MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE NUMBER: DRAFT ISSUE DAT E: DRAFT EFFECTIVE DATE: DRAFT SUBJECT: Behavioral Health Services: Telehealth and Telemedicine - DRAFT BY: Signature Image Name Title BY: Signature Image Name Title SCOPE: This bulletin applies to the provision of Behavioral Health Services to include both Telemedicine and Telehealth services. Telemedicine services are provided by Physicians, CRNP s, RN s and Physician Assistants. Telehealth services are provided by Psychologists, Social Workers, other behavioral health providers, and outpatient clinics enrolled with the Office of Medical Assistance Programs (MA) in either the Behavioral Health Fee for Service Program or the Health Choices Program. PURPOSE: The purpose of this Bulletin is to advise providers of Behavioral Health Services to MA recipients, that Telemedicine, particularly Telepsychiatry, Telehealth services and Telephone Consultations may be provided by the Behavioral Health Managed Care Organization (BHMCO) within the HealthChoices Program or the Fee-for-Service Program effective November 1, 2008. BACKGROUND: Telemedicine and Telehealth are Behavioral Health Services provided to remote site locations. Both employ the use of electronic communication and information technologies to provide Behavioral Health Services to consumers having difficulty with access for a variety of reasons, particularly rural areas with shortages of qualified providers. Telemedicine, particularly Telepsychiatry, and Telehealth are appropriate in 1
situations where on-site services are not available due to distance, location, time of day or availability of resources. Telemedicine and Telehealth may be used to aid the consumer in other locations where professional services are not readily available to provide emergency services, such as crisis intervention to prevent movement to a higher level of service provision due to a delay in accessing medically necessary services. Telephone intervention by a Behavioral Health clinician, may only be provided in emergency situations to prevent or stabilize a behavioral health crisis. Telephone Consultations between a non-psychiatric Physician, CRNP or PA with a Psychiatrist to review medications and treatment recommendations is permitted over the telephone, when the consumer is present and part of this process. Telemedicine, particularly Telepsychiatry, and Telehealth services, as defined in this bulletin are BH services provided by a physician or other licensed clinician, within their scope of practice using real-time, two way interactive audio, video and/or audiovideo transmissions. They do not include brief telephone conversations, electronic mail messages, written reports or facsimile transmission between a health care provider and a consumer. They do include Telephone Consultations between two licensed health care practitioners collaborating to coordinate care, as long as the consultation includes the consumer as part of the collaboration process. Reasonable accommodations will be made on a case by case basis, to address the special needs of consumers, which can include accommodation, at a minimum, for visually impairment, blindness, deafness and hard of hearing, culturally or faith based differences. With the advancements in technology, Telemedicine and Telehealth can be provided in a confidential and professional manner, when inability to access Behavioral Health and/or Substance Abuse Services creates a hardship for consumers and their families. The technology utilized to provide these services must conform to the industry wide compressed audio-video communication standards for real-time, two way interactive audio-video, audio or video transmission. Compliance with all HIPAA standards for confidentiality is required. 2
DISCUSSION The State of Pennsylvania along with other states has been considering adding Telehealth/Telemedicine and Telepsychiatry services as a compensable Medicaid Service. Determining the circumstances under which consumers can access these services has been controversial. It was felt that personal and confidential treatment could only be provided face to face, and was more easily monitored to prevent fraud and abuse. With improved technology, the quality of the audio-video transmission achieves a reasonable standard for assuring personal and confidential treatment. While it is always better to meet with a practitioner in person, there are instances where, due to a shortage of providers, a particular condition or disability of a consumer, or the geographic location of a consumer, Telemedicine and Telehealth are the only means to accessing a Behavioral Health practitioner who can assist in the diagnosis and provision of timely behavioral health and substance abuse treatment for the consumer. Both parties to the interaction must be able to assure confidentiality of the entire treatment interaction and the related documentation, in accordance with HIPPA standards. In addition, a family member, certified peer support specialist, school nurse, counselor or other Behavioral Health clinician must be onsite and available to the consumer to address any difficulties that could arise during the Telemedicine or Telehealth treatment session. The consumer and/or legal guardian must give informed written consent to participate in Telemedicine and/or Telehealth, with full disclosure of its risks and benefits. If individuals beside the consumer and their family are present, the consumer and/or the legal guardian must provide written consent, as well as the Telemedicine or Telehealth practicioner/s. The consent of the consumer is required for the provision of all Behavioral Health and Substance Abuse Services via Telemedicine/Telepsychiatry and Telehealth. Consumers must give consent for any additional individual/s to be present during the provision of Behavioral Health and/or Substance Abuse Services by the provider. Providers need to approve of the physical environment of the site being used, the availability of support staff, and the quality of the 3
equipment and technology available to support the treatment being provided. Consumers and providers have the right to discontinue the Behavioral Health and/or Substance Abuse Services provided in this alternate venue, if either feels the risks outweigh the intended benefits. All approved Telemedicine/Telepsychiatry and Telehealth providers, will add the new modifier, the GT prefix to all billing codes, when billing for these services. The Department is also adding procedure codes for consultation between and among healthcare professionals to coordinate medical management, behavioral health and substance abuse treatment with physical healthcare for the consumer. These services are added to increase accessibility to services, to coordinate all healthcare and to significantly improve the quality of healthcare for MA recipients. It is expected that Telemedicine/Telepsychiatry and Telehealth will promote increased treatment integration of physical, behavioral health and substance abuse services in the areas of greatest need throughout Pennsylvania. Increased integration will provide a comprehensive and coordinated treatment plan, addressing the complexity of multiple healthcare needs, so that consumers can understand and manage their own healthcare, to the greatest extent possible. It is anticipated that consumer empowerment will motivate engagement in the pursuit of wellness, with emphasis on decreasing the morbidity and mortality of individuals with SMI. Additional Benefits Improved consumer access to specialists, behavioral health and substance abuse providers Improved quality of care through earlier evaluation and diagnosis, with emphasis on evidence based treatment, and timely follow up on treatment recommendations Decreased need for psychiatric hospitalization and/or other higher levels of care when early expert intervention is provided 4
Fewer commutes, less time off from work or school, and fewer childcare issues for consumers and their families Flexibility for consumer and provider scheduling to increase consumer access Reduced transportation expenses for accessing care Reduced need to transport medically and psychiatrically complex MA recipients for routine follow up treatment Increased recruitment of behavioral healthcare and substance abuse professionals to provide services to underserved areas PROCEDURE FOR ENROLLMENT AND REIMBURSEMENT Providers wishing to render Telemedicine/Telepsychiatry or Telehealth services to MA recipients in the BH Health Choices programs will be specifically enrolled for these services with their respective Behavioral Health MCO. Provider agencies will submit their request for initiation of all new services to their respective BHMCO, who will then submit the program request to the OMHSAS Health Choices Prior Authorization Review Panel (PARP) for approval, before initiation of services. MA Recipients that are not covered by a BHMCO, will be under the jurisdiction of the BH Bureau of Fee-for- Service. These MA recipients will be evaluated for Telemedicine/Telepsychiatry or Telehealth services on a case by case basis by the BH Bureau of Fee-for-Service, with all services needing approval before initiation. Any out-of-state providers are required to be licensed by the Department of State in the Commonwealth of Pennsylvania. For providers wishing to use Telemedicine/Telepsychiatry and Telehealth services, to provide crisis intervention services, the following memorandum of understanding with the county MH/MR Administrator and MH Delegates is a necessary prerequisite: 1. Telemedicine/Telepsychiatry and Telehealth providers will be permitted to provide telephone testimony as a petitioner on all commitment hearings. 2. All commitment documents can be faxed to the admitting hospital, with the 5
understanding that the original document will be delivered or sent overnight to the hospital in time for the commitment hearing. 3. The policies and procedures that support this process are established before this Service is instituted. The evaluating and admitting hospitals have approved of these policies and procedures, with incorporation of them into their respective hospital policies and procedures. After the issuance of the Bulletin on Telemedicine/Telepsychiatry and Telehealth services, approved providers may bill for those services provided to MA eligible recipients. The following are approved codes for reimbursement for all Telemedicine/Telepsychiatry and Telehealth Providers of Service: 90801 Psychiatric Diagnostic Interview examination (approximately 60 minutes) 90804 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility approximately 20 to 30 minutes face-to-face with the patient 90805 - Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility approximately 20 to 30 minutes face to face with the patient, with medical evaluation and management services 90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility approximately 45 to 50 minutes face-to-face with the patient. 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility approximately 45 to 50 minutes face to face with the patient, with medical evaluation and management services. 6
90808 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility approximately 75 to 80 minutes face-to-face with the patient; 90809 - Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility approximately 75 to 80 minutes face to face with the patient, with medical evaluation and management services. 90862- Pharmacologic Management, including prescription, use, and review of medication with no more than minimal medical psychotherapy, with 10 to 15 minutes face to face with patient. 99213 - Office or other outpatient visit (15 minutes of face to face with the patient and/or family) for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity 99214 - Office or other outpatient visit (25 minutes of face to face with the patient and/or family) for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. 99215 - Office or other outpatient visit (40 minutes of face to face with the patient and/or family) for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decisions making of high complexity. 7
99241- Office consultation (15 minutes of face to face with the consumer and/or family) for a new or established patient, which requires these three components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and /or coordination of care with other providers or agencies 99242- Office consultation (30 minutes of face to face with the consumer and/or family) for a new or established patient, which requires these three components: an expanded problem focused history; an expanded problem focused examination; and straight forward medical decision making. Counseling and /or coordination of care with other providers or agencies 99243- Office consultation (40 minutes of face to face with the consumer and/or family) for a new or established patient, which requires these three components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies 99244- Office consultation (60 minutes face to face with the consumer and/or family) for a new or established patient, which requires these three components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and /or coordination of care with other providers or agencies 99245- Office consultation (80 minutes face to face with the consumer and/or family) for a new or established patient, which requires these three components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and /or coordination of care with other providers or agencies Reimbursement: All codes used for reimbursement of claims must be listed in the updated Behavioral Health Services Reporting Classification Chart (BHSRCC). All Behavioral Health MCOs are responsible to determine rates commensurate with those codes listed in the most recent MA Fee Schedule. All codes used for 8
Telemedicine/Telepsychiatry and Telehealth will have a prefix of GT, to denote this change in venue and access any increased reimbursement for these services. If the mental health practitioner will be providing the on-going treatment to the consumer, the office consultation code should not be billed. The office consultation code is only used by the consultant when the referring practitioner will continue the treatment of the consumer. More than one consultation monthly requires prior authorization. The enhanced rate may be a higher rate for an existing code with the GT prefix, that includes the cost of the technology and equipment prerequisite to providing Telemedicine/Telepsychiatry/Telehealth or it may be a separate Equipment and Technology rate for these services, denoted by code Q3014. The technology utilized to provide these services must conform to the industry wide compressed audio-video communication standards for real-time, two way interactive audio-video, audio or video transmission. Compliance with all HIPPA standards for confidentiality is required. Telemedicine/Telepsychiatry/Telehealth Requestors of Service When a practitioner or clinic requests Telemedicine/Telepsychiatry/Telehealth services and provides the coordination for the appointment, location and qualified individual to be with or be available to the consumer for the Telemedicine or Telehealth service, they may bill using the code Q3014. 3. Interpreter Auxiliary Service- When free interpreter services are not available through the community, an educational institution, or other means, the following codes may be billed for services rendered at the physician, behavioral health and/or substance abuse practitioner s office or clinic. Codes for Interpreter Services such as signlanguage for the deaf and hard of hearing, or those non-english speaking consumers who are only fluent in a foreign language are listed below. These codes may also be approved on a case by case basis for individuals needing special accommodations 9
based on disability, barriers in accessing services, identified cultural or faith based needs, and other special circumstances that require reasonable accommodation to meet identified behavioral health needs. 90810- Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient 90811- Individual psychotherapy, interactive with play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face to face with the patient with medical evaluation and management services 90812- Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication in an office or outpatient facility, approximately 45 to 50 minutes face to face with the patient 90813- Individual psychotherapy, interactive using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication in an office or outpatient facility, approximately 45 to 50 minutes face to face with the patient with medical evaluation and management services 90814- Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication in an office or outpatient facility, approximately 75 to 80 minutes face to face with the patient 90815- Individual psychotherapy, interactive using play equipment, physical devices, language interpreter or other mechanisms of non-verbal communication in an office or outpatient facility, approximately 75 to 80 minutes face to face with the patient with medical evaluation and management services 10
B. Telephone: The following codes have been added to the Office of Medical Assistance Fee Schedule to allow physicians and licensed practitioners involved with the consumer s behavioral health care to coordinate treatment with other professionals with or on behalf of the consumer. 99371 - Telephone calls by a physician to patient for consultation or medical management; coordinating medical management with other Health Care professionals (e.g. nurse, therapist, social worker, nutritionist, physician, pharmacists) simple at least 15 minutes. 99372 - Telephone calls by a physician to patient for consultation or medical management; or coordinating medical management with other Health Care professionals (e.g. nurse, therapist, social worker, nutritionist, physician, pharmacists) intermediate at least 30 minutes. 99373 - Telephone calls by a physician to patient for consultation or medical management or coordinating medical management with other Health Care professionals (e.g. nurse, therapist, social worker, nutritionist, physician, pharmacists) complex at least 45 minutes. Documentation Requirements: All documentation requirements for the provision of Behavioral Health Services are consistent with existing standards in place for BH FFS and Health Choices Providers. However, the documentation of services provided is to be kept by both the Consultant and the requestor. When the consumer is not present, consultants may use the most recent mental status or physical examination results if completed within the prior 30 days. Specific procedures for documentation are outside the scope of this Bulletin. 11
COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Office of Mental Health and Substance Abuse Services P.O. Box 2675 Harrisburg, PA 17105 Telephone (717) 705-8289 12