5/1/2017. Medicare Coverage Guidelines for DSMT and MNT Telehealth. Telehealth Defined

Transcription

1 Medicare Coverage Guidelines for DSMT and MNT Telehealth Mary Ann Hodorowicz, RDN, MBA, CDE Certified Endocrinology Coder Mary Ann Hodorowicz Consulting, LLC MEDICARE DSMT - MNT TELEHEALH KEY TOPICS T Telehealth Defined E Expect Same Medicare Reimbursement as for In-Person DSMT L Limit on Types of Approved Rendering Providers E Ensure Modifier GT Used with DSMT-- MNT Procedure Code on Claim H Hour of In-Person DSME Required if Beneficiary Needs Training on Injectable Medication E Eligible Distant and Originating Sites A Assure HIPAA-Compliant Telehealth Software Used L Limit on Types of Approved Billing Providers T Telehealth Visit Must be Attended by Beneficiary H Have Originating Site Bill Facility Fee For Each DSMT--MNT Visit 1

2 D Distant Site Clinician Must Have: Licensure or Certification in State Where Clinician is Located Also in State Where Beneficiary is Located S Specific Sites Are Excluded from Being Distant and/or Originating Site M Must Use Both the Place of Service Code 02 and Procedure Code Modifier GT on the Distant Site Claim E Expect Coverage from Most Private Payers and More Medicaid Plans for DSMT MNT Telehealth TELEHEALH DEFINED The use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. 1 Broad term; can refer to clinical and non-clinical services involving medical education, administration and research Includes technologies such as telephones, faxes, electronic mail systems, and remote pt monitoring devices used to collect and transmit data for monitoring and interpretation example: o Physicians use to communicate with pts, order drug Rx and provide other health services 1. American Telemedicine Association. Telemedicine Defined Centers for Medicare and Medicaid Services. Telemedicine and Telehealth. MEDICARE DSMT - MNT TELEHEALH BILLING BASICS MEDICARE S DEFINITION: HIPAA-compliant, interactive audio and video telecommunication permitting real time communication and visualization. See next 2 slides for more HIPAA information. EXCLUDED: Telephone calls, faxes, without audio and visualization. Real time texts. Stored and delayed transmissions of images of beneficiary. Source: 2

3 HIPAA-COMPLIANT SOFTWARE: 8 KEY ISSUES 1. HIPAA requires covered health entities to: o Conduct own risk assessments for chosen technologies o Have contractual agreements with vendors and subcontractors providing technology and equipment 2. In contracts or business associate agreements (BAA), vendors and subcontractors must: o Promise to comply with HIPAA rules, making them directly liable for any HIPAA violations o Only exception is in case of conduit (see below) 3. Many popular online chat services do not promise HIPAA compliance 3. If one did claim exemption from HIPAA Privacy Rules under the conduit exception, service may not be able to conduct approved security audits via audit trails 4. Service may not satisfy HIPAA conduit exception HIPAA-COMPLIANT SOFTWARE: 8 KEY ISSUES 5. One exception to who counts as HIPAA business associate is any data transmission organization that acts as a conduit 6. State laws regarding privacy and security can be more stringent than federal laws, in which case the state law overrules the federal HIPAA and HITECH laws 7. So if online video chat service allowed under federal law, it may not satisfy video conferencing security requirements under a state s law 8. Thus clinicians practicing across state lines need to make sure they satisfy telemedicine/telehealth requirements for each state in which they plan to practice MEDICARE DSMT - MNT TELEHEALH BILLING BASICS, CONT. REIMBURSEMENT: Same as for original face-to-face DSMT - MNT benefits. HCPCS CODE MODIFIER REQUIRED: HCPCS code modifier GT added to DSMT - MNT procedure code on claim: interactive audio and video telecommunications system. PRIVATE PAYERS: Some private payers require code T1014: Telehealth transmission, per minute, professional services bill separately 3

4 MEDICARE DSMT - MNT TELEHEALH BILLING BASICS, CONT. INDIVIDUAL and GROUP DSMT - MNT Both can be delivered via telehealth. All original billing and coding reimbursement rules apply. DSMT SPECIAL REQUIREMENTS OVER & ABOVE ORIGINAL: >1 hour of 10 hours in initial year and >1 hour of 2 hours in follow-up years to be furnished in-person for training on injectable mediation (individual or group). Beneficiary must be present and participate in telehealth visit. MEDICARE DSMT - MNT TELEHEALH BILLING BASICS, CONT. ORIGINATING SITE vs. DISTANT SITE Originating site: where beneficiary is during DSMT - MNT visit. Distant site: where HCP is during DSMT MNT visit. STATE LICENSURE/CERTIFICATION REQUIREMENT FOR INDIVIDUAL RENDERING AND BILLING PROVIDER Rendering and billing provider must be licensed or certified in state where the provider furnishes telehealth DSMT - MNT AND in state where beneficiary receives the DSMT MNT. MEDICARE DSMT - MNT TELEHEALH BILLING BASICS, CONT. INDIVIDUAL RENDERING PROVIDER: WHO IS ALLOWED TO FURNISH DSMT TELEHEALTH? Medicare telehealth services, including individual DSMT services furnished as a telehealth service, could only be furnished by a licensed physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse-midwife (CNM), clinical psychologist, clinical social worker, or registered dietitian or nutrition professional. Source: Payment for Diabetes Self-Management Training (DSMT) as a Telehealth Service (Rev. 3476, Issued: , Effective: , Effective: ), Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners (Rev. 3678, ) 4

5 APPROVED DISTANT SITE PRACTITIONERS OF MEDICARE MEDICARE DSMT TELEHEALTH Physicians (MDs, DOs) Physician assistants (PAs) Nurse practitioners (NPs) Clinical nurse specialists (CNSs) Certified nurse midwives (CNMs) Clinical psychologists Clinical social workers (CSWs) Registered dietitians (RDs) and nutrition professionals APPROVED DISTANT SITE PRACTITIONERS OF MEDICARE MEDICARE MNT TELEHEALTH Registered dietitians (RDs) Nutrition professionals o If employed by hospital, clinic, etc., must re-assign reimbursement to employer by completing CMS 855 R form o Allows employer to bill Medicare on behalf on RD or nutrition professional and receive the reimbursement DISTANT SITES TO USE PLACE OF SERVICE CODE 02 WHEN BILLING DSMT MNT TELEHEALTH VISIT Effective : Place of service (POS) code is 02 for use by physician or practitioner furnishing telehealth services from a distant site o POS 02 = The location where health services and health related services are provided or received, through telecommunication technology POS code 02 does NOT apply to originating site facilities billing a facility fee Source: MLN Matters Number: MM9726, New Place of Service (POS) Code for Telehealth and Distant Site Payment Policy 5

6 MUST USE PLACE OF SERVICE CODE 02 and PROCEDURE CODE MODIFIER GT ON CLAIM FROM DISTANT SITE If telehealth service billed with POS code 02, but without GT modifier, MAC will deny service with messages: o Group Code CO (Contractual Obligation; provider financially liable) o Claim Adjustment Reason Code (CARC) 4: Procedure code inconsistent with modifier used or required modifier missing o Remittance Advice Remarks Code (RARC) MA130. Your claim contains incomplete and/or invalid information; no appeal rights afforded because claim is unprocessable. Please submit new claim with complete/correct information. Source: MLN Matters Number: MM9726, New Place of Service (POS) Code for Telehealth and Distant Site Payment Policy MUST USE PLACE OF SERVICE CODE 02 and PROCEDURE CODE MODIFIER GT ON CLAIM FROM DISTANT SITE, CONT. Conversely, if telehealth services billed with procedure code modifier GT but without POS code 02, MAC will deny service with messages: o Group Code CO o CARC 5 (The procedure code/bill type is inconsistent with the place of service.) o RARC M77 (Missing/incomplete/invalid/inappropriate place of service) Source: MLN Matters Number: MM9726, New Place of Service (POS) Code for Telehealth and Distant Site Payment Policy EXCLUDED DISTANT SITES: WHERE HCP IS DURING DSMT MNT VISIT Federally qualified health centers (FQHCs) Rural health clinics (RHCs) Independent renal dialysis facilities Pharmacies Beneficiary s home 6

7 APPROVED ORIGINATING SITES: WHERE BENEFICIARY IS DURING VISIT Physician or qualified non-physician practitioner office Hospital Critical Access Hospital (CAH) Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Hospital and CAH-based renal dialysis center (including satellites) Skilled nursing facility (SNF) Community mental health center GEOGRAPHIC CRITERIA FOR ORIGINATING SITES Originating sites must be located in health professional shortage area (HPSAs) located in rural census tracts of urban areas as determined by Office of Rural Health Policy OR County outside of metropolitan statistical area (MSA) NOTE: Originating sites NOT approved for telehealth: o Beneficiary s home o Independent renal dialysis facility o Sites within a MSA or not within a HPSA ORIGINATING SITES ELIGIBLE FOR FACILITY FEE FOR DSMT MNT TELEHEALTH VISIT CMS recognizes that originating site (facility) which hosts patient access to remote provider deserves compensation for this service o Is origin of telehealth site facility fee To claim facility fee, originating site bills HCPCS code Q3014, telehealth originating site facility fee o Medicare deductible and coinsurance apply to code Q3014 By submitting HCPCS code Q3014, originating site authenticates that it is located in either a rural HPSA or non-msa county 7

8 ORIGINATING SITES ELIGIBLE FOR FACILITY FEE FOR DSMT MNT TELEHEALTH VISIT, CONT. Type of service is "9 on claim form ( other items and services ) For carrier-processed claims only, the office place of service code (= code 11) is the only payable setting for code Q3014 Originating site facility fee is a Part B payment o Medicare pays it outside of current fee schedule or other payment methodologies 2017 Medicare facility fee = 80% of lesser of actual charge, or $25.40 Payment set annually in Medicare Physician Fee Schedule Final Rule DSMT MNT TELEHEALTH SUCCESS DEPENDS on 3 P s STATE INSURANCE DSMT--MNT PAYMENT MANDATES for PRIVATE PAYERS 46 states and DC have state insurance laws that require private payers have some degree of coverage for DSMT, MNT and diabetes-related services and supplies 1 4 states with no laws: AL, ID, ND, OH Laws override any coverage limitations in health plan Exclusions exist (e.g., state/federal employer health plans often exempt from state mandates) 1. (National Conference of State Legislatures) 8

9 CHANGES IN BILLABLE ICD-10 DIAGNOSIS CODES FOR DSMT AND MNT: EFFECTIVE 2016 and 2017 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for DSMT Invalid ICD-10 dx codes end-dated effective 9/30/16: o E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E o E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E o E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E o E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E o E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E08.37X1, E08.37X2, E08.37X3 o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E09.37X1, E09.37X2, E09.37X3 DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E10.37X1, E10.37X2, E10.37X3 9

10 DSMT: Added new 2017 ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E11.37X1, E11.37X2, E11.37X3 o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E13.37X1, E13.37X2, E13.37X3 o O24.415, O24.425, O o Unspecified codes deleted effective 1/1/17: O O O CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT Remove ICD10 dx codes effective 1/1/17: o E08.21, E08.311, E08.319, E08.36, E08.39, E08.65 o E09.21, E09.311, E09.319, E09.36, E09.39 o E10.311, E10.319, E10.36, E10.39 o E11.311, E11.319, E11.36, E11.39 o E13.311, E13.319, E13.36, E13.39 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT ICD-10 dx codes expire and end-dated effective 9/30/2016: o E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E o E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E o E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E o E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E o E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E

11 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT Add new ICD-10 dx codes effective 10/1/16: o O24.03, O24.13, O24.011, O24.012, O24.013, O24.111, O24.112, O24.113, O24.415, O24.425, O24.435, O24.811, O24.812, O24.813, O24.83 o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E08.37X1, E08.37X2, E08.37X3 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT Add new ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E09.37X1, E09.37X2, E09.37X3 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT Add new ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E10.37X1, E10.37X2, E10.37X3, E , E , E , E , E , E , E

12 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT Add new ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E11.37X1, E11.37X2, E11.37X3 CMS CR9861 Made Adjustments to CMS National Coverage Determination (NCD) 40.1 for MNT Add new ICD-10 dx codes effective 10/1/16: o E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E , E13.37X1, E13.37X2, E13.37X

13 EXTRA INFO ABOUT FACILITY FEE BILLING Hospital OP Dept.: Fee payment is as described on previous slide and not under OP prospective payment system (OPPS). Part A is billed. CAH: Fee payment is separate from cost-based reimbursement methodology and is 80% of originating site facility fee. Part A is billed. Physicians and practitioners offices: Fee payment is lesser of 80% of actual charge or 80% of originating site facility fee, regardless of location. Part B contractor does not apply geographic practice cost index to fee; fee statutorily set; not subject to geographic payment adjustments authorized under Physician Fee Schedule. Part B is billed. Renal dialysis center (or satellite) based in hospital or CAH: Fee covered in addition to any composite rate or MCP amount. Bills Part A and must use revenue code 78x.. EXTRA INFO ABOUT FACILITY FEE BILLING, CONT. Skilled nursing facility (SNF): Fee outside SNF prospective payment system bundle and not subject to SNF consolidated billing; separately billable Part B payment. Bills Part A and must use revenue code 78x. Community Mental Health Center (CMHC): Fee not partial hospital service; does not count towards number of services used to determine payment for partial hospitalization services. Fee not bundled in per Diem payment for partial hospitalization; separately billable Part B payment. Bills Part A and must use revenue code 78x. Independent and provider-based RHCs and FQHCs: Fee billed to Part A using RHC or FQHC bill type and billing number. Code Q3014 is only non-rhc/fqhc service that is billed using clinic/center bill type and provider number. Must use revenue code 078x. WE GOT RID OF THE KIDS.. THE CAT WAS ALLERGIC 13

14 Mary Ann Hodorowicz Consulting, LLC Turn Key Materials for AADE DSME Program Accreditation DSME Program Policy & Procedure Manual Consistent with NSDSME (69 pages) Medicare, Medicaid and Private Payer Reimbursement Electronic and Copy-Ready/Modifiable Forms & Handouts Fun 3D Teaching Aids for AADE7 Self-Care Topics Complete Business Plan 3-D DSME/T and Diabetes MNT Teaching Aids How-To-Make Kit Kit of 24 monographs describing how to make Mary Ann s separate 3-D teaching aids plus fun teaching points, evidence-based guidelines and references Money Matters in MNT and DSMT: Increasing Reimbursement Success in All Practice Settings, The Complete Guide Establishing a Successful MNT Clinic in Any Practice Setting EZ Forms for the Busy RD : 107 total, on CD-r; Modifiable; MS Word Package A: Diabetes and Hyperlipidemia MNT Intervention Forms, 18 Forms Package B: Diabetes and Hyperlipidemia MNT Chart Audit Worksheets: 5 Forms Package C: MNT Surveys, Referrals, Flyer, Screening, Intake, Analysis and Other Business/Office and Record Keeping Forms: 84 Forms 14