Supporting Telehealth Billing

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Bryce Cox
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1 Supporting Telehealth Billing Partnership HealthPlan of California April 15, 2013 Robert Moore, MD MPH, Chief Medical Officer, Partnership HealthPlan of California

2 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

- consultation - treatment - education - care management - self-management of patient at a

3 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

home, etc Expands the definition of health care provider to include all state licensed medical professionals No additional written

4 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

Synchronous - non-traditional*: Provider connects with patient in other than office setting (home, hospital, SNF,

5 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*

6 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

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

7 Originating Site (Patient Present) Service Site facility fee (billable only when no CPT/E&M code is billed) Transmission Cost Code Q3014 T1014 (per minute for maximum of 90 min. per patient) Licensed provider fee (if present)* E&M codes and other CPT codes for services distinct and in addition to those rendered by the Distant Site Provider. *Billable for services distinct and in addition to those rendered by the Distant Site. Medical necessity must be documented in chart. Service Transmission Cost Distant Site (Provider Present) Code T1014 (per minute for maximum of 90 min. per patient) Initial hospital care or subsequent hospital care (new or established patient) Consultations: Office or other outpatient ( initial or follow-up) Inpatient, and confirmatory Nutrition Counseling per PHC Guidelines (See Policy MCUP3052) Required Modifer , 97803, 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.

8 Sample Claim - Traditional Originating Site (Location of Patient) CPT Code 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

Transmission Code - T1014 Provider included in visit bill CPT Code

9 Sample Claim - Traditional Bill Provider CPT Code PLUS GT Modifier Bill Transmission Code T1014 Distant Site (Specialist Location)

10 Synchronous Telehealth Non-Traditional Service No Billing Originating Site (Location of Patient) Code Originating Site may be home, health facility, residential care or other location. Service Transmission Cost Distant Site/Provider Site (Location of Provider) Code T1014 (per minute for maximum of 90 min. per patient) Licensed provider fee E&M codes Nutrition Counseling per PHC Guidelines (See Policy MCUP3052) Required Modifier 97802, 97803, GT modifier required for all CPT-Codes except Transmission Cost codes

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

11 Sample Claim Non Traditional Originating Site: may be home, health facility, residential care or other Provider Site No billing for originating site Bill for Provider Site (can be specialists or primary care provider) GT Modifier Bill consult with GT modifier Bill Transmission Cost T1014

originating site Bill for Provider Site (can be specialists or primary

12 Asynchronous Telehealth: (Store & Forward) Originating Site (Patient Location) Service Site facility fee (billable only when no provider at visit) Transmission Cost Licensed provider fee (if present) * Code Q3014 T1014 (per minute for maximum of 90 min. per patient) E&M codes and other CPT codes for services distinct and in addition to those rendered by the Distant Site Provider. * Billable for services distinct and in addition to those rendered by the Distant Site. Medical necessity must be documented in chart. Distant Store and Forward Site (Specialist Location) Service CPT Codes Office consultation, new or established patient Retinal photography with interpretation for services provided by optometrists or ophthalmologists Required Modifier: All asynchronous, store-and-forward services are billed with a GQ modifier

13 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

T1014 No billable provider present so no CPT Code Bill

14 Sample Claims Asynchronous Bill CPT Code with GQ modifer Distant Site (Location of Specialist) Ophthalmology, Optometry & Dermatology Only GQ Modifier GQ Modifier

15 Partnership HealthPlan Quality Improvement Program (QIP) Pay for Performance Program for 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 1 st 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

Improvement Program At least 25 encounters completed between July 1 st 2012 through June 30, 2013 Data collected through

16 Future Directions in Telehealth Reimbursement communication with Patients Medication Therapy Management with Telehealth

17 Resources/More Questions Partnership HealthPlan Telehealth Policy (MCU3113) available at Contact me at

medne tele Medicine: Telemedicine 1

medne tele Medicine: Telemedicine 1 Medicine: Telemedicine 1 The Telemedicine Act of 1996 made the practice of telemedicine a legitimate means by which an individual may receive medical from a health care provider without requiring person-to-person