new telehealth regulations › › resource › resmgr › covid... · 2020-04-03 · our speakers...

Confidential—For Use By Authorized Parties Only. Do Not Distribute.

New Telehealth Regulations and their impact on Orthopedic Practices

Confidential—For Use By Authorized Parties Only. Do Not Distribute.2

Our Speakers

Chris EmperPresidentEmper Healthcare Advisors, LLC

Molly Van Oordt Specialty Director Musculoskeletal

Cheryl LejbolleVice PresidentPatient Engagement Solutions


100,000+Providers

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Agenda

Telehealth Defined

The State of the Union: Yesterday, Today & Tomorrow

Medicare expands Telehealth benefits

What it means for Ortho


Telehealth Defined

Telehealth is a broad term that encompasses a handful of different ways patients can communicate with their providers without being in person.


Established Patient & Condition

New or Established Patient/New condition Provider to Provider

Virtual visit scheduled Scheduled or Urgent Care visit Tele-specialty consultation

• Patient scheduling• Copay

• Marketing• Triage• Insurance eligibility, billing

and payments

• Collect and share diagnostic information

Place the patient in a virtual waiting room and see patient Patient with provider

EHR documentation, prescribing and billing

Virtual Visits– a widely used modality of telehealthReal-time (synchronous), two-way audio-video communication between a patient and a provider

Live Video Visit


Who offers or plans to offer virtual visits?

• Offers

• Plans to offer

• No plans to offer


The State of the UnionYesterday, Today and Tomorrow

TODAY

TOMORROWYESTERDAY


The Need for Virtual Visits has Drastically Changed


New Virtual Visits DriversPreviously Virtual Healthcare was:• Driven by convenience and choice

• MRI/Test Follow-up• Injection Follow-up• Post-op Visits

Now Virtual Healthcare is:• Driven by convenience, choice, access & safety• Helping practices stay operational

• Full range of office visit use cases• New patients via telehealth


Phase 2: Integrated ImplementationPhase 1: Non-Integrated Deployment

JOIN VISIT

Schedule a Virtual Visit in your EHR/PM

Appointment flows into Platform

Patient joins Virtual Visit via secure link in their email

Conduct HIPAA compliant Virtual Visit

Provider sees status change in EHR and joins patient in Virtual Visit room by

logging on to Platform

Billing & documentation remains in your EHR/PM

JOIN VISIT

Schedule a Virtual Visit in Platform

We highly recommend scheduling in your EHR/PM

Patient joins Virtual Visit via secure link in their email

Conduct HIPAA compliant Virtual Visit

Billing & documentation remains in your EHR/PM

Provider joins patient in Virtual Visit by logging on to Platform

Practice must check-in patient and start the encounter in PM/EHR

Providers are willing to adapt to meet the demandTrading ideal workflow for rapid deployment of virtual care


Payers take action to support telehealth during crisisMedicare, Medicaid, commercial payers and states remove policy barriers

Changes include:• Recommending using telehealth when

possible to help prevent the spread of a virus• Allowing the originating site to be the patients

home and waiving cost sharing for telehealth visits, including visits for mental health care

Problems that may arise:• Continuously evolving• Not consistent by payer• Not necessarily permanent


New Medicare Telehealth Regulations -COVID-19 Emergency


Background: Medicare “Telehealth Services” prior to the COVID-19 Emergency

Medicare Part B (Physician Fee Schedule) has the following requirements for covered telehealth services:

1. Patient geography: patient is in a qualifying rural area

2. Patient physical location: patient is at a qualifying healthcare facility (“originating site”)

3. Provider: service is provided by one of ten eligible professionals (“distant site practitioner”)

4. Technology: is real-time audio & video (interactive audio and video telecommunications system that permits real-time communication between the beneficiary & distant site provider)

5. Service: is among the list of CPT/HCPCS codes covered by Medicare

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1) Geographic Location of the Patient

• Originating site (where the patient is) must be in either:

- a rural Health Professional Shortage Area (HPSA) in a rural census tract; or

- a county outside of a Metropolitan Statistical Area (MSA)

• U.S. Health Resources and Services Administration (HRSA) makes geographic designations

• Location analyzer

https://data.hrsa.gov/tools/medicare/telehealth

https://data.hrsa.gov/tools/medicare/telehealth


2) Physical Location of the Patient

- Physician office

- Hospital

- Critical Access Hospital

- Rural Health Clinic

- Federally Qualified Health Center

- Hospital-based Dialysis Center

- Skilled Nursing Facility

- Community Mental Health Center

- Homes of beneficiaries with ESRD receiving home dialysis

- Mobile Stroke Unit

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Approved list of “originating sites” where a patient can be located when the service is delivered:


3) Eligible Providers (“Distant Site Practitioners”)

• Physicians

• Nurse practitioners

• Physician assistants

• Nurse-midwives

• Clinical nurse specialists

• Certified registered nurse anesthetists

• Clinical psychologists

• Clinical social workers

• Registered dietitians or nutrition professionals

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4) Technology

• Must be “synchronous.”Communication must be live interactive audio and video connection that allows for “real time” communication.

• No coverage for “asynchronous” or “store and forward” technology.

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5) Covered Service

Code Short Descriptor90785 Psytx complex interactive90791 Psych diagnostic evaluation90792 Psych diag eval w/med srvcs90832 Psytx pt&/family 30 minutes90833 Psytx pt&/fam w/e&m 30 min90834 Psytx pt&/family 45 minutes90836 Psytx pt&/fam w/e&m 45 min90837 Psytx pt&/family 60 minutes90838 Psytx pt&/fam w/e&m 60 min90839 Psytx crisis initial 60 min90840 Psytx crisis ea addl 30 min90845 Psychoanalysis90846 Family psytx w/o patient90847 Family psytx w/patient90951 Esrd serv 4 visits p mo <2yr90952 Esrd serv 2-3 vsts p mo <2yr90954 Esrd serv 4 vsts p mo 2-1190955 Esrd srv 2-3 vsts p mo 2-1190957 Esrd srv 4 vsts p mo 12-1990958 Esrd srv 2-3 vsts p mo 12-1990960 Esrd srv 4 visits p mo 20+90961 Esrd srv 2-3 vsts p mo 20+90963 Esrd home pt serv p mo <2yrs90964 Esrd home pt serv p mo 2-1190965 Esrd home pt serv p mo 12-1990966 Esrd home pt serv p mo 20+90967 Esrd home pt serv p day <2

90968 Esrd home pt serv p day 2-1190969 Esrd home pt serv p day 12-1990970 Esrd home pt serv p day 20+96116 Neurobehavioral status exam96150 Assess hlth/behave init96151 Assess hlth/behave subseq96152 Intervene hlth/behave indiv96153 Intervene hlth/behave group96154 Interv hlth/behav fam w/pt96160 Pt-focused hlth risk assmt96161 Caregiver health risk assmt97802 Medical nutrition indiv in97803 Med nutrition indiv subseq97804 Medical nutrition group99201 Office/outpatient visit new99202 Office/outpatient visit new99203 Office/outpatient visit new99204 Office/outpatient visit new99205 Office/outpatient visit new99211 Office/outpatient visit est99212 Office/outpatient visit est99213 Office/outpatient visit est99214 Office/outpatient visit est99215 Office/outpatient visit est99231 Subsequent hospital care99232 Subsequent hospital care99233 Subsequent hospital care99307 Nursing fac care subseq99308 Nursing fac care subseq

G0443 Brief alcohol misuse counselG0444 Depression screen annualG0445 High inten beh couns std 30mG0446 Intens behave ther cardio dxG0447 Behavior counsel obesity 15mG0459 Telehealth inpt pharm mgmt

99309 Nursing fac care subseq99310 Nursing fac care subseq99354 Prolonged service office99355 Prolonged service office99356 Prolonged service inpatient99357 Prolonged service inpatient99406 Behav chng smoking 3-10 min99407 Behav chng smoking > 10 min99495 Trans care mgmt 14 day disch99496 Trans care mgmt 7 day disch99497 Advncd care plan 30 min99498 Advncd are plan addl 30 minG0108 Diab manage trn per indivG0109 Diab manage trn ind/groupG0270 Mnt subs tx for change dxG0296 Visit to determ ldct eligG0396 Alcohol/subs interv 15-30mnG0397 Alcohol/subs interv >30 minG0406 Inpt/tele follow up 15G0407 Inpt/tele follow up 25G0408 Inpt/tele follow up 35G0420 Ed svc ckd ind per sessionG0421 Ed svc ckd grp per session

Documentation, Billing & Payment Medicare telehealth services are billed as if the service had

been furnished in-person, but the claim should reflect the designated Place of Service (POS) code 02-Telehealth.

Medicare pays the same amount for telehealth services as it would if the service were furnished in person, but for services that have different rates in the office vs the facility, Medicare uses the lower facility payment rate for telehealth.

Originating sites are eligible for a facility fee & must submit a separate claim.

Documentation requirements for a telehealth service are the same as for a face-to-face encounter for the particular code.

List of Medicare Telehealth Services CY 2020Payable under PFS when furnished via telehealth

G0425 Inpt/ed teleconsult30G0426 Inpt/ed teleconsult50G0427 Inpt/ed teleconsult70G0436 Tobacco-use counsel 3-10 minG0437 Tobacco-use counsel>10minG0438 Ppps, initial visit

G0439 Ppps, subseq visitG0442 Annual alcohol screen 15 min

G0506 Comp asses care plan ccm svcG0508 Crit care telehea consult 60G0509 Crit care telehea consult 50G0513 Prolong prev svcs, first 30mG0514 Prolong prev svcs, addl 30mG2086 Off base opioid tx first mG2087 Off base opioid tx, sub mG2088 Off opioid tx month add 30


Background: Medicare “Telehealth Services” prior to the COVID-19 Emergency


1. Patient geography: patient is in a qualifying rural area

2. Patient physical location: patient is at a qualifying healthcare facility (“originating site”)

3. Provider : service is provided by one of ten eligible professionals (“distant site practitioner”)


5. Service: is among the list of CPT/HCPCS codes covered by Medicare

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Medicare telehealth service = live video visit (4) for an approved service (5) delivered by an approved provider (3) for a patient in a rural geographic area (1) when the patient is physically present at a healthcare facility (2).


Federal Legislative Response to COVID-19Phase 1: Completed (signed into law on March 6)

• $8.3 billion package funds vaccine development, provides money to state and local governments to assist with prevention efforts, includes health policy changes.

Phase 2: Completed (signed into law on March 18)

• $100 billion package that expands unemployment insurance, paid sick leave, and mandates testing for the virus to be free for recipients.

Phase 3: Completed (signed into law on March 27)

• $2.2 trillion package includes regulatory relief and economic aid for individuals, families, businesses, and the healthcare sector.

Phase 4 and beyond: TBD

Regulatory Changes

• Federal & state government agencies have issued major new regulatory changes at a rapid pace.

• Changes include a mix or regulatory relief from current programs/regulations and an expansion of emergency assistance/programs.

• Major HHS and CMS federal regulatory changes have been announced multiple times per week each of the past few weeks.


Medicare telehealth regulatory changes for COVID-19

Timeline• March 6: Coronavirus Preparedness and Response

Supplemental Appropriations Act is signed into law and it allows certain telehealth rules to be waived during a National Emergency.

• March 13: President Trump announced an emergency declaration under the Stafford Act and the National Emergencies Act.

• March 17: consistent with the March 6 law & President Trump’s emergency declaration, CMS expands Medicare’s telehealth benefits under 1135 waiver authority.

• March 30: CMS announces additional regulatory actions to promote telehealth in a 221-page regulation.


CMS: Medicare Telehealth FAQs - March 17, 2020

Q: What payment requirements for Medicare telehealth services are affected by the waiver?

A: Under the waiver, limitations on where Medicare patients are eligible for telehealth will be removed during the emergency. In particular, patients outside of rural areas, and patients in their homes will be eligible for telehealth services, effective for services starting March 6, 2020.

Q: Would physicians and other Qualified Providers be able to furnish Medicare telehealth services to beneficiaries in their homes?

A: Yes. The waiver temporarily eliminates the requirement that the originating site must be a physician’s office or other authorized healthcare facility and allows Medicare to pay for telehealth services when beneficiaries are in their homes or any setting of care.


Q: Is any specialized equipment needed to furnish Medicare telehealth services under the new law?

A: Currently, CMS allows for use of telecommunications technology that have audio and video capabilities that are used for two-way, real-time interactive communication. For example, to the extent that many mobile computing devices have audio and video capabilities that may be used for two-way, real-time interactive communication they qualify as acceptable technology.

The new waiver in Section 1135(b) of the Social Security Act explicitly allows the Secretary to authorize use of telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the COVID-19 PHE. In addition, effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.

Q: Are there beneficiary out of pocket costs for telehealth services?

A: The use of telehealth does not change the out of pocket costs for beneficiaries with Original Medicare. Beneficiaries are generally liable for their deductible and coinsurance; however, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Q: Can qualified providers let their patients know that Medicare covers telehealth?

A: Yes. Qualified providers should inform their patients that services are available via telehealth.



Q: Are the telehealth services only limited to services related to patients with COVID-19?

A: No. The statutory provision broadens telehealth flexibility without regard to the diagnosis of the patient. This is a critical point given the importance of social distancing and other strategies recommended to reduce the risk of COVID-19 transmission, since it will prevent vulnerable beneficiaries from unnecessarily entering a health care facility when their needs can be met remotely. For example, a beneficiary could use this to visit with their doctor before receiving another prescription refill. However, Medicare telehealth services, like all Medicare services, must be reasonable and necessary under section 1862(a) of the Act.

Q: What flexibilities are available in the Medicaid program to provide care via telehealth for individuals who are quarantined or self-isolated to limit risk of exposure?

A: States have broad flexibility to cover telehealth through Medicaid. No federal approval is needed for state Medicaid programs to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services. A state plan amendment would be necessary to accommodate any revisions to payment methodologies to account for telehealth costs.



• Removes frequency limitations for all Medicare telehealth visits- Subsequent inpatient telehealth visits previously limited to once every three days (CPT codes 99231-99233)

- Subsequent skilled nursing facility telehealth visits previously limited to once every 30 days (CPT codes 99307-99310)

- Critical care consult telehealth codes previously limited to once per day (CPT codes G0508-G0509)

• Allows 1-5 level code selection for E/M outpatient/office telehealth visits using time or MDM- Certain E/M documentation policies set for implementation in 2021 effective immediately for outpatient office E/M telehealth visits

- Removes any requirements regarding documentation of history and/or physical exam

- Time = total time personally spent by the reporting practitioner on the day of the visit (including face-to-face & non-face-to-face time)

• Changes place of service (POS) coding for telehealth to pay same as in-person visit rates- Typically, CMS requires claims for telehealth services to include POS code 02 for telehealth services, which means the provider is paid at the lower facility rate (vs non-facility

rate) with the originating site where the patient is located receiving a facility fee

- Change allows use of CPT telehealth modifier 95, to allow providers who bill for Medicare telehealth services to report the POS code that would have been used if the patient had been seen face-to-face, allowing for higher telehealth payment at the level of what would have been an office visit (non-facility rate)

• Adds more services to the list of Medicare telehealth services- Adds 80+ services to the list of Medicare telehealth services for the COVID-19 public health emergency period

CMS: new regulatory policies released on March 30 that are effective during the COVID-19 emergency


• Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)

• Initial and Subsequent Observation and Observation Discharge Day Management (CPT codes 99217- 99220; CPT codes 99224- 99226; CPT codes 99234- 99236)

• Initial hospital care and hospital discharge day management (CPT codes 99221-99223; CPT codes 99238- 99239)

• Initial nursing facility visits, All levels (Low, Moderate, and High Complexity) and nursing facility discharge day management (CPT codes 99304-99306; CPT codes 99315-99316)

• Critical Care Services (CPT codes 99291-99292)

• Domiciliary, Rest Home, or Custodial Care services, New and Established patients (CPT codes 99327- 99328; CPT codes 99334-99337)

• Home Visits, New and Established Patient, All levels (CPT codes 99341-99345; CPT codes 99347- 99350)

• Inpatient Neonatal and Pediatric Critical Care, Initial and Subsequent (CPT codes 99468- 99473; CPT codes 99475- 99476)

• Initial and Continuing Intensive Care Services (CPT code 99477- 994780)

• Care Planning for Patients with Cognitive Impairment (CPT code 99483)

• Psychological and Neuropsychological Testing (CPT codes 96130- 96133; CPT codes 96136- 96139)

• Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507)

• Radiation Treatment Management Services (CPT codes 77427)

• Licensed clinical social worker services, clinical psychologist services, physical therapy services, occupational therapist services, and speech language pathology services can be paid for as Medicare telehealth services.

List of additional services covered as Medicare Telehealth Services during COVID-19 Emergency

CMS: new regulatory policies released on March 30 that are effective during the COVID-19 emergency


Summary: Medicare “Telehealth Services” during the COVID-19 Emergency


1. Patient geography: patient is in a qualifying rural area can be located anywhere geographically

2. Patient physical location: patient is at a qualifying healthcare facility (“originating site”) can be located anywhere physically, including at home

3. Provider : service is provided by one of ten eligible professionals (“distant site practitioner”)


5. Service: is among the list of CPT/HCPCS codes covered by Medicare, including 80+ new services

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Patient co-payment requirements have been waived

Billing & payment requirements have been changed to pay the same as for in-person visits


Beyond Medicare “Telehealth Services” (Video Visits) -Medicare “Technology-Based Services”

• Virtual patient check-ins*• $15 for 5-10 minute medical discussion initiated by an established patient (G2012)

• Remote evaluation of video and/or pictures*• $13 for remote evaluation of recorded video and/or images submitted by a new or

established patient including interpretation with verbal follow-up with patient (G2010)

• Interprofessional Consultations - Time-based consultations between two providers (99446-99449, 99451, 99452)

• Care Management Services (CCM, TCM, PCM)

• Remote Patient Monitoring (RPM)

These “technology-based” service codes are: Innately non-face-to-face

Do NOT include geographic & site restrictions

Commonly referred to as “telehealth”, but do not meet the CMS definition

*Can be provided to new or established patients during the emergency

*Patient consent can be documented by auxiliary staff under general supervision during the emergency

*Cannot stem from or lead to an E/M visit (during & not during emergency)

For the emergency, CMS will also reimburse for Telephone Evaluation and Management (E/M) Services (CPT codes 98966-98968; 99441-99443)


Telehealth – Other Payers

• Medicare Advantage: varies by MA plan, but plans have the flexibility to have more expansive telehealth policies related to types of services covered by Medicare.

• Medicaid: varies by state, but states have flexibility to institute their own telehealth policies; several states have issued new policies in the past few weeks & 40 states have received federal section 1135 waivers from CMS.

• Commercial Payers: varies by payer, but several commercial payers have announced new telehealth policies in the past few weeks.

Confidential—For Use By Authorized Employees Only. Do Not Distribute. 31

What does it mean for ORTHO?


Asking the Right Questions about Telehealth • Will services provided by physical therapists (and PTAs working under the

direction and supervision of the PT) be covered when provided via telehealth?• If so, what codes should be billed and what modifiers are required?• What device(s) or application(s) can be utilized?• What, if any, consents are required?• Are there any special documentation requirements?


ORTHOPEDIC USE CASES FOR TELEHEALTH


Orthopedic Use Cases for Telehealth

Post-op follow ups

After-hours care

MRI/CT & Lab reviews

Wound checks

*New Patients – E&M

*Document as if servicewas performed in person


• Screen share• Pass documents

• Messaging

In-Visit Features

• After-hours call transition• Integrated into EHR/PM

On-Demand Integrated Visits

• Key for FQHCs• Medicare originating sites*• Mobile health services• In-home care

Hub and Spoke Functionality

• Verify insurance information• Intake reviews

• Schedule follow-up appointments

Clinical Administrator Workflow

• Patient email + text• Control frequency of outreach and

reminders• Campaign-driven outreach

Customizable Patient Communication

• Collect patient payment• Integrated with common payment

processors

Payment Flow

Product Features


Keys to Success

Choose your team

Identify use cases and goals

Identify your starting users

Thoughtful workflow review


Consumers will continue to drive the industrynow more than ever, patients will choose providers who offer virtual visit capabilities

Providers will want to continue to meet the demand of their patientsproviders will want to continue to see their own patients virtually, get paid for it, and will want video visits to integrate with their practice management workflow and the electronic health record (EHR).

What hasn’t changed?


Contact Molly at:[email protected]

NextGen Resources


QUESTIONS?


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new telehealth regulations › › resource › resmgr › covid... · 2020-04-03 · our speakers...

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