Supporting Telehealth Billing

Partnership HealthPlan of California April 15, 2013

Robert Moore, MD MPH, Chief Medical Officer, Partnership HealthPlan of California

Telehealth defined by AB415 The audio-visual mode of delivering health care and public health services utilizing information and communication technologies to enable: -diagnosis - consultation - treatment - education - care management - self-management of patient at a distance from health care providers Source: California Assembly Bill 415, Passed October, 2011

Telehealth Advancement Act of 2011 What Changed?

• New Name: Telemedicine is now Telehealth

• Removes restriction on physical location of where service is provided – can be office, hospital, home, etc

• Expands the definition of health care provider to include all state licensed medical professionals

• No additional written patient consent required – verbal consent acceptable with documentation in medical record

• Removes requirement for in-person visit prior to telehealth visit for Medi-Cal members

• Does not mandate use or reimbursement of telehealth services

PHC Telehealth Policy *Applies to Medi-Cal Members Only*

Three basic forms of telehealth 1. Synchronous - traditional: Patient in provider office

connecting to specialist in a distant office

2. Synchronous - non-traditional*: Provider connects with patient – in other than office setting (home, hospital, SNF, residential care, etc)

3. Asynchronous - Store & Forward: Patient in office with consult by specialist at a later time

Interaction must be through an audio-visual connection

PHC Telehealth Policy (Cont.)

• Two Telehealth Billing Codes – Transmission Code – T1014 (Per minute for max. of 90 min.)

– Facility Site Fee – Q3014 • Two Telehealth Modifiers

– GT for synchronous telehealth visit – GQ for asynchronous telehealth visit

* All PHC Specialist Referral and Prior Authorization requirements apply to Telehealth services*

Type Description Eligible Providers

Originating Site (Patient)

Distant Site (Provider)

Synchronous (Traditional)

Real time interaction between patient and distant site provider (office to office)

Physicians PAs & NPs RN, LVN Nutrition Counselors & More

Bill: •Transmission Cost (T1014) AND • PCP Consult Code OR •Site Facility Fee (Q3014)

Bill: •Transmission Cost (T1014) •Consult Code with GT Modifier

Synchronous (Non-Traditional) PHC Enhanced Benefit

Real time interaction between provider and distant site patient (patient could be home, hospital or other location)

Physicians PAs & NPs RN, LVN Nutrition Counselors & More

Bill: None

Bill: •Transmission Cost (T1014) •Consult Code with GT Modifier

Asynchronous (Store & Forward)

Review of medical information at a later time by Specialist

Ophthalmologists Dermatologists Optometrists

Bill: •Transmission Cost (T1014) AND • PCP Consult Code OR •Site Facility Fee (Q3014)

Bill: •Consult Code with GQ Modifier

Originating Site (Patient Present) Service Code Site facility fee (billable only when no CPT/E&M code is billed)

Q3014

Transmission Cost T1014 (per minute for maximum of 90 min. per patient)

Licensed provider fee (if present)* E&M codes 99201 - 99215 and other CPT codes for services distinct and in addition to those rendered by the Distant Site Provider.

Distant Site (Provider Present) Service Code Transmission Cost T1014 (per minute for maximum of 90 min.

per patient)

Initial hospital care or subsequent hospital care (new or established patient)

99221 – 99233

Consultations: Office or other outpatient ( initial or follow-up) Inpatient, and confirmatory

99241 – 99275

Nutrition Counseling per PHC Guidelines (See Policy MCUP3052)

97802, 97803, 97804

Required Modifer GT modifier required for all CPT-Codes except Transmission Cost code

*Billable for services distinct and in addition to those rendered by the Distant Site. Medical necessity must be documented in chart.

Sample Claim - Traditional

CPT Code

Originating Site (Location of Patient)

•No billable provider present •Bill Facility Site Fee - Q3014 •Bill Transmission Code - T1014

•Provider included in visit – bill CPT Code •Bill Transmission Code – T1014 •No Facility Site Fee allowed if CPT Code billed

Sample Claim - Traditional Distant Site (Specialist Location)

•Bill Provider CPT Code PLUS GT Modifier •Bill Transmission Code – T1014

Synchronous Telehealth Non-Traditional

Originating Site may be home, health facility, residential care or other location.

Distant Site/Provider Site (Location of Provider) Service Code Transmission Cost T1014 (per minute for maximum of 90 min. per

patient)

Licensed provider fee E&M codes 99201 – 99215

Nutrition Counseling per PHC Guidelines (See Policy MCUP3052)

97802, 97803, 97804

Required Modifier GT modifier required for all CPT-Codes except Transmission Cost codes

Originating Site (Location of Patient) Service Code No Billing

Sample Claim – Non Traditional

•Originating Site: may be home, health facility, residential care or other

•No billing for originating site

•Bill for Provider Site (can be specialists or primary care provider)

• Bill consult with GT modifier

• Bill Transmission Cost – T1014

Provider Site

GT Modifier

Asynchronous Telehealth: (Store & Forward)

Originating Site (Patient Location) Service Code Site facility fee (billable only when no provider at visit) Q3014 Transmission Cost T1014 (per minute for maximum of 90 min.

per patient) Licensed provider fee (if present) E&M codes 99201 - 99215 and other CPT

codes for services distinct and in addition to those rendered by the Distant Site Provider.

Distant Store and Forward Site (Specialist Location) Service CPT Codes Office consultation, new or established patient

99241 - 99243

Retinal photography with interpretation for services provided by optometrists or ophthalmologists

92250

Required Modifier: All asynchronous, store-and-forward services are billed with a “GQ” modifier

* Billable for services distinct and in addition to those rendered by the Distant Site. Medical necessity must be documented in chart.

*

Sample Claims – Asynchronous Originating Site (Location of Patient)

•Bill Facility Site Fee – Q3014 •Bill Transition Code – T1014 •No billable provider present – so no CPT Code

•Bill Transition Code – T1014 •Bill CPT Code •No Facility Site Fee billable if CPT Code billed

Sample Claims – Asynchronous

GQ Modifier

Distant Site (Location of Specialist)

•Bill CPT Code with GQ modifer

Ophthalmology, Optometry & Dermatology Only

GQ Modifier

Partnership HealthPlan Quality Improvement Program (QIP)

• Pay for Performance Program for 2012-13 includes an incentive for significant use of telemedicine

– One time incentive payment of $2,500 for Primary Care Sites participating in the Quality Improvement Program

– At least 25 encounters completed between July 1st 2012 through June

30, 2013 – Data collected through claims information – Claims submitted with a T1014, Q3014, GT or GQ modifier apply to

QIP when submitted in accordance with PHC Telehealth Policy

Future Directions in Telehealth Reimbursement

• Email communication with Patients

• Medication Therapy Management with

Telehealth

Resources/More Questions

• Partnership HealthPlan Telehealth Policy (MCU3113) available at www.partnershiphp.org

• Contact me at

rmoore@partnershiphp.org