Telehealth in Nephrology. What it is and what it could be. Chester Amedia Jr MD FACP FASDIN

Transcription

1 Telehealth in Nephrology What it is and what it could be. Chester Amedia Jr MD FACP FASDIN

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3 Origins of Telemedicine Historically, telemedicine can be traced back to the mid to late 19 th century with one of the first published accounts occurring in the early 20 th century when electrocardiograph data were transmitted over telephone wires Einthoven W. Le télécardiogramme [The telecardiogram]. 5. Archives Internationales de Physiologie, 1906, 4:

4 Telemedicine Telemedicine, in its modern form, started in the 1960s in large part driven by the military and space technology sectors, as well as a few individuals using readily available commercial equipment Ronald Merrell, M.D., F.A.C.S Professor of Surgery Department of Surgery School of Medicine Virginia Commonwealth University

5 Telehealth vs. Telemedicine The terms Telemedicine" and Telehealth" are often used interchangeably Telehealth intended to include a broader definition of remote activity to improve health that does not always involve clinical services. These activities may use videoconferencing, remote monitoring, online medical evaluations, transmission of still images to accomplish education, counseling, nurse call centers or any of a multitude of devices to capture physical, mental or emotional metrics. The main proposed advantage of telehealth is the capability of delivering medical services and improving the condition of distant areas with low access to medical specialists. This distance limitation is waning due to patient demand and improved technology. Telemedicine Refers specifically to the subset of telehealth represented by the delivery of clinical services in a synchronous or asynchronous fashion, using interactive audio, video or other telecommunications systems. 5

6 Telemedicine Applications Telemedicine applications can be classified into two basic types, according to the timing of the information transmitted and the interaction between the individuals involved be it health professional-to-health professional or health professional-to-patient Real time, or synchronous, telemedicine requires the involved individuals to be simultaneously present for immediate exchange of information, as in the case of videoconferencing Store-and-forward, or asynchronous, telemedicine involves the exchange of prerecorded data between two or more individuals at different times. For example, the patient or referring health professional sends an description of a medical case to an expert who later sends back an opinion regarding diagnosis and optimal management In both synchronous and asynchronous telemedicine, relevant information may be transmitted in a variety of media, such as text, audio, video, or still images.

7 Synchronous: Real Time Asynchronous: Store and Forward Synchronous Asynchronous

8 Data Transmission ICTs Information and communication technologies (ICTs) Computers The Internet Cell phones CD Non-secure telephone line Open Broadband Encrypted Internet messaging Telemedicine uses ICTs to overcome geographical barriers and increase access to health care services

9 Societal Barriers Paucity of studies documenting economic benefits and cost-effectiveness of telemedicine applications Infrastructure in developing countries is largely insufficient to utilize the most current Internet technologies. Cost also poses both a real and perceived barrier to the application and adoption of telemedicine in developing countries Sociocultural differences between sites, which can limit the pertinence of telemedicine collaborations Cross-border legal issues between states or even countries are insufficiently addressed or are restrictive Professional liability exposure for Healthcare Professionals offering telemedicine services is often unclear

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11 Accelerators Sophistication of general population with use of digital devices Smart Phones Smart Watches Portable Devices Home Devices Patient demand for more immediate access to services Commercial Payers increasingly adopting Telemedicine / Telehealth coverage Increased management of chronic disease in non-hospital environment Medicare making Telemedicine a primary benefit for more conditions Growth of the elderly population

12 A New Industry Has Developed American Telemedicine Association Guidelines Practice Guidelines for Live on Demand Primary and Urgent Care Clinical Guidelines for Telepathology Guidelines for TeleICU Operations Core Operational Guidelines for Telehealth Services Involving Provider-Patient Interactions Practice Guidelines for ideo-based Online Mental Health Services Quick Guide to Store-Forward and Live-Interactive Teledermatology for referring Providers Business Case Address Manpower Shortage Issues Reinforce Quality Efforts Increase Patient Satisfaction Thru Enhanced Responsiveness Reduce System-wide Health Care Cost

13 Partnerships, Mergers & Acquisitions CVS partnered with three telemedicine providers American Well, Teladoc and Doctor on Demand to significantly expand its telehealth capabilities Walgreens offers telemedicine services through a partnership with MDLive that now exists in 25 states Feb 24, WebMD, the media and healthcare information company, is hinting that it will enter the telemedicine space as acquisition prices become more reasonable

14 Health Monitoring & Wearable Devices Market Will Exceed $2.9 Billion in 2016 BP Cuffs Thermometers Scales Bioimpedence measures Pulse oximeters Peak Flow meter ECG monitors Metabolic (glucose) monitors Stethoscopes Dermatoscopes Otoscopes Ophthalmoscopes Ultrasounds Flouroscopy Medication dispensers Fall Pads ADLs (activity, bathroom use, bed use Call assistance Pedometers Calorimeters / Diaries Video monitoring

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16 What Can We Easily Do Today?

17 Existing Applications of Non-Face-to-Face Services Telephone Services Physician or qualified health provider to an established patient; not reported if patient seen in next 24 hours or if patient was seen or if reported in past 7 days minutes of E&M minutes of E&M minutes of E&M Online Medical Evaluation (Internet) Physician to a patient s online inquiry not originating from an E&M within the last 7 days utilizing internet or similar electronic communication. Response must be timely, be permanently stored. Multiple physicians may report in the same period. Reportable visit includes Rxs, lab orders and call summary includes related prescriptions and labs Interprofessional Telephone/Internet Consultations (IPTIC) Consultation with attending or primary physician or other qualified health care professional requesting opinion/treatment advice, without need for face-to-face contact with consultant. Restrictions if seen in last 14 days or is scheduled for next 14 days, or if transfer has been accepted. May use if decision for transfer is dependent on the IPTIC minutes minutes minutes minutes or more

18 Existing Non-Face-to-Face Nonphysician Services Telephone Services Qualified healthcare professional to an established patient using the telephone Episodes of care initiated by an established patient or guardian of an established patient Not used if the service ends with a decision to see the patient within 24 hours or the next available urgent visit appointment; or if the Service reported refers to a service provided in the past 7 days either a face to face visit, telephone service, or a procedure minutes of medical discussion minutes of medical discussion minutes of medical discussion Do not report with CCM Services ( ) Do not report when performed during service time of TCM Services ( ) Online Medical Evaluation (Internet) Qualified health care professional to a patient using internet resources in response to the patient s online inquiry not originating from an Assessment and Management service provided within the last 7 days utilizing internet or similar electronic communication or procedure. Response must be timely, be permanently stored. Reportable visit includes telephone calls, Rxs, lab orders and call summary includes related prescriptions and labs Do not report with , (Care Plan Oversight Services) Do not report (Anticoagulation Management) Do not report with (CCM) during the same month Do not report with (TCM) during the same service time

19 Telemedicine American Medical Association policy H The Promotion of Quality Telemedicine. 1. The physician is responsible for supervising the safety and quality of services provided to patients by non-physician providers through telemedicine. 2. Supervising physicians are required to visit sites where patients receive care from non-physician providers. They must also have knowledge of the nonphysicians qualifications and should be able to contact those providers as necessary. Both supervising providers and non-physician providers must conform to the applicable medical practice act in the state where the patient receives services. 3. Providers who utilize telemedicine systems, must maintain recording, reporting and supervision of patient care and conform to confidentiality and privacy principles. 19

20 Originating Sites An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in: A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract A county outside of a MSA.

21 Reimbursement Issues Medicare reimburses for telehealth services when the originating site (where the patient is) is in a Health Professional Shortage Area (HPSA) or in a county that is outside of any Metropolitan Statistical Area (MSA), defined by HRSA and the Census Bureau, respectively. This originating site must be a medical facility and not the patient's home Must use an interactive audio and video telecommunications system that permits real-time communication between the practicitioner and the beneficiary Medical facilities currently include: practitioners' offices, hospital, and rural health clinics. This reimbursement is not affected by the location from which the telehealth services are being delivered (the "distant" site). Medicare will only pay for "face-to-face", interactive video consultation services wherein the patient is present. Medicare does cover store-and-forward applications, such as teleradiology and remote EKG applications, as they do not typically involve direct interactions with patients. Medicare only covers store-and-forward applications, such as teledermatology, in Demonstration Sites in Alaska and Hawaii.

22 DISTANT SITE PRACTITIONERS Physicians Nurse practitioners (NPs) Physician assistants (PAs) Nurse-midwives Clinical nurse specialists (CNSs) Certified registered nurse anesthetist Clinical psychologists (CPs) and clinical social workers (CSWs). CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and Registered dietitians or nutrition professionals

23 Nephrology Specific Payment -- Remote Patient Face-To-Face, Interactive Services The 2013 list of Medicare telehealth covered services included the monthly capitation payment for specific End-Stage Renal Disease related services 90951, 90952, 90954, 90955, 90957, 90958, 90960, and Do not use 90953, 90956, 90959, However, because of the requirement for at least one Face-to-Face visit to evaluate the vascular access this is almost never used Need to meet the criteria of Rural as defined by Professional Shortage Area (HPSA) or in a county that is outside of any Metropolitan Statistical Area (MSA), defined by HRSA and the Census Bureau, respectively

24 Submitting Medicare Claims Submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, via interactive audio and video telecommunications systems (for example, GT). By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth service. By coding and billing the GT modifier with a covered ESRD-related service telehealth code, you are certifying that you furnished one hands on visit per month to examine the vascular access site.

25 Other Payers and Telemedicine Payment Commercial Payers: There is no single widely-accepted standard for private payers. Some insurance companies value the benefits of telehealth and will reimburse a wide variety of services. Others have yet to develop comprehensive reimbursement policies, and so payment for telehealth may require prior approval. Medicaid: Different states have various standards by which their Medicaid programs will reimburse for telehealth expenses. Check with the Medicaid program in the state to get a clearer policy perspective on coverage.

26 Current Originating sites The originating sites authorized by law are: The offices of physicians or practitioners; Hospitals Critical Access Hospitals (CAHs) Rural Health Clinics Federally Qualified Health Centers Hospital-based or CAH-based Renal Dialysis Centers (including satellites) Skilled Nursing Facilities (SNFs) Community Mental Health Centers (CMHCs). Note: Independent Renal Dialysis Facilities are not eligible originating sites

27 Filing for Payment for the Originating Site Fee Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. Bill the MAC for the originating site facility fee, which is a separately billable Part B payment. Note: When a CMHC serves as an originating site, the originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services.

28 What s in the Future?

29 Telemedicine NEW! As of 1/1/2016, Home Dialysis CPT Codes ( ) have been added to approved telemedicine service code list BUT, the patient s home and the dialysis facility are NOT approved originating sites which limits immediate widespread use of these codes Pending legislation may relieve these barriers

30 Telemedicine Services 2016 Medicare Payment Physician Services MCP CPT codes included Do not use 90953, 90956, 90959, (At least one Face-to-Face Visit is required to evaluate the vascular access) Home Dialysis MCP codes included Legislation for Originating Site anticipated

31 CONNECT Bills HR 4442 and S 2484 To amend titles XVIII and XI of the Social Security Act to promote cost savings and quality care under the Medicare program through the use of telehealth and remote patient monitoring services, and for other purposes. Introduced in the US House of Representatives and US Senate in early February 2016 Bipartisan Support Sec Allowing telehealth to meet monthly clinician in-person visit requirement for certain home dialysis. Allows a patient with end stage renal disease receiving home dialysis to elect to receive the monthly clinical assessment via telehealth at a dialysis facility, as long as an in-person examination is done at least once every three consecutive months.

32 Coming Soon???

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35 CPT and RUC Activity Codes are being introduced to report telemedicine activities in a rapid fashion Modifiers for existing E & M Services to report Synchronous services To reinforce the current GT modifier promoted by CMS which is not recognized by all payers New Code sets to report E & M services for Asynchronous services Expect changes for 2017 CMS appears to be supportive of much of this activity

36 2016 Medicare Resources Telehealth Services: on the Centers for Medicare & Medicaid Services (CMS) website Chapter 15 of the Medicare Benefit Policy Manual (Publication ) on the CMS website Chapter 12 of the Medicare Claims Processing Manual (Publication ) on the CMS website Health Professional Shortage Areas: Medicare Learning Network (MLN) publication titled Health Professional Shortage Area (HPSA) Physician Bonus, HPSA Surgical Incentive Payment, and Primary Care Incentive Payment Programs on the CMS website

37 Other Resources Telemedicine: opportunities and developments in Member States: report on the second global survey on ehealth, 2009; World Health Organization Resolution WHA ehealth. In: Fifty-eighth World Health Assembly, Geneva, May 16 25, 2005 ( accessed 17 June 2010) Einthoven W. Le télécardiogramme [The telecardiogram]. 5. Archives Internationales de Physiologie, 1906, 4: Benschoter RA, Eaton MT, Smith P. Use of videotape to provide individual instruction in techniques of psychotherapy. Academic Medicine,1965, 40(12): Dwyer TF. Telepsychiatry: psychiatric consultation by interactive television. American Journal of Psychiatry 1973, 130: Senate Bill 2424 CONNECT for Health Act, 114th Congress, February Healthsense in-home sensors, Healthsense.com Telehealth Collaboration: Mapping the Way Forward, June 22, 2015, Washington, DC

38 The End

39 Satisfying Conditions for Claims for Telehealth Services As a condition of payment, you must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site. Asynchronous store and forward technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii.

40 Telemedicine and Telehealth Services Medicare Reimbursement Medicare reimbursement for telemedicine or telehealth services is divided into three areas: 1. Remote patient face-to-face services seen via live video conferencing 2. Non face-to-face services that can be conducted either through live video conferencing or via store and forward telecommunication services 3. Home telehealth services In addition, national and local coverage determinations may alter or expand the services that are eligible for reimbursement. American Telemedicine Association Jan 2013