Understanding Eligibility and Billing for Telehealth · 2020-05-05 · Understanding Eligibility...
7
Andrew N. Pollak, MD Ben Steffen CHAIR EXECUTIVE DIRECTOR Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 1 Payer Telehealth Policies – A Reference Guide for Ambulatory Practices Background The COVID-19 public health crisis created urgency for ambulatory practices (practices) to adopt telehealth. Prior to March 2020, telehealth was viewed as a promising strategy in part to improve access to mental health and substance use treatment. 1 The COVID-19 public health crisis resulted in a nearly 60 percent decline of in-person office visits 2 , which has rebounded by about two thirds as a result of telehealth. 3 Laudably, practices response enabled telehealth to provide care to individuals in need and mitigate spread of the virus. Changes in telehealth polices across payers have greatly supported practices ability to offer telehealth. 4 Policies for government payers (Medicare and Medicaid) are similar. There is close alignment among private payers for fully-insured 5 plans; however, variation in coverage exists across self-funded plans. 6 Practices are encouraged to verify patient eligibility and reimbursement for telehealth before scheduling a telehealth encounter. Telehealth – Privacy Standards The Department of Health and Human Services, Office for Civil Rights (OCR) is the federal agency responsible for enforcing the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 7 Privacy and Security Rules. 8 OCR issued a notice to waive penalties for HIPAA violations against health care providers that provide care through non-public facing remote communication systems (includes texting applications), such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, and Skype when used in good faith for treatment and diagnostic purposes. 9 OCR has not included in its waiver the use of public-facing products such as TikTok, Facebook Live, Twitch, or a chatroom like Slack. 10 About this Reference Guide Information included in the tables that follow was obtained from payer websites and is intended for educational purposes; users of this document are encouraged to contact payers for the most up to date information. Items from the Current Procedural Terminology CPT® code set used in this document are copyright of the American Medical Association. 11 Italicized items represent temporary measures waiving certain use requirements for telehealth during the COVID-19 public health crisis. 1 States Lead the Way in Adapting Telehealth to Meet Mental Health Needs, available at: www.mhealthintelligence.com/news/states-lead-the-way-in-adapting-telehealth-to-meet-mental-health-needs . 2 Declines may vary by practice type and size. 3 The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges, available at: www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits 4 COVID-19 may permanently alter the telehealth landscape, from reimbursement to utilization, available at: www.healthcarefinancenews.com/news/covid-19-may-permanently-alter-telehealth-landscape-reimbursement- utilization. 5 COMAR 10.25.16.02(B)(5): Fully-insured plans are those where an employer pays a per-employee premium to a payer to assume the risk of providing health care coverage for their employees or an individual pays a premium to an insurance carrier for health care coverage. 6 COMAR 31.11.02.02(B)(8): Self-funded plans (also known as self-insured) are those where an employer pays to provide its employees with hospital, medical, surgical, or major medical benefits on an expense-incurred basis similar to benefits which could be provided under a group health insurance policy . 7 The law is available at: www.govinfo.gov/content/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf . 8 HIPAA Enforcement, available at: www.hhs.gov/hipaa/for-professionals/compliance-enforcement/index.html . 9 OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency, available at: www.hhs.gov/about/news/2020/03/17/ocr- announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html 10 U.S. Department of Health and Human Services, Office for Civil Rights, FAQs on Telehealth and HIPAA during the COVID-19 Nationwide Public Health Emergency, available at: www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf . 11 U se of this information is permitted for educational purposes under the Copyright Law of the United States (Title 17), Section 107 - Limitations on exclusive rights: Fair use.
Transcript of Understanding Eligibility and Billing for Telehealth · 2020-05-05 · Understanding Eligibility...
Andrew N. Pollak, MD Ben Steffen CHAIR EXECUTIVE DIRECTOR
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 1
Payer Telehealth Policies – A Reference Guide for Ambulatory Practices
Background
The COVID-19 public health crisis created urgency for ambulatory practices (practices) to adopt telehealth. Prior to March 2020, telehealth was viewed as a promising strategy in
part to improve access to mental health and substance use treatment.1 The COVID-19 public health crisis resulted in a nearly 60 percent decline of in-person office visits2, which
has rebounded by about two thirds as a result of telehealth.3 Laudably, practices response enabled telehealth to provide care to individuals in need and mitigate spread of the virus.
Changes in telehealth polices across payers have greatly supported practices ability to offer telehealth.4 Policies for government payers (Medicare and Medicaid) are similar. There
is close alignment among private payers for fully-insured5 plans; however, variation in coverage exists across self-funded plans.6 Practices are encouraged to verify patient eligibility
and reimbursement for telehealth before scheduling a telehealth encounter.
Telehealth – Privacy Standards
The Department of Health and Human Services, Office for Civil Rights (OCR) is the federal agency responsible for enforcing the Health Insurance Portability and Accountability
Act of 1996 (HIPAA)7 Privacy and Security Rules.8 OCR issued a notice to waive penalties for HIPAA violations against health care providers that provide care through non-public
facing remote communication systems (includes texting applications), such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, and
Skype when used in good faith for treatment and diagnostic purposes.9 OCR has not included in its waiver the use of public-facing products such as TikTok, Facebook Live, Twitch,
or a chatroom like Slack.10
About this Reference Guide
Information included in the tables that follow was obtained from payer websites and is intended for educational purposes; users of this document are encouraged to contact payers
for the most up to date information. Items from the Current Procedural Terminology CPT® code set used in this document are copyright of the American Medical Association.11
Italicized items represent temporary measures waiving certain use requirements for telehealth during the COVID-19 public health crisis.
1 States Lead the Way in Adapting Telehealth to Meet Mental Health Needs, available at: www.mhealthintelligence.com/news/states-lead-the-way-in-adapting-telehealth-to-meet-mental-health-needs. 2 Declines may vary by practice type and size. 3 The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges, available at: www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits 4 COVID-19 may permanently alter the telehealth landscape, from reimbursement to utilization, available at: www.healthcarefinancenews.com/news/covid-19-may-permanently-alter-telehealth-landscape-reimbursement-
utilization. 5 COMAR 10.25.16.02(B)(5): Fully-insured plans are those where an employer pays a per-employee premium to a payer to assume the risk of providing health care coverage for their employees or an individual pays a
premium to an insurance carrier for health care coverage. 6 COMAR 31.11.02.02(B)(8): Self-funded plans (also known as self-insured) are those where an employer pays to provide its employees with hospital, medical, surgical, or major medical benefits on an expense-incurred
basis similar to benefits which could be provided under a group health insurance policy. 7 The law is available at: www.govinfo.gov/content/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf. 8 HIPAA Enforcement, available at: www.hhs.gov/hipaa/for-professionals/compliance-enforcement/index.html. 9 OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency, available at: www.hhs.gov/about/news/2020/03/17/ocr-
announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html 10 U.S. Department of Health and Human Services, Office for Civil Rights, FAQs on Telehealth and HIPAA during the COVID-19 Nationwide Public Health Emergency, available at:
www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf.
11 Use of this information is permitted for educational purposes under the Copyright Law of the United States (Title 17), Section 107 - Limitations on exclusive rights: Fair use.
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 2
Government Payers
Maryland Medicaid Medicare
Eligibility
Distant Provider Types
No restrictions for somatic services as long as the applicable licensing board permits use of telehealth
Licensed Physical Therapist
Individualized Education Program (IEP)/Individualized Family Service Program (IFSP)
o Licensed Speech Pathologist
o Licensed Occupational Therapist
o Qualified Service Coordinator per COMAR 10.09.40 or COMAR 10.09.52
Dentist
Behavioral Health:*
o Psychiatrists
o Psychiatric Nurse Practitioners (CRNP-PMH).
o Advanced Practice Nurses (APRN-PMH)
o LCPC, LCMFT, LCADC, LCPAT
o LCSW-C
o In Outpatient Mental Health Clinics - only under supervision - LMSW or LCSW, LGPC, LGADC LGMFT, LGPAT
o In ASAM Level 1 outpatient SUD program, State licensed providers only – CAC-AD, CSC-AD
o FQHCs who bill through the Specialty Behavioral Health System
o Licenses Psychiatric Rehabilitation Program
o Licensed Substance Use Disorder Intensive Outpatient Centers
o Substance Use Disorder Residential Treatment Program
Remote Patient Monitoring
o Physician
o Physician Assistant
o Certified Nurse Practitioner
o Home Health Agency with physician referral
See Resources: 1, 3, 6, 8, 10, 11, 12, 13
Physicians
Nurse Practitioners
Physician Assistants
Nurse Midwives
Clinical Nurse Specialists (CNS)
Certified Nurse Anesthetists
Clinical Psychologists
Clinical Social Workers
Registered Dietitians or Nutrition Professionals
Physical Therapists
Occupational Therapists
Speech Language Pathologists
See Resources: 1, 5
Locations
Originating site
o Medicaid Program Manual outlines permitted facilities (see resources)
o Patient’s home or another secure location
Distant site
o Any secure, private location
See Resources: 1, 4
Originating site
o Certain facilities in a rural area (see resources)
o Any health care facility or the patient’s home regardless of rural designation
Distant site
o Any secure, private location
See Resources: 1, 3
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 3
Maryland Medicaid Medicare
Eligibility
Types of Technology
Acceptable telehealth technology in order of priority**
Meets the formal requirements outlined in the Program Manual (see resources)
Notebook computers and smart-phones that do not fully meet the qualifications outlined in the Program Manual
Audio-only telephones
o Patient must be provided with a clear explanation of potential limitations, including confidentiality, and provide explicit consent
See Resources: 1, 5, 6, 7
For a telehealth visit, interactive, real-time audio and video telecommunications system
For a virtual check-in, system that enables secure communication (e.g., telephone, secure text message/email, video, or image)
For an E-Visit, online portal
See Resource: 3
Billing***
Originating Site Same as in-person
See Resource: 1
HCPCS Code Q3014 to bill the originating site fee
See Resource: 1
Distant Site
Audio-visual o Appropriate CPT code with“-GT” modifier
o The following with the “GT” modifier”
o Physical Therapy with“-GT” modifier: 97161-97162;97164; 97014; 97110; 97112; 97116; 97750
Individualized Education Program (IEP)/Individualized Family Service Program (IFSP): T1023-TG; T1023; T2022
IEP/IFSP Physical Therapy: 97161-97162;97164; 97110
IEP/IFSP Autism Waiver: W9322-W9324 IEP/IFSP Physical Therapy: 97161-97162;97164; 97110 IEP/IFSP Occupational Therapy: 97165-97166; 97168; 97530 IEP/IFSP Speech Therapy: 92507-92508; 92521-92524; 92523 with -52
Modifier IEP/IFSP Psychotherapy: 90791; 90832; 90834; 90847 IEP/IFSP Speech Therapy: 92507-92508; 92521-92524; 92523 with -52
modifier IEP/IFSP Nutrition Services: 97802-97803 Outpatient Substance Use Disorder Treatment: H0015 Residential Substance Use Disorder Treatment billed the same as in-
person services o Dental with Place of Service “02: D0140
Audio-only Telephone o The following with the “-UB” modifier
Somatic Services: 99211-99213 Behavioral Health: 99211-99215; 90832; 90834; 90833; 90836; 90837;
90839; 90840; 90853; H0016; H0001; H0004; H0005; H0015; H2036; H0032; H2018; S9480
Outpatient Substance Use Disorder Treatment: H0015
Telehealth Visit (real-time audio-visual)
o 99201–99215; G0425-G0427; G0406-G0408
Virtual Check-Ins (several modalities) o G2010; G2012
o Not related to a medical visit within the previous 7 days
o Does not lead to a medical visit within the next 24 hours
E-Visit (online portal) o 99431; 99422-99423; G2061-G2063
o Patient initiated
o Occurs over a maximum of 7 days
Full list of telehealth codes included on CMS website (see resources)
See Resources: 1, 2, 3
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 4
*Behavioral health providers must be enrolled in the Maryland Department of Health’s Specialty Behavioral Health Program
**May not apply to remote patient monitoring
Maryland Medicaid Medicare
Billing***
Distant Site Cont.
Residential Substance Use Disorder Treatment billed the same as in-person services
See Resources: 1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13
Cost-Sharing
Same as in-person visits
See Resources: 1
Generally applies to services rendered
For telehealth visits only, flexibility to reduce or waive cost-sharing paid by federal healthcare programs (may not apply to virtual check ins or e-visits)
See Resource: 3, 4
Prior Authorization
Same as in-person visits
Required for remote patient monitoring
See Resources: 1, 3
Check with carrier
Resources
1. Maryland Medicaid Telehealth Program Manual 2. Maryland Medicaid Telehealth Program Website 3. Remote Patient Monitoring 4. Temporary Expansion of Telehealth Services 5. Guidance for Audio-Only Health Care Services Executive Order - Somatic Care 6. Guidance for Audio-Only Health Care Services Executive Order – Behavioral Health (1) 7. Guidance for Audio-Only Health Care Services Executive Order – Behavioral Health (2) 8. Guidance for OT/PT/Speech and EPSDT 9. Temporary Expansion of Remote Patient Monitoring Services 10. Telehealth Dentistry Guidance 11. IEP/IFSP Provider Alert 12. Telephone/Telehealth Services Authorized For Intensive Outpatient SUD Programs During
the COVID-19 Outbreak 13. Telehealth Guidance for SUD Residential Treatment Services During the COVID-19
Outbreak
1. CMS Telehealth Services 2. List of Medicare Telehealth Services Payable under Physician Fee Schedule 3. Medicare Telemedicine Health Care Provider Fact Sheet 4. Medicare Telehealth 5. Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 5
Private Payers
Aetna CareFirst Cigna UnitedHealthcare
Payer Sponsored Telehealth Program (through third-party
vendor)
Teladoc®
MinuteClinic
See Resource: 1
CareFirst Video Visit
See Resource: 2
Cigna Telehealth Connection (MDLive and Amwell)
See Resources: 3, 4
Virtual Visits (Teladoc, American Well and Doctor on Demand)
See Resource: 1
Eligibility
Distant Provider Types
In-network providers
See Resource: 1
Clinicians and Associated Nurse Practitioners in:
o Primary Care
o General Practice
o Internal Medicine
o Pediatrics
o OBGYN
Behavioral Health
o Psychiatrists
o Nurse Practitioners
o Psychologists
o Licensed Certified Social Workers
o Licensed Professional Counselors
Dentists
See Resource: 1
Physician
Nurse Practitioner
Physician Assistant
Physical Therapist
Occupational Therapist
Speech Therapist
In-Network Behavioral Health Providers
See Resource: 2, 4
Physician
Nurse Practitioner
Physician Assistant
Nurse-Midwife
Clinical Nurse Specialist
Registered Dietitian or Nutrition Professional
Clinical Psychologist
Clinical Social Worker
Certified Registered Nurse Anesthetists
Physical Therapist
Occupational Therapist
Speech Therapist
Chiropractic Therapists
See Resources: 2, 3, 7, 9
Locations
Check with carrier Check with carrier Check with carrier Telehealth and Telemedicine Policy outlines permitted originating site facilities (see resources)
Patients home or other secure location is permitted as an originating site
See Resources: 2, 4
Type of Technology
Synchronous audio-visual connection in accordance with Telemedicine Policy (see resources)
Telephone only for minor acute evaluation and management services care services
See Resource: 1
Interactive audio, video, or other electronic media
Telephone only consultations
Resource: 2
Audio-visual or telephone (audio-only)
Audio-visual technology only for behavioral health
Resource: 3
For a telehealth visit, synchronous audio-visual connection
For a virtual check-in, several communication modalities, including telephone
For e-visits, online portal
Resource: 3
Originating Site Check with carrier Check with carrier Check with carrier Check with carrier
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 6
Aetna CareFirst Cigna UnitedHealthcare
Billing*
Distant Site
Audio-visual
Somatic: Same as face-to-face encounters using POS 02 and GT or 95 modifier
Behavioral Health using POS 02 and GT or 95 modifier: H0015, H2012, S9480; H0035; H2036
Partial Hospitalization Program: H0035, H2036, 97151, 97153, 97155-97157
Dental: With D9995-D9996, any oral evaluation covered under Aetna dental plans
Audio-visual or Telephone
Using POS 02 and GT or 95 modifier
o Somatic: G2010; G2012; 98966 – 98968; 99441- 99443
o Behavioral Health: 90791-90792; 90832-90834; 90836 -90840; 90845-90847; 90853; 90863; G0410; G2088; G0459; 96116; 96121; 96130-96133; 96136-96139; 96158-96139; 96158-96159; 96164-96165; 96168; 96170-96171; 96156
Services not noted will be covered according to Aetna Telemedicine policy
See Resources: 1, 2, 3
Appropriate CPT Code with the HCPCS modifier-GT or CPT modifier-95
Non‑facility payment rate Place of Service (POS) .02
With GT or 95 Modifier and POS 02: 90964; 90966; 90968; 90970
With GT Modifier and POS 02: 90965; 90967; 90969; 96160-96161; 97151; 97155-97157; 99497-99498
No modifier and POS 02: 92508; 92521-92524; 92626-92627; 92630; 92633; 96105; 96125; 97110; 97112; 97129-97130; 97153; 97161-97166; 97168; 97533; 97535; 99381-99387; 99391-99397
Telephone: 99441
Behavioral Health: 99441; 98966
Dental: Audio visual with D9995 and POS 02: D0140; D1070
See Resources: 3, 4
Audio-visual
Certain conditions deemed appropriate for telehealth**
The following with GT modifier and POS service normally billed***
o All standard face-to-face visit E/M codes
COVID-19 with GQ modifier:
o Z03.818 or Z20.828 with modifier CR or condition code DR
o B97.29 or U07.1
Telephone (audio-only)
G2012
For COVID-19 Screening: Z03.818; Z20.828
See Resources: 2, 3, 4,
Audio-visual (real-time audio-visual)
Services recognized by CMS and appended with modifiers GT or GQ
Services recognized by the American Medical Association (AMA) included in Appendix P of CPT and appended with modifier 95
Reimbursable codes are found in the Telehealth and Telemedicine Policy (see resources).
Physical Therapy: 97161-97164; 97110; 97116; 97530; 97112; 97535; 97750; 97755; 97760-97761
Occupational Therapy: 97165-97168; 97110; 97530; 97112; 97535; 97750; 97755; 97760-97761
Speech Therapy: 92507; 92521-92524; 92526; 96105; 9719-97130
Chiropractic: 99201-99205; 99211-99215; 997110; 97116; 97530; 97112; 97535; 97750; 97755; 97760-97761
Audio-visual or audio-only
99211-99215 with modifier 95 and normal place of service
Virtual Check-In (several modalities)
G2010; G2012
Not related to a medical visit within the previous 7 days
Does not lead to a medical visit within the next 24 hours
E-visit (online portal)
CPT codes 99421-99423 and HCPCS codes G2061-G2063
See Resources: 2, 5, 6, 7, 8, 9, 10
Maryland Health Care Commission | mhcc.maryland.gov | (410) 764-3460 | June 2020 7
Aetna CareFirst Cigna UnitedHealthcare
Cost-Sharing
Waived for outpatient behavioral and mental health counseling
See Resource: 1
Waived for in-network providers
See Resource: 1
Waive for virtual screening telephone consult (G2012)
See Resource: 2
Cost sharing waived for in-network medical, outpatient behavioral and PT/OT/ST services
See Resource: 4
Prior Authorization Check with carrier Check with carrier Same as in person
See Resource: 3
Check with carrier
Resources
1. COVID-19: Telemedicine FAQs 2. Billing and coding FAQs 3. Approved Behavioral Health
Telemedicine Services
1. COVID-19 Information for Providers 2. Message from CareFirst CEO 3. CareFirst Provider Manual
4. CareFirst Procedure Code/Modifier/Place of Service Instructions for Telemedicine Claims During Covid-19 Public Health Emergency
1. CIGNA COVID-19 Actions 2. Cigna Coronavirus (COVID-19) Interim
Billing Guidance for Providers 3. Cigna Telehealth Connection 4. Cigna Telehealth Connection
Presentation
1. Virtual Visits 2. Telehealth and Telemedicine Policy 3. COVID-19 Telehealth Services 4. COVID-19 Telehealth 5. Optum Provider Express COVID-19
Updates (Behavioral Health) 6. COVID-19 UnitedHealthcare Telehealth
Services: Care Provider Coding Guidelines
7. COVID-19 Physical, Occupational and Speech Therapy Telehealth
8. Telehealth Services for Physical, Occupational and Speech Therapy
9. Chiropractic Therapy 10. Telehealth Services for Chiropractors
*Maryland law12 requires payers to reimburse for services that can be appropriately delivered via telehealth in the same manner as in-person.13
**Coverage is provided on the MD Live or Amwell platforms for the following conditions (P=covered for Pediatric): Acne; Allergies; Asthma; Bronchitis; Colds and flu (P); Constipation (P only); Diarrhea; Earaches (P);
Fevers; Headaches; Infections; Insect bites; Joint aches; Nausea (P); Pinkeye (P); Rashes; Respiratory infections; Sinus infections; Skin infections; Sore throats; and Urinary tract infections.
***Billing the typical place of service in place of POS 02 ensures providers receive the same reimbursement as they typically get for a face-to-face visit.
Questions
This document was developed by Justine Springer, MHCC Program Manager
For questions, email Justine at [email protected]
12 Md Code, Insurance Art., §15–139. Available at: mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin§ion=15-139&enactments=false. 13 The law requires coverage for services he use of interactive audio, video, or other telecommunications or electronic technology by a licensed health care provider to deliver a health care service within the scope of practice of the health care provider at a site other than the site at which the patient is located. Payers can decide not to provide coverage he decision is based on a finding that telemedicine is not medically necessary, appropriate, or efficient. More information available at: mgaleg.maryland.gov/mgawebsite/laws/StatuteText?article=gin§ion=15-139&enactments=false.
