Category: Telemedicine

CMS Proposes Expansion to Telehealth Reimbursement

CMS recently released its proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program, containing several amendments meant to expand telehealth and remote patient monitoring. These proposed changes signal that CMS is recognizing that telemedicine (including remote patient monitoring) is going to play a role in the future of health care.

With regards to remote patient monitoring, CMS has introduced three new codes (CPT 999X0, 999X1, and 994X9). Currently, remote patient monitoring is billed under 99091 “Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (where applicable) requiring a minimum of 30 minutes of time.” The current code is restrictive as it requires at least 30 minutes of time, and the services must be provided by a physician and/or qualified health care professional. The new codes reduce the timeframe to 20 minutes per calendar month, allow for clinical staff to provide the services, and also allows for reimbursement for work incident to providing services such as setting up the patient’s remote monitoring account, educating the patient on the application, and onboarding the patient into the system.

The fee schedule also introduced the concept of the virtual check-in (CPT GVC11), which is a brief face-to-face visit with a patient through a technology platform, allowing the provider to assess whether the patient requires an office visit. The virtual check in has some restrictions such as a limited timeframe of 5 to 10 minutes of evaluation and management; the patient must be an established patient; and the services cannot originate from a related e/m service provided within the past 7 days or cannot relate to services that are to be provided (in person) within the next 24 hours or at the soonest available appointment. If the virtual check-in is related to either a visit within the past 7 days or a future appointment, such services must be bundled with those in-person services.

Similarly, CMS expanded the fee schedule to include photo and video evaluations (CPT GRAS1). Unlike the previous edition, this new service will allow providers to bill for the review of previously recorded videos or images. The same restrictions apply regarding bundling. Further, if the photo and video evaluation leads to an in-person evaluation, such services must be bundled together and not separately billed.

The proposed codes for virtual check-ins and photo/video evaluations is a step in the direction from the rigidity of in-person health care to a more flexible style of providing health care to patients. Under the proposed rules, patients no longer have to make an appointment or visit an emergency department or urgent care center to have a simple question answered by a provider. Aside from the convenience provided to the patient, this change in the delivery of health care can also alleviate the problem of overcrowding in emergency departments and the inability to quickly obtain an appointment with a physician. The patient also is more likely to seek medical attention early before his or her condition worsens if the patient believes that he or she can obtain quick and efficient advice. Further, the interaction will be cheaper for the patient.

CMS also proposes to expand covered preventative services in office and outpatient settings, services that are reimbursable under the current fee schedule, to include codes for situations where the direct patient contact is prolonged. CPT code G0513 can be used for the first 30 minutes of the prolonged in-person visit while G0514 can be used for each additional 30minute period until the visit concludes.

Although many of the proposed changes appear to be small, the changes made under the fee schedule signal that CMS understands that telemedicine is an important tool that can be used to provide quality and timely health care to people not only in rural areas but throughout the country. It also signals that CMS understands the role that telemedicine will play in population health.

Has CMS been overpaying for Telehealth Services?

The Office of the Inspector General (“OIG”) of the Department of Health and Human Services (“HHS”) recently completed a review of Medicare payment for telehealth services. From 2001 to 2015, the Medicare reimbursement for telehealth services increased from $61,302 to $17.6 million. A study performed by the Medicare Payment Advisory Commission in 2009 determined that the professional fee (the fee paid to the practitioner performing the services at a distant site) without a corresponding originating site fee (the fee paid to the facility where the patient receives the services) was more likely to be associated with unallowable telehealth payments than those professional fees with a corresponding originating site fee. Further, an OIG audit of 2014 and 2015 claims discovered that more than half of the professional fees did not have a corresponding originating site fee. Due to these discrepancies, the OIG did a deep dive on telehealth payments for professional fees without a corresponding originating site fee to determine whether the Centers for Medicare and Medicaid Services (“CMS”) were paying practitioners for telehealth services that did not meet the telehealth Medicare requirements as set forth in the statutes and regulations.

The OIG’s review consisted of 191,118 Medicare paid distant-site telehealth claims without corresponding originating site claims. Of those claims, 100 were extracted for further review. The OIG obtained data and supporting documentation of the 100 claims to determine if the payments were in accordance with the Medicare telehealth reimbursement requirements. The OIG found that 69 of the 100 claims were substantiated. The remaining 31 claims had one or more deficiency.

The largest deficiency that the OIG discovered was that the patient received telehealth services at non-rural originating sites. Of the 31 claims that the OIG found to be deficient, 24 were unallowable because the patient received telehealth services at a non-rural originating site. 42 CFR 410.78(b)(4) sets forth the requirements of an originating site, including that the site be (i) located in a health professional shortage area (“HPSA”) that is outside of a metropolitan statistical area (“MSA”) as of December 31 of the preceding calendar year or within a rural census tract of an MSA as of December 31 of the preceding calendar year or (ii) located in a county that is not included in a MSA as of December 31 of the preceding calendar year.

Additionally, 7 claims were billed by ineligible institutional providers. Distant site practitioners may bill telehealth services to Medicare if an exception is met. The two exceptions are (i) the facility is a critical access hospital (“CAH”) that elected the method II payment option an the practitioner reassigned his or her benefits to the CAH or (ii) the facility provided medical nutrition therapy (MNT) services. For these seven claims, neither exception was met and therefore the auditor believed that the claim should not have been paid.

A smaller number, 3 claims, arguably should have been denied because the patient received services at an unauthorized originating site. An originating site, as set forth in 42 CFR 410.78(b)(3) must be either a practitioner officer, hospital, CAH, rural health clinic, FQHC, hospital based or CAH based renal dialysis center, skilled nursing facility, or community mental health center. Two of the claims originated at the patient’s residence while the third originated at a private renal dialysis center, which is not classified as an originated site according to the regulations.

The regulations also require that, in order for a telehealth service to receive Medicare reimbursement, the telehealth service must have been provided using an interactive (i.e., voice and video) telecommunication system. Store and forward technology is only allowed in certain circumstances, including for the use in federal telemedicine demonstration projects in Alaska and Hawaii. For two claims, store and forward technology was used but no exception was met. Lastly, one unallowed claim was for a non-covered service and one un-allowed claim was for services provided by a physician located outside of the United States. All services that are allowable are set forth on the CMS website.

Along with the findings of claims that were not allowed, the OIG’s audit revealed that the deficiencies occurred because CMS did not ensure that there was oversight to deny payments for errors where telehealth claim edits could not be implemented (i.e., CMS form does not have a field to identify geographic location), all Medicare Administrative Contractor (“MAC”) claim edits were implemented, and practitioners were not properly educated on Medicare telehealth requirements. The OIG report concluded by recommending that CMS take the following three steps: conduct periodic post-payment reviews to disallow payments for errors for which telehealth claim edits cannot be implemented; work with Medicare contractors to implement all telehealth claim edits listed in the Medicare Claims Processing Manual; and offer education and training sessions to practitioners on Medicare telehealth requirements and related resources.

Due to the large number of claims that the OIG found to be unallowable, it is probable that the OIG will continue to monitor telehealth billing and continue to audit telehealth billing practices. If the error rate does not decline, the future of telehealth could become even more heavily regulated with more oversight and stricter regulations around the services that qualify for reimbursement and the procedures for requesting such reimbursement.

How Telemedicine May Change the Landscape of Health Care In New Jersey

Technological advances such as EMR, remote patient monitoring, and the use of tablet based patient registration have revolutionized the health care industry. Today, a patient can use an app on their phone to schedule an appointment, obtain their medical records, and locate physicians in the area. It is no surprise that over the past five years, telemedicine has become a popular form of treatment for physicians and patients. New Jersey recently unanimously passed legislation that establishes the requirements for the practice of telemedicine in the state of New Jersey. The passage of this legislation signals the importance of telemedicine to the state of New Jersey and the health care field.

The New Jersey bill defines key terms as follows: “health care provider” as an individual who provides a health care service to a patient, which includes, but is not limited to, a licensed physician, nurse, nurse practitioner, psychologist, psychiatrist, psychoanalyst, clinical social worker, physician assistant, professional counselor, respiratory therapist, speech pathologist, audiologist, optometrist, or any other health care professional acting within the scope of a valid license or certification issued pursuant to Title 45 of the New Jersey Statutes; and “Telemedicine” as the delivery of a health care service using electronic communications, information technology, or other electronic or technological means to bridge the gap between a health care provider who is located at a distant site and a patient who is located at an originating site. The term telemedicine, as explained in the bill, does not include “the use, in isolation, of audio-only telephone conversation, electronic mail, instant messaging, phone text, or facsimile transmission.”

The New Jersey legislation sets standards that those providing telemedicine services must follow. Prior to engaging in telemedicine, a provider-patient relationship must be established. The provider must (i) properly identify the patient using, at a minimum, the patient’s name, date of birth, phone number, and address; (ii) disclose and validate the provider’s identity and credentials, such as the provider’s license, title, and, if applicable, specialty and board certifications; (iii) review the patient’s medical history and any available medical records before initiating the telemedicine consult; and (iv) determine whether or not he/she will be able to meet the same standard of care as if the services were provided in person. When necessary, the provider also must refer the patient to appropriate follow up care, including making appropriate referrals for emergency care, if needed.

The newly passed law allows telemedicine to be covered under New Jersey Medicaid and commercial health insurance plans. As currently written, the law does not go as far as to require that the reimbursement rates for telemedicine be equal to the reimbursement rates that would be paid if the service was provided in-person. The language of the bill reads, “The State Medicaid and NJ FamilyCare programs shall provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey.” The language for commercial plans reads the same regarding parity of payments for telemedicine. As expected, the law sets the in-person reimbursement rate as the maximum reimbursement for telemedicine services. The law allows reimbursement to be paid to either the provider or the facility/organization with whom the provider is associated with, depending on the appropriate billing practices.

The emergence and acceptance of telemedicine as a viable option in the health care setting is extremely beneficial to patients who find themselves within the service area of a community hospital. Many community hospitals do not offer the array of service lines that large facilities offer. In situations where time is of the essence, telemedicine saves lives. One example of telemedicine at work in the community hospital setting is with pediatrics. Prior to telemedicine, when a child was brought into an emergency department without pediatric capabilities, the hospital and the patient’s family was faced with quickly transporting the patient to a facility with pediatric capabilities. Often, had the hospital had the ability to diagnose the patient, the transport would not have had to occur. Telemedicine allows the hospital to connect with a pediatric physician at another facility for a quick and accurate diagnosis. It must be noted that once a diagnosis is made, the patient may still require transportation, but the transportation is now only made in situations where it is medically necessary. For other situations, a physician, via telemedicine, can diagnose and prescribe treatment options that can be carried out in the community hospital or through prescription medicines, eliminating the stress and cost of transportation for the patient and the patient’s family.

Teleneurology, another important use of telemedicine, makes prompt neurological care available to patients in even the most remote locations—an important consideration since, with the treatment of stroke symptoms, every second counts. Teleneurology allows a patient, presenting to a hospital without a neurologist on-site, to have his or her symptoms observed by a physician via tele-conference for diagnosis purposes. The diagnosing physician can observe and converse with the patient and obtain close images of the patient’s eyes to determine if the patient is expecting or has experienced a stroke. Ischemic strokes, which are most commonly treated by giving the patient an injection of tissue plasminogen activator (“tPA”). tPA is used to dissolve the blood clot to improve blood flow to the part of the brain being deprived of blood. tPA, while highly effective, must be administered within three hours of the patient experiencing a stroke. Subtracting the time that it takes for a patient to arrive at a hospital for treatment, the patient may now have less than two hours to be given lifesaving medication. Given this shorter timeframe, it is essential for a hospital to quickly and accurately diagnose stroke symptoms. The use of teleneurology gives the patient the best possible chance of receiving a quick diagnosis and obtaining tPA within the three hour timeframe.

Telemedicine can also be utilized in hospitals to facilitate patient discharge. Often, a patient is ready to be discharged, but continues to wait at the hospital until his or her physician can physically discharge the patient from the hospital. For physicians with robust offsite practices, this step may not be immediate. A patient waiting to be discharged can cause patient flow and capacity issues for the hospital and can cause frustration for the patient and their family, ultimately leading to low patient satisfaction scores for the hospital. Allowing a physician to evaluate the patient via telemedicine would alleviate some of these issues. The physician could have a face to face discussion with the patient, asking the necessary questions prior to discharge, while not having to leave his or her office.

As technology advances and health care becomes more reliant on technology, the uses of telemedicine will continue to grow. Telemedicine will become engrained in the culture of providing top level care to patients, regardless of geographical location. Providers seeking to utilize this technology to implement this new means of delivering medical services must be sensitive to the current laws regulating this area and the fact that this area is continually evolving and developing, especially in New Jersey where the law is brand new.

A Light at the End of the Telemedicine Tunnel Appears (on the New Jersey Side)

Upon recently reviewing the healthcare coverage benefits under a particular health plan, I was almost giddy to note that telemedicine services (both medical and mental health) were covered and reimbursable at the same rate as traditional in-person services. While some carriers have come to appreciate this form of health care service delivery, standards for licensure, practice, reimbursement, and prescription of medication have to date been unregulated and thus unclear in New Jersey.

Nevertheless, New Jersey lawmakers are working hard toward enacting legislation that would provide clarity by regulating the practice of telemedicine. The Senate Health and Human Services Committee and the Senate Appropriations Committee unanimously recommended the passage of Bill No. S291, while testimony was recently taken by the Assembly Health and Senior Services Committee on an identical Bill No. A1464.

What is Telemedicine?

The bill’s definition of “telemedicine” is quite technical and I would refer you to the bill for that technical definition. In sum, telemedicine is the delivery of a health care service using electronic means or technology to remotely bring together a health care practitioner (e.g., a physician, nurse practitioner, psychologist, and psychiatrist) with a patient typically via two-way videoconferencing or store-and-forward technology. (Store-and-forward technology is the transmission of medical data from a patient’s location to a distant site practitioner for later assessment.) This form of communication is meant to replicate the in-person encounter experience; thus, real-time visual and auditory communication is a must. Telemedicine is not a simple phone call, email, instant message, text, or fax.

Standard of Care

Another important issue, particularly if a health care practitioner is located out-of-state, is which state’s standard of care would apply? One view has been to look to the standard of care where the patient is located. The proposed bill confirms, for New Jersey, a health care practitioner is subject to the same standard of care as he/she would be subject to if the patient encounter was physically located within New Jersey. This would apply to recordkeeping rules as well as maintenance of patient confidentiality.

Added Responsibility of Hospitals

Where a health care practitioner wishes to engage in telemedicine with patients in a hospital, the hospital’s governing body must first verify and approve the credentials of, and grant telemedicine practice privileges to, the practitioner based solely upon the recommendations of the medical staff. The medical staff recommendation is based on information provided by the originating site employer (i.e., employer of health care practitioner at location where service rendered).

Licensing

License portability is an added challenge. Most states that permit telemedicine require that a health care practitioner be licensed in the state where the patient is located. This makes sense given the state’s responsibility to protect its residents. Pursuant to the telemedicine bill, the process to obtain a New Jersey license by an out-of-state practitioner wishing to practice here will be easier or harder depending on the laws of the practitioner’s home state. If the following criteria are met, the appropriate licensing board will be required to grant a reciprocal license to an out-of-state health care practitioner: (1) the other state has substantially equivalent requirements for licensure, registration, or certification; (2) the applicant has practiced in the profession within the five-year period preceding application; (3) the respective New Jersey State board receives documentation showing that the applicant’s out-of-state license is in good standing, and that the applicant has no conviction for a disqualifying offense; and (4) an agent in New Jersey is designated for service of process if the non-resident application does not have an office here. Further, the bill proposes clarifying State Board regulations that provide only for discretionary reciprocal license: the discretion is limited to permit a reciprocal license where not all of the criteria above are met; if they are all satisfied, a license must be granted.

Face-to-face Encounter for Online Prescribing

Federal law makes if generally illegal to prescribe a controlled dangerous substance based solely on an online questionnaire completed by a patient. The question with online prescription of medication is always whether a health care practitioner (who is authorized to prescribe medication) must have an in-person encounter with a patient before prescribing medication to that patient via telemedicine. The bill permits a physician to prescribe, dispense or administer medication to a New Jersey patient if (1) the physician first performs a face-to-face examination of the patient (which examination may occur in-person or via telemedicine and must comply with the standard of care) and (2) the physician adheres to particular laws that apply to that medication. 

Reimbursement

Last, but certainly not least, there is the issue of reimbursement. Even though state regulators currently may permit various providers to engage in telemedicine, the issue of reimbursement remains. The bill would generally prohibit New Jersey Medicaid and New Jersey FamilyCare programs and private health benefit plans from requiring in-person encounters between a health care practitioner and patient, or establishing location restrictions, as a condition of reimbursement under the pertinent program. Further, parity is required for benefits covered and reimbursement rates whether the encounter is in-person or via telemedicine. A drawback to the reimbursement parity, cited by insurance plans, is that it will prevent the use of telemedicine as a cost-savings tool. Of course, the use of telemedicine in the particular situation would have to make sense (and not be contraindicated).

To date, there has been no indication on when the Assembly Health and Senior Services Committee will be voting on Bill No. A1464. If the bill were to pass, it would go before the Governor for review and consideration.