trn per indiv G0408 Inpt/tele follow up 35 G0109 Diab manage trn ind/group Presentation to Florida Telehealth Advisory Council (Page 15)

18 G0420 Ed svc ckd ind per session G0270 Mnt subs tx for change dx G0421 Ed svc ckd grp per session G0396 Alcohol/subs interv 15-30mn G0425 Inpt/ed teleconsult30 G0397 Alcohol/subs interv >30 min G0426 Inpt/ed teleconsult50 G0406 Inpt/tele follow up 15 G0427 Inpt/ed teleconsult70 G0407 Inpt/tele follow up 25 G0436 Tobacco-use counsel 3-10 min G0408 Inpt/tele follow up 35 G0437 Tobacco-use counsel>10min G0420 Ed svc ckd ind per session G0438 Ppps, initial visit G0421 Ed svc ckd grp per session G0439 Ppps, subseq visit G0425 Inpt/ed teleconsult30 G0442 Annual alcohol screen 15 min G0426 Inpt/ed teleconsult50 G0443 Brief alcohol misuse counsel G0427 Inpt/ed teleconsult70 G0444 Depression screen annual G0438 Ppps, initial visit G0445 High inten beh couns std 30m G0439 Ppps, subseq visit G0446 Intens behave ther cardio dx G0442 Annual alcohol screen 15 min G0447 Behavior counsel obesity 15m G0443 Brief alcohol misuse counsel G0459 Telehealth inpt pharm mgmt G0444 Depression screen annual G0445 High inten beh couns std 30m G0446 Intens behave ther cardio dx G0447 Behavior counsel obesity 15m G0459 Telehealth inpt pharm mgmt G0508 Telehealt con initial ccare G0509 Telehealt con subseq ccare Presentation to Florida Telehealth Advisory Council (Page 16)

19 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9726 Related Change Request (CR) #: CR 9726 Related CR Release Date: August 12, 2016 Effective Date: January 1, Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the effective date for nonmedical data code sets, of which the POS code set is one, is the code set in effect the date the transaction is initiated. It is not date of service. Related CR Transmittal #: R3586CP Implementation Date: January 3, 2017 New Place of Service (POS) Code for Telehealth and Distant Site Payment Policy Provider Types Affected This MLN Matters Article is intended for physicians, other practitioners, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed CR 9726 updates the Place of Service (POS) code set by creating a new code (POS 02) for Telehealth services, effective January 1, You should ensure that your billing staffs are aware of this new POS code. Background As an entity covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medicare must comply with standards, and their implementation guides, adopted by regulation under this statute. The currently adopted professional implementation guide for the ASC X12N 837 standard requires that each electronic claim transaction include a Place of Service (POS) code from the POS code set that the Centers for Medicare & Medicaid Services (CMS) maintains. The POS code set provides setting information necessary to appropriately pay Medicare and Medicaid claims. Presentation to Florida Telehealth Advisory Council (Page 17)

20 As a payer, Medicare must be able to recognize, as valid, any valid code from the POS code set that appears on the HIPAA standard claim transaction. Further, unless prohibited by national policy to the contrary, Medicare not only recognizes such codes, but also adjudicates claims that contain these codes. At times, Medicaid has had a greater need for code specificity than has Medicare; and many of the new codes, over the past few years, have been developed to meet Medicaid s needs. While Medicare does not always need this greater specificity in order to appropriately pay claims, it nevertheless adjudicates claims with the new codes to ease coordination of benefits and to give Medicaid and other payers the setting information they require. Effective January 1, 2017, CMS is creating a new POS code 02 for use by the physician or practitioner furnishing telehealth services from a distant site. CR 9726 updates the current POS code set by adding this new code (POS 02: Telehealth), with a descriptor of The location where health services and health related services are provided or received, through telecommunication technology. Medicare will pay for these services using the Medicare Physician Fee Schedule (MPFS), including the use of the MPFS facility rate for Method II Critical Access Hospitals billing on type of bill 85x. This Telehealth POS code would not apply to originating site facilities billing a facility fee. Remember that under HIPAA, the effective date for nonmedical data code sets, of which the POS code set is one, is the code set in effect the date the transaction is initiated. It is not date of service. Modifiers GT (via interactive audio and video telecommunications systems) and GQ (via an asynchronous telecommunications system) are still required when billing for Medicare Telehealth services. If you bill for Telehealth services with POS code 02, but without the GT or GQ modifier, your MAC will deny the service with the following messages: Group Code CO Claim Adjustment Reason Code (CARC) 4 (The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present) Remittance Advice Remarks Code (RARC) MA130 (Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information) Conversely, if you bill for Telehealth services with modifiers GT or GQ, but without POS code 02, your MAC will deny the service with the following messages: Group Code CO Presentation to Florida Telehealth Advisory Council (Page 18)

21 CARC 5 (The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present) RARC M77 (Missing/incomplete/invalid/inappropriate place of service) Additional Information The official instruction, CR9726, issued to your MAC regarding this change is available at Guidance/Guidance/Transmittals/downloads/R3586CP.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory- Interactive-Map/. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2015 American Medical Association. All rights reserved. Presentation to Florida Telehealth Advisory Council (Page 19)

22 Medicare Coverage of Telehealth Services Florida Telehealth Advisory Council Presentation to Florida Telehealth Advisory Council (Page 20) 2015 Foley & Lardner LLP Attorney Advertising Prior results do not guarantee a similar outcome Models used are not clients but may be representative of clients 321 N. Clark Street, Suite 2800, Chicago, IL

23 Five Conditions for Coverage Patient in a qualifying rural area Patient at one of eight qualifying facilities ( originating site ) Service provided by one of ten eligible professionals ( distant site practitioner ) Technology is real-time audio-video (interactive audio and video telecommunications system that permits real-time communication between the beneficiary and the distant site provider) The service is among the list of CPT/HCPCS codes covered by Medicare Presentation to Florida Telehealth Advisory Council (Page 21) 2015 Foley & Lardner LLP

24 Telehealth Has Not Been a Budget Buster In 2001, the Congressional Budget Office estimated it would cost the Medicare program $150 million ($30 million a year) to cover telehealth services from 2001 through 2005 Reality, during those first five years, Medicare paid a total of $3,103,912 for telehealth services CY 2014: Medicare paid a total of $13,934,430 for telehealth services (214,346 claims) CY 2015: Medicare paid a total of $17,601,996 for telehealth services (271,877 claims) Total Medicare telehealth payments to date ( ): $75,460,785 Medicare annual budget: $600 Billion Presentation to Florida Telehealth Advisory Council (Page 22) 2015 Foley & Lardner LLP

25 2015 Foley & Lardner LLP Presentation to Florida Telehealth Advisory Council (Page 23)

26 2015 Foley & Lardner LLP Presentation to Florida Telehealth Advisory Council (Page 24)

27 Continued Bipartisan Federal Efforts to Expand Telehealth Coverage Medicare Telehealth Parity Act Telehealth Enhancement Act Telehealth Modernization Act Telehealth Innovation and Improvement Act CONNECT for Health Act 21 st Century Cures Act Presentation to Florida Telehealth Advisory Council (Page 25) 2015 Foley & Lardner LLP

28 Speaker Contact Nathaniel Lacktman Foley & Lardner LLP News & Resources Presentation to Florida Telehealth Advisory Council (Page 26) 2015 Foley & Lardner LLP

29 Nathaniel M. Lacktman Nathaniel (Nate) Lacktman is a partner and health care lawyer with Foley & Lardner LLP. His practice focuses on health care compliance and strategic counseling, with a particular emphasis on telemedicine and telehealth. Mr. Lacktman is listed in 2013, 2014 and 2015 Chambers USA: America s Leading Business Lawyers, which says, Clients are effusive in their praise, with one saying, 'I would describe Nate as the regulatory guidance expert.' PARTNER NLACKTMAN@FOLEY.COM NORTH TAMPA STREET SUITE 2700 TAMPA, FL He is the chief legal counsel to the Telehealth Association of Florida and co-chairs the Telemedicine and ehealth Affinity Group of the American Health Lawyers Association. A true believer in health innovation, he is a frequent author and speaker on telehealth thought leadership, and is an active member of the American Telemedicine Association. Mr. Lacktman is a Certified Compliance & Ethics Professional (CCEP). Telemedicine, Telehealth, Virtual Care Mr. Lacktman advises a number of clients including hospitals, health systems, clinics, pharmacies, physician groups, and start-ups on the emerging opportunities and regulatory issues presented by telemedicine and telehealth. He has advised clients on the following representative telemedicine matters:» Strategic counsel for multistate licensure and scope of practice issues for direct-to-patient, peer-to-peer, and remote monitoring telemedicine business models. Issues include cross-border compliance, patient consent, practitioner licensure, use of physician extenders, application of telemedicine to consultation exception and call/coverage arrangements, ability to provide telemedicine consults without a prior in-person examination, ability to issue prescriptions following telemedicine consults (controlled substances vs. other prescriptions), and associated recordkeeping requirements. Presentation to Florida Telehealth Advisory Council (Page 27)

30 Nathaniel M. Lacktman» Multistate statutes, pending legislation, and strategic advocacy regarding commercial payor coverage of telemedicine services, including any limitations on scope and reimbursement rates.» Corporate practice of medicine analysis and compliance considerations for virtual care physician services across the country.» Internet pharmacies and federal and state requirements for remote prescribing.» E-prescribing practices and application of e- prescribing to telemedicine consults.» Teleradiology and telepathology arrangements and associated licensure and Medicaid reimbursement issues.» Contracts regarding virtual care wellness clinic, hormone replacement therapy clinic, and integrative medicine clinic.» DTC online urgent care services by physicians.» Telehealth payment and reimbursement issues, including Medicare billing requirements and coverage, modifiers, state Medicaid coverage, teleradiology overreads and second reads under Medicaid billing, states with commercial telehealth payment statutes, patient self-pay, employer-pay arrangements, insurance benefit issues, and charging Medicare and Medicaid beneficiaries out-ofpocket for telehealth services.» Virtual care terms of service, provider terms of use, notice of privacy practices, consent forms, authorization forms, patient authentication and verification documents, e-signatures, payment acknowledgements, employment agreements, independent contractor agreements, and the multitude of operational documents associated with telehealth practices.» Telemedicine service lines, including international telemedicine arrangements, for several different children s hospitals.» Strategy and contracting for international telemedicine arrangements between U.S.-based providers and entities across the Globe.» Compliance counseling and fraud and abuse guidance for telemedicine companies with multistate footprints, including Anti-Kickback Statutes, physician self-referral laws, fee splitting rules, healthcare marketing, and corporate practice of medicine.» Represent provider group before Florida Department of Health on petition for declaratory statement regarding telemedicine arrangement. Health Care Compliance and Counseling Mr. Lacktman advises a variety of other health care entities on a range of business, legal and regulatory issues affecting the industry. He handles matters involving contracting fraud and abuse compliance, Medicare and Medicaid reimbursement, selfdisclosures and overpayments, the Anti-Kickback Statute, physician self-referrals (the Stark Law), health care marketing rules, HIPAA, corporate compliance programs, licensing, contracting, change of ownership, confidentiality and information sharing, and policies and procedures. Thought Leadership Mr. Lacktman speaks and writes frequently on issues at the forefront of telehealth and is often quoted for his insight about legal and business developments in this area. He has helped write telemedicine policy letters and position statements with such organizations as the ATA and the American Heart Association. He has provided comments and policy input on telehealth to lawmakers, the Drug Enforcement Agency, the Congressional Research Service, state Medicaid Agencies, and state boards of medicine across several states. He has appeared in publications such as Inside Presentation to Florida Telehealth Advisory Council (Page 28)

31 Nathaniel M. Lacktman Counsel, Buzzfeed, Politico, Modern Healthcare, Forbes, Fox News, Bloomberg, Reuters, and Information Week, among others. Health Care Enforcement and Litigation In the health care litigation and enforcement context, Mr. Lacktman has focused experience in matters involving enforcement actions by state and federal regulators, qui tam actions and the False Claims Act, internal investigations, ALJ hearings and reimbursement disputes, surveys and deficiencies, medical staff peer review, and long-term care. He has represented health care clients in state, federal and appellate courts, administrative hearings, mediations and arbitrations, including the following representative matters:» Internal investigations for DMEPOS suppliers and skilled nursing facilities regarding potential Medicare and Medicaid overpayments and self-disclosures. Community Involvement, Pro Bono and Professional Memberships Mr. Lacktman is active in the community and is a member of the firm's Tampa pro bono committee. He is a board member of the Gulf Ridge Council Boy Scouts of America. He serves as a volunteer judge in the Teen Court juvenile diversion program through the Hillsborough County Courts, having first volunteered with the Sarasota Teen Court program over 20 years ago. He is a member of the American Health Lawyers Association (AHLA), the Health Care Compliance Association (HCCA), the Health Law Section of the Florida Bar, Health Law Litigation Committee of the American Bar Association (ABA), and the American Telemedicine Association. Mr. Lacktman is admitted to practice in Florida and California, including the U.S. Court of Appeals for the 9th and 11th Circuits.» Representation of suppliers in Medicare and Medicaid ALJ hearings and reimbursement appeals.» Representation of hospitals, providers, and suppliers in defense of False Claims Act whistleblower suits. Education and Accolades Prior to joining Foley & Lardner, Mr. Lacktman was a judicial extern for the Honorable Ronald S.W. Lew of the United States District Court for the Central District of California. He was selected for inclusion to the Florida Super Lawyers - Rising Stars lists ( ). Mr. Lacktman received his law degree from the University of Southern California School of Law, where he was an editor for the Hale Moot Court Honors Program. He is a graduate of the University of Florida (B.A., with honors), where he was a University of Florida Scholar, member of Golden Key National Honor Society, and a member of Sigma Phi Epsilon fraternity. Presentation to Florida Telehealth Advisory Council (Page 29)

32 Selected Telemedicine and Telehealth Publications & Speaking Engagements Presentations and Media» Legal & Regulatory: How to Create a Multi-State Telehealth Clinic, MedTech Impact Expo & Conference 2016 (December 9-10, 2016)» Telehealth Business Arrangements and Contracting, Cambridge Healthtech Institute s Business of Telemedicine Symposium (August 26, 2016)» Hot Topics in Telemedicine 2016: Payment Policy, Prescribing, and Practice Standards, American Health Lawyer s Association (AHLA) Annual Meeting (June 28, 2016)» Advanced Telehealth Contracting and Network Development, American Health Lawyer s Association (AHLA) In-House Counsel Program (June 26, 2016)» Telehealth Coverage and Parity Laws: Trends, Challenges and Opportunities, 2016 Telemedicine & Telehealth Service Providers Showcase (June 21-22, 2016)» Using Telehealth and Informatics Under New Payment Models, Workgroup for Electronic Data Interchange (WEDI) 25th Annual National Conference (May 24-26, 2016)» From the East Coast to the Far East: Building U.S. to China International Telemedicine Arrangements, American Telemedicine Association (ATA) Annual International Meeting and Expo (May 15-17, 2016)» Melding Worlds of Established and Emerging Telehealth Models, American Telemedicine Association (ATA) Annual International Meeting and Expo (May 15-17, 2016)» Telemedicine Start-Ups: What Entrepreneurs Need to Know, American Telemedicine Association (ATA) Annual International Meeting and Expo (May 15-17, 2016)» Advanced Discussion on Telemedicine Legal Issues, Institutional Contracting, and Network Development, American Telemedicine Association (ATA) Annual International Meeting and Expo (May 15-17, 2016)» Telemedicine in Florida: Practice and Payment, Florida Bar Health Law Section Web Conference (May 10, 2016)» The Use of Telemedicine in the Emergency Department, Emergency Department Practice Management Association (EDPMA) 2016 Solutions Summit (May 1-4, 2016)» Telemedicine Legal & Compliance Issues for Academic Medical Centers," Vizient 2016 Academic Medical Center Networks Meeting (April 20-21, 2016)» Improving Telehealth Care Through Legislative Initiatives: Understanding the Politics and Processes, Mid-Atlantic Telehealth Resource Center (MATRC) 2016 Annual Summit (April 10-12, 2016)» The Patient Will See You Now: Understanding and Navigating the Direct to Consumer Evolution in Healthcare, Mid-Atlantic Telehealth Resource Center (MATRC) 2016 Annual Summit (April 10-12, 2016)» Where Do We Go From Here? Mid-Atlantic Telehealth Resource Center (MATRC) 2016 Annual Summit (April 10-12, 2016)» Building Telemedicine Contracts for Hospitals & Health Systems, ACI Conference on Implementing, Advancing and Exploring Telemedicine Programs and Services for Hospitals and Health Systems (April 6-8, 2016) Presentation to Florida Telehealth Advisory Council (Page 30) 2016 Foley & Lardner LLP Attorney Advertisement Prior results do not guarantee a similar outcome 321 North Clark Street, Chicago, IL