Category: Practice Management

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Strategies for Telehealth Implementation

telemedicine

telemedicine

Telehealth is an important clinical delivery model, especially for home-based providers during the COVID-19 pandemic. Here are some practical implementation considerations:

Practice Implementation

  • Consider current and future COVID-related workflow needs when selecting a technology vendor
  • Train staff by conducting mock virtual visits among team members
  • Develop documentation templates and educate staff on documentation and consent requirements
  • Define the scheduling process (e.g., time slot allotments for virtual versus in-person visits)
  • Use support staff to set up the visit with patients/caregivers before connecting the provider

Provider Telehealth Etiquette

  • Conduct visits in a well-lit, private space; choose solid-colored clothing/backgrounds
  • Greet patients as you would normally, consider showing your I.D. badge to new patients
  • Set camera at eye level, maintain eye contact, and explain if and why you need to look away
  • Speak in a normal tone of voice using empathetic speech and body language
  • Keep “lag time” of technology in mind, allow for pauses
  • Communicate next steps (e.g., follow-up appointments, prescriptions)

Post-Visit

  • Conduct patient and caregiver satisfaction surveys, analyze feedback
  • Identify outcome metrics (e.g., number of successful visits, phone versus video, technical difficulties, billing level)
  • Discuss challenges and successes with your team
  • Conduct internal monitoring and audits to ensure documentation and compliance requirements are met for all types of telehealth encounters
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Agendas for Interdisciplinary Team Meetings

Interdisciplinary team meeting
Interdisciplinary team meeting

Interdisciplinary team (IDT) meetings improve staff communication, encourage teamwork, and promote optimal patient care and outcomes within house call programs. During the COVID-19 pandemic, IDT meetings are especially important for maintaining team cohesiveness. Following a structured meeting agenda can help maximize IDT meeting effectiveness. In addition, brief staff huddles can serve to supplement IDT meetings and address immediate concerns.

Sample IDT Meeting Agenda:

  1. Key Metrics – discuss outcomes and/or clinical quality metrics being used
  2. Hospitalizations – review recent hospitalizations, brainstorm solutions for future
  3. Case Management – social workers, pharmacists, clinical staff, and/or providers present complex cases to initiate action/planning for patient resources
  4. Announcements / Updates – address logistical or operational changes affecting the team
  5. Waste Identification – discuss process breakdowns/inefficiencies, assign team members to strategize solutions
  6. Recognition – encourage team members to acknowledge others who have gone above and beyond or highlight a team accomplishment to end the meeting on a high note

Effective IDT meetings are a proven way to optimize patient care and outcomes, but they require planning, commitment, and time. To access and download a copy of the full IDT sample agenda, click here (new users will need to complete a one-time registration).

 

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CMS releases additional interim final rule, creating more telehealth flexibility and featuring significant regulatory changes

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a second Interim Final Rule with new flexibilities and changes relevant to home-based medical care providers. The changes in this most recent Interim Final Rule are effective immediately, with many modifications retroactively effective as of 3/01/2020. These include the following:

  • CMS increased the payment for telephone Evaluation and Management (E/M) visits to be similar to payment for an office visit. This was done to accommodate providers who are caring for patients without access to two-way audio and video technology. When seeking reimbursement for telephone visits, physicians and other qualified healthcare professionals (i.e., nurse practitioners and physician assistants) may use the Telephone E/M CPT codes listed below. CMS also designated these telephone E/M services as “Medicare telehealth services,” and as such, they will require modifier 95.
    • CPT 99441Telephone E/M 5-10 minutes; Increased Non-Facility Payment $46.19; wRVU 0.48
    • CPT 99442Telephone E/M 11-20 minutes; Increased Non-Facility Payment $76.15; wRVU 0.97
    • CPT 99443Telephone E/M 21-30 minutes; Increased Non-Facility Payment $110.43; wRVU 1.50
  • In addition, the following services can also now be billed when using audio only:
    • Advance Care Planning (CPT 99497, 99498)
    • Annual Wellness Visits (HCPCS G0438, G0439)
    • Smoking Cessation Services (CPT 99406, 99407)
    • Alcohol and/or substance abuse (other than tobacco) structured assessment (e.g., AUDIT*, DAST**), and brief intervention services (HCPCS G0396, G0397)
    • Annual Alcohol Misuse Screening and Counseling (HCPCS G0442, G0443)
    • Annual Depression Screening (HCPCS G0444)
    • Chronic Care Management (CCM) Care Planning Services; please note this service is only to be used one time for new patients or patients who are not seen within a year when first enrolled in CCM (HCPCS G0506)

*Drug Abuse Screening Test
**Alcohol Use Identification Test

  • Be aware Medicare has designated additional services, e.g., psychotherapy and other therapy-related, nutrition, and education services, that allow for payment when provided via audio-only telehealth. To review the full list of Medicare audio-only telehealth services, visit the Medicare list of telehealth services.
  • The home and domiciliary E/M codes still require a two-way audio and video telecommunication method. Please review the CMS Fact Sheet and the revised FAQ that was released on 4/30/2020 for additional details.

Additional Key Updates:

  • CMS has officially adopted the regulation allowing for nurse practitioners, physician assistants, and clinical nurse specialists to order, establish and monitor plans of care, and certify and re-certify patients for home health services as mandated under the CARES Act. This change is permanent and applies to any service provided on or after 3/01/2020. (Click here for a guide to the CARES Act.)
  • CMS finalized on an interim basis that they will not enforce the clinical indications for therapeutic glucose monitors and they’re not subject to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCSs). CMS had previously finalized on an interim basis that they will not enforce the clinical indications for respiratory devices, anticoagulation management, and infusion pumps. CMS did remind clinicians that services must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member to be paid under Medicare. Physicians, practitioners, and suppliers are required to continue documenting the medical necessity for all services.
  • CMS waived the 16-day minimum requirement to bill for Remote Patient Monitoring (RPM) services, but only for patients who have suspected or confirmed COVID-19. In such cases, CMS recognized the value of short-term monitoring (no less than two days) for acute conditions and is allowing payment for CPT codes 99453, 99454, 99091, 99457, and 99458.
  • Until now, CMS used only its rulemaking process to add new services to the list of approved Medicare telehealth services. However, CMS is changing its process during the Public Health Emergency and will add new telehealth services on a sub-regulatory basis.
  • CMS waived some restrictions on the types of healthcare professionals that can furnish Medicare telehealth services for the remainder of the Public Health Emergency. Physical therapists, occupational therapists, and speech-language pathologists are now added to the list of eligible providers, which had already included physicians, nurse practitioners, physician assistants, licensed clinical social workers, and clinical psychologists. These providers can bill for telehealth services subject to the scope of practice laws.
  • CMS will no longer require a practitioner’s written order for patients to receive a COVID-19 test or other certain testing (e.g., serology testing) to diagnose and treat COVID-19. Pharmacists can also now perform COVID-19 tests if they’re enrolled in Medicare as a laboratory. Additionally, pharmacists can work with qualified healthcare professionals who are credentialed to bill Medicare to provide assessment and specimen collection services relating to a COVID-19 diagnosis. The physician or other qualified healthcare professional can bill Medicare for the test. This allows for parking-lot test sites and more rapid testing. (This is subject to state scope of practice laws.)
  • CMS is allowing hospitals to bill as the originating site for telehealth services, even if the patient is located at home. This applies to hospital-based practitioners for Medicare patients who are registered as hospital outpatients. This may be impactful for Hospital at Home® providers.
  • CMS is adjusting the financial methodology used for COVID-19 costs incurred by Accountable Care Organizations (ACOs) so they will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. ACOs can also forgo the annual application process; if their participation is set to end this year, they have the option to extend for another year. ACOs that are required to increase their financial risk during the current agreement period will have the option to maintain their current risk level for next year, instead of advancing automatically to the next risk level. CMS also includes virtual services, including virtual check-ins, remote evaluations, and telephone E/M services, as primary care services considered for beneficiary attribution.
  • CMS announced a new Coronavirus Commission for Safety and Quality in Nursing Homes. Read the Fact Sheet here.

Disclaimer: This information is current as of 5/05/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses its content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region. Medicare Advantage and commercial payor policies will vary.

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COVID-19 Update 04/24/20 – More on Medicare Telehealth Services-related Changes

As providers and practices continue to determine the best way to safely care for their patients while navigating the ever-changing regulatory requirements related to COVID-19, HCCI is committed to continuing to provide accurate, clarifying and timely information.

“Medicare telehealth services” refer to a certain list of services that would normally be provided in-person, but due to the Public Health Emergency, are temporarily being allowed by Medicare in all locations when they are furnished using two-way audio and video technology that permits real-time communication between the provider and the patient who are in different locations.

Medicare has also previously allowed these services in geographic areas that were rural or designated as a Healthcare Professional Shortage Area (HPSA), subject to distant and originating site requirements (temporarily waived).

As a result of the interim final rule published on 3/26/20, for visits conducted via telehealth, for Medicare’s purposes, providers should report the Place of Service (POS) where the patient would have been seen face-to-face (to allow for non-facility rate payment) and use modifier 95 to identify it as a telehealth service. Telehealth services no longer require POS 02.

The following are not considered Medicare telehealth services because they would not normally be provided face-to-face. Instead, providers should report the POS where the service was rendered, with no modifier required.

  • Telephone Evaluation & Management (E/M) Services: CPT code range 99441-99443 and CPT code range 98966-98968
  • Virtual Check-in (phone call): HCPCS code G2012
  • Review of recorded video and/or photo or image: HCPCS code G2010
  • E-visits (patient portal communications over a 7-day period): CPT code range 99421-99423 and HCPCS code range G2061-G2063
  • Remote Patient Monitoring: CPT codes 99453-99454, 99091, 99473-99474, 99457, 99458

Other Modifiers

  • CS Modifier: Physician and practitioner services that lead toeither an order for, or administration of, a COVID-19 lab test are not subject to a co-pay or deductible charges. The CS Modifier is added to the physician/practitioner service to define this circumstance and allow the claim to process without co-pay or deductible application.
  • CR Modifier: Catastrophe/disaster-related; required when an item or service is impacted by an emergency or disaster and Medicare payment for that item or service is conditioned on the presence of a “formal waiver.” Please note telehealth services are excluded from CR modifier use, so do not report for telehealth services. Be sure to follow the guidance provided by your local Medicare Administrator Contractors (MAC) as a recent NGS article advised to use CR for telephone E/M services.

Additional Key Updates

Previous HCCI Home-Based Primary Care-Specific Updates

Disclaimer: This information is current as of 4/24/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region.

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Infection Control in Home-Based Primary Care

As home-based primary care (HBPC) expands across the U.S., we’re reminded of how critical this model of care is, particularly during a Public Health Emergency like COVID-19.  Because of this, and more than ever, HBPC providers must keep infection surveillance, prevention, and control efforts top-of-mind to protect patients, caregivers, household family members, and themselves. To this end, HCCI offers these important reminders for providers about basic infection control strategies:

  • When scheduling appointments, ask about the travel history and current state of health of the patient and all household contacts.
  • Use proper hygiene and follow recommendations for transporting, storing and disposing of supplies.
  • Disinfect the medical bag and supplies before and after every visit.
  • Assess the home environment before entering and use appropriate personal protection equipment (PPE).
  • Position the medical bag and laptop/tablet on clean, dry surfaces, out of reach of children and pets.

For more information about practical infection control strategies for HBPC providers, download HCCI’s Infection Control Resource Guide.  You can also access more information and resources on the HCCI COVID-19 Information Hub, including HCCI’s online course, Infection Control in Home-Based Primary Care, available at no cost now through June 30, 2020.

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COVID-19 Update 04/08/20 – Additional Key Information and Flexibilities in the CMS Interim Final Rule

In addition to changes in the Centers for Medicare & Medicaid Services (CMS) Interim Final Rule discussed in our previous update, Providers and practices should be aware of the following additional information and waiver flexibilities in the rule:

  • Home Health Agencies can now provide additional services to patients via telehealth if it’s part of the patient’s plan of care and does not replace the needed in-person care as ordered in the plan of care.
  • Hospice Organizations can provide services to Medicare patients via telehealth if feasible and appropriate to do so.
  • Clinicians now have maximum flexibility in determining patient needs for respiratory-related devices and equipment and the flexibility for more patients to manage their treatments at home. The current National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) that restrict coverage of these devices and services to patients with specific clinical characteristics do not apply during the Public Health Emergency. For example, Medicare will cover non-invasive ventilators, respiratory assist devices, and continuous positive airway pressure devices based on the clinician’s assessment of the patient. So, in summary, on an interim basis, CMS will not enforce clinical indications across respiratory (including home oxygen), home anticoagulation management, and infusion pump NCDs and LCDs (including articles).

The above policies include but are not limited to the following:

  • Home Oxygen
  • Continuous Positive Airway Pressure for Obstructive Sleep Apnea
  • Respiratory Assist Devices (ventilators for home use)
  • Intrapulmonary Percussive Ventilator
  • Oxygen and Oxygen Equipment (for home use)
  • Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management
  • Infusion Pumps
  • External Infusion Pumps

For additional information:

Previous HCCI Updates related to COVID-19:

Disclaimer: This information is current as of 4/08/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region.

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COVID-19 HCCI Update: Week of 03/30/20

During HCCI’s recent webinar, “The Impact of COVID-19 on Home-Based Providers, Practices, and Patients we encouraged practices to reach out to their local Medicare Administrator Contractors (MAC) for specific guidance on whether home-based primary care (HBPC) providers can bill for the home and domiciliary visit CPT code ranges under the 1135 telehealth waiver.

New Centers for Medicare & Medicaid Services (CMS) Fact Sheet

On March 30, CMS published an important new fact sheet announcing that they’re adding 80 additional services when furnished via telehealth. CMS also added home and domiciliary CPT codes to the list. These codes can now be billed for when performed via telehealth using two-way audio and video.

Following are the home and domiciliary visits added for payment during the COVID-19 Public Health Emergency:

  • New patient domiciliary visits CPT code 99327 (Level 4 New/60 minutes) and CPT 99328 (Level 5 New/75 minutes)
  • Established patient domiciliary visits CPT code range 99334-99337 (complete levels of service 1-4)
  • New patient home visits CPT code range 99341-99345 (complete levels of service 1-5)
  • Established patient home visits CPT code range 99347-99350 (complete levels of service 1-4)

Please note that CMS advised they expect providers to use the Evaluation & Management (E/M) code that best describes the nature of the care they are providing, regardless of the physical location or status of the patient (e.g., HBPC providers using home and domiciliary visits rather than the office visit code set).

As a result of the new interim final rule, CMS also did the following:

NEW MODIFIER and Place of Service REQUIREMENTS

  • Finalized its interim policy of requiring modifier 95 for E/M services furnished via telehealth. CMS no longer requires the use of Place of Service 02 for telehealth; instead, providers are instructed to report the POS that would have been reported if the visit was conducted face-to-face (e.g., POS 12 for home) and modifier 95 which identifies the service as telehealth. Following is a complete description:
    • Modifier 95 is used to indicate services performed via real-time interactive audio and visual telecommunication system.
    • You can also refer to the CMS interim final rule for a complete list of covered telehealth services.
  • Added CPT code ranges for Telephone E/M services which allow for payment of audio-only interactions:
    • CPT 99441 Telephone E/M 5-10 minutes; National Facility Payment $13.32
    • CPT 99442 Telephone E/M 11-20 minutes; National Facility Payment $26.64
    • CPT 99443 Telephone E/M 21-30 minutes; National Facility Payment $39.60
  • Other qualified healthcare professionals who can bill for telehealth services per CMS include licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists. These providers can bill for telephone E/M services using the following CPT codes:
    • CPT 98966 Telephone E/M 5-10 minutes Non-Physician Practitioner; National Facility Payment $13.32
    • CPT 98967 Telephone E/M 11-20 minutes Non-Physician Practitioner; National Facility Payment $26.64
    • CPT 98968 Telephone E/M 21-30 minutes Non-Physician Practitioner; National Facility Payment $39.60
  • Clarified that their interim policy for telephone E/M, virtual check-ins, and E-visits can now be furnished to new and established patients. POS 02 and modifier 95 should not be used in these instances since they are not considered to be “telehealth” services. Instead, the POS where the services would typically be rendered should be used.
  • Retained the requirement that the Communication Technology-Based Services (CTBS), e.g., virtual check-ins and telephone E/M, described above cannot be related to an E/M visit within the past 7 days and cannot result in the need for a face-to-face visit or a telehealth E/M visit. (To see additional information on CTBS, refer to the links for the previous HCCI COVID-19 articles below.)

Additional Legislation Updates

  • On March 25, the United States Senate passed H.R. 748 – the Coronavirus Aid, Relief, and Economic Security Act (The CARES Act).
    • The Home Centered Care Institute (HCCI) is pleased to announce that section 3708 of the CARES Act allows Nurse Practitioners (NP), Physician Assistants (PA), and Certified Nurse Specialists (CNS) to prescribe and certify home health services and be reimbursed for such services under Medicare Parts A & B.
    • With the new act, Advanced Practice Providers can now establish the plan of care and fulfill plan review requirements. This also applies to Medicaid requirements and must be implemented within 6 months of the date of enactment of the act.
  • CMS also announced the Expansion of the Accelerated and Advance Payments Program, which may be beneficial for practices and providers struggling with cash flow issues due to COVID-19.
  • Home Health and Hospice agencies also have increased flexibility in the types of services they can perform via telehealth, which is further described in the interim final rule.

Please continue to visit HCCI’s COVID-19 Information Hub When you’re on the site, look for the word “New,” which will flag the information added that week.

You can also join the conversation happening in the new Home Centered Care Institute COVID-19 Group on LinkedIn. Once you’re logged into LinkedIn, join your colleagues who are already members by searching the name of the group on LinkedIn and requesting to join – or by going directly to https://www.linkedin.com/groups/12383537/ to make the request.

Previous HCCI COVID-19 Update Articles:

Disclaimer: This information is current as of 4/1/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region.

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HCCIntelligence™ Update: COVID-19 Telehealth Billing Requirements

COVID-19 Telehealth Billing Requirements

COVID-19 Telehealth Billing Requirements

In our recent article, Providing Telephonic and Virtual Care Requirements as part of COVID-19 Precautions, available on HCCI’s COVID-19 Information Hub, we highlighted the requirements of virtual visits. We also provided an overview of the 1135 Telehealth Waiver as part of the president’s emergency declaration during the country’s current public health emergency.

We realize this is a challenging time for Home-Based Providers, and the Home Centered Care Institute (HCCI) is committed to supporting the field by providing timely information so you can make the best decisions for your practice. In response to recent questions, we’ve outlined more information below to clarify additional questions you may have.

Q: What are the current Evaluation and Management (E/M) codes that can be billed for when the services are provided via telehealth under the 1135 Waiver?

A: Here are the appropriate E/M codes:

  • Office/Outpatient CPT code range 99201-99215
  • Transitional Care Management CPT codes 99495 and 99496
  • Advance Care Planning CPT codes 99497 and 99498
  • Annual Wellness Visits HCPCS codes G0438 and G0439
  • Administration of caregiver-focused health risk assessment instrument CPT code 96161
  • Telehealth consultations ED or initial inpatient visits HCPCS code range G0425-G0427
  • Follow-up inpatient telehealth consultations in hospitals or SNF’s HCPCS range G0406-G0408

For a complete list of CPT codes, please refer to Medicare’s list of telehealth services

HCCI is awaiting official guidance from CMS on whether Home-Based Practices that historically bill only for home or domiciliary visits should be concerned about a potential heightened audit risk if they use the office visit code set during this pandemic. We realize, however, that many Home-Based Practices are choosing to use the set office visit code, in the interim, to maintain their practice. Our recommendation is to review all the facts before making the best decision for your practice and consider contacting your local Medicare Administrator Contractor (MAC) for specific guidance.

Q: What Place of Service (POS) and modifiers are required to bill for telehealth services?

A: For services furnished via telehealth, report Place of Service (02) for telehealth.

Per the CMS FAQs & The Medicare Learning Network’s March 20th update, CMS does not generally require additional or different modifiers on Medicare claims for telehealth services furnished under these waivers, except in the following three instances:

  • GQ – Telehealth services are furnished via asynchronous (store and forward) technology as part of a federal telemedicine demonstration project in Alaska and Hawaii
  • GT – Telehealth services are furnished under CAH Method II (Via interactive audio and video telecommunication systems)
  • G0 – Telehealth services are furnished for the purposes of diagnosis and treatment of an acute stroke

As an example of when receiving guidance from your local MAC is beneficial, a practice in Indiana reached out to their MAC (i.e., WPS Government Health Administrators) and was advised to use modifiers for telehealth claims.

Q: How do I contact and confirm who my local MAC is?

A: CMS has a contractor directory and map on their website that allows you to search by state to confirm your MAC along with links to each contractor’s site where you can find their Provider Contact Center phone number. You will need to call your MAC directly to request clarification on proper billing for home visits under the 1135 waiver. They may refer you to a specific governance email, however, HCCI is aware that practices are generally receiving timely responses within a few days.

It’s also important to note the requirement for practices to use an interactive audio and video telecommunications system that permits real-time communication between the provider and the patient at home even under the telehealth waiver. This means you cannot bill for an E/M visit via telehealth for phone call audio-only. However, under the U.S. Department of Health and Human Services (HHS), the Office of Civil Rights (OCR) Notification of Enforcement Discretion relaxed HIPAA requirements so that providers may use platforms such as Apple FaceTime, Skype, Zoom, the WhatsApp, etc., as a form of two-way audio and video telecommunications. Doxy.me, a free HIPAA-compliant telemedicine platform that allows for two-way audio and video interaction with patients and caregivers, is another option. Consider checking with your Electronic Health Record (EHR) vendor as they may have technologies available for video visits, too.

If you are providing virtual services to patients via phone call audio-only, you must refer to the Virtual Check-in Codes (requirements detailed in previous HCCI article), or use other forms of reimbursement, such as care management services (e.g., Chronic Care Management) to bill for your time.

The E-visits codes, which capture time over a 7-day period for communicating and reviewing patient information on a digital communication platform, such as a patient portal or secure email, are listed below in an HCCI chart for easy reference:

For additional information, refer to the CMS General Provider Telehealth and Telemedicine Tool-kit, or contact a member of the HCCIntelligence™ Hotline staff at 630-283-9222 or email [email protected].

Disclaimer: This information is current as of 3/23/2020. Coding regulations are subject to change annually, and COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing.

Online Digital E/M Services_1280

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Providing Telephonic and Virtual Care Requirements as part of COVID-19 Precautions

telemedicine female physicianThe Home Centered Care Institute (HCCI) understands that many Home-Based Practices and Providers are increasing the use of virtual and telephonic care as an alternative to face-to-face care, as appropriate, due to the current COVID-19 pandemic.

Though a telehealth waiver is mentioned under recent legislation (H.R.6074 – Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020), CMS initially responded to the bill advising providers to use Communication-Technology Based Services (CTBS) and interprofessional consults.

In the CMS FAQ published on 3/5/2020, Medicare directs providers to use the current CTBS services as a means of telehealth for traditional Medicare purposes. There are, however, exceptions for Medicare Advantage (MA) patients whose MA Plan offers telemedicine as one of their supplemental benefits.

On 3/17/2020, a new Medicare Fact Sheet and FAQ’s (links below) were then published, indicating authority for the expansion of telehealth under the 1135 waiver to pay for Evaluation & Management (E/M) Office visits, Hospital visits, and other specified visits in the patient’s place of residence valid 3/6/2020.

Before billing for E/M Home Visits (CPT Code Range 99347-99350) or Domiciliary Visits, e.g., assisted living and group homes (CPT Code Range 99334-99337), however, please be advised these services are not included on the list of Medicare Telehealth Services. So, in summary, E/M Office visits (CPT Code Ranges 99201-99205 and 99211-99215) can be paid under telehealth, but E/M Home and E/M Domiciliary visits cannot at this time.

Below are the limited services included on Medicare’s list of telehealth services, which Home-Based Providers typically provide and can potentially bill for − if furnished via telehealth using Place of Service (POS) code 02 for telehealth:

  • CPT codes 99495 and 99496 for Transitional Care Management
  • CPT codes 99497 and 99498 for Advance Care Planning
  • Annual Wellness Visits CPT codes G0438 and G0439
  • CPT code 96161 − Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring, and documentation, per standardized instrument.

CTBS Services and E-Visits (CPT Code Range 99421-99423) can be provided and billed for now and prior to the telehealth waiver without Medicare telehealth restrictions.  We’ve detailed the requirements to bill for these services below (currently, and per the 2019 Medicare Physician Fee Schedule Final Rule, there is no frequency limitation for G2012 and G2010):

G2012: Brief Communication Technology-Based Virtual Check-in

  • Includes a minimum of a 5-10-minute medical discussion by a physician or other qualified healthcare professional (e.g., Advanced Practice Providers) with the patient/caregiver; this cannot include clinical staff time
  • Communication may be audio-only (e.g., telephone) or two-way video
  • Can only be used for established patients
  • Intended to assess the patient’s condition to determine if a face-to-face (F2F) visit is needed
  • Cannot be related to an E/M F2F visit within the previous 7 days and cannot result in an E/M visit within the next 24 hours or the next available appointment
  • Requires a patient-initiated question or call
  • Verbal patient consent is required, however, please note that, as a result of the Medicare 2020 Physician Fee Schedule Final Rule, only a once-per-year annual consent is required for CTBS services as long as the patient is made aware of possible cost-sharing
  • CMS National Payment Amount: $14.80

G2010: Remote Evaluation of Recorded Video and/or images

  • Pre-recorded image and/or video of sufficient quality provided by the patient or caregiver
  • Requires documentation of consent at least once per year (may be verbal, written, or electronic)
  • Requires interpretation and follow-up to the patient and/or caregiver within 24 business hours (follow-up may be via a patient portal communication, telephone, secure text/email or two-way video)
  • Can only be used for established patients
  • CMS National Payment Amount: $12.27

Please note: In the CMS FAQ published on 3/17/20, CMS clarifies that, while these interactions must be patient-initiated, CMS does condone providers making their patients aware of these services and billing for them, as appropriate. Please keep in mind medical necessity is always a requirement of payment, and documentation needs to support the necessity and decision-making of the care provided.

  • Supporting excerpt from CMS FAQ: “We expect that these virtual services will be initiated by the patient, however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation.”

CMS has explicitly stated that they do not consider Remote Patient Monitoring (RPM) Services and CTBS to be part of their definition of telehealth services. Therefore, you can bill for the above and below additional services without the regulatory restrictions of Medicare telehealth requirements (e.g., originating and distant site, geographic restrictions do not apply).

  • 99451, 99452, 99446-99449 (Interprofessional Telephone/Internet/Electronic Health Record Consultation Services)
  • 99453, 99454, 99457, 99458 (Remote Physiologic Monitoring)
  • 99091 (Review and analysis of physiologic data)
  • 99421, 99422, 99423 (Online Digital E/M by a qualified provider); Please note this service is bundled with Chronic Care Management (CCM); Refer to our 2/19/20 HCCIntelligence™ Webinar “What You Should Know About 2020 Coding Updates!” for further details regarding online E/M services
  • G2061, G2062, G2063 (Online Digital E/M by a nonphysician healthcare professional); Please note this service is bundled with CCM

Other Key Considerations:

  • CMS will not enforce an existing provider-patient relationship to furnish telehealth services. The Department of Health & Human Services (HHS) advised: “HHS will not conduct audits to ensure an existing provider relationship during this public health emergency.”
  • Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
  • HCCI encourages all Home-Based Providers and Practices to contact their local Medicare Administrator Contractor (MAC) to inquire if they will pay for E/M Home Visits furnished via telehealth under the current telehealth waiver.

For additional information on COVID-19 regulations and legislation, please visit the CMS current emergencies page or contact a member of the HCCIntelligence™ Hotline staff at 630-283-9222 or email [email protected]..

You can also visit the HCCI COVID-19 Information Hub for additional information and resources.

Disclaimer: This information is current as of 3/17/2020. Coding regulations are subject to change annually, and COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population; the Home Centered Care Institute focuses our content on CMS guidelines. All G codes are used for Medicare purposes, and commercial payors utilize a corresponding set of CPT codes.

 

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HCCIntel Practice Management Training & Education Uncategorized

Annual Chart Audits Can Greatly Benefit HBPC Providers and Practices

medical charts

medical charts

About this Article:

Regular chart audits can significantly help home-based primary care (HBPC) practices improve their coding accuracy and the quality of their documentation, while also identifying lost revenue due to under-coding or missed billing. In this interview, HCCI’s Brianna Plencner discusses how chart audits can also uncover potential compliance issues and ensure documentation and coding practices are current and appropriate.

Article:

In addition to its education offerings in home-based primary care (HBPC), the Home Centered Care Institute (HCCI) offers consulting services, including chart audits, which are a valuable tool that HBPC practices can use to evaluate provider performance and improve coding and documentation. “A formal audit provides confidential, qualified feedback on a provider’s documentation and coding practices,” explains Brianna Plencner, HCCI’s Manager of Practice Improvement.

A Certified Professional Medical Coder and Certified Professional Medical Auditor, Plencner also holds a diploma in Medical Insurance Billing and Coding. Before joining HCCI, she also served as practice manager for Northwestern Medicine HomeCare Physicians, which was founded by Dr. Thomas Cornwell, CEO of HCCI. HCCInsights recently asked Plencner to share her perspective on the benefits of conducting a chart audit.

HCCInsights: Why would an HBPC practice consider using an outside agency to perform a formal chart audit?

Plencner: First, there are many reasons to conduct routine chart audits. Medical practices can use the audit process to educate providers and staff and foster a culture of continuous quality improvement. Expert reviews of patient charts also promote more accurate and complete documentation and maximize the likelihood the practice will receive appropriate reimbursement for the services provided. Because the home-based patient population is complex, the practice’s coding must fully represent the severity of each patient’s illnesses and all the services rendered. At the same time, the audit process can minimize compliance risks by identifying and correcting billing errors.

In terms of why an outside agency would be used, external auditors inherently provide an objective point of view. Their audit decisions are not influenced by an intimate knowledge of the practice and are solely based on the data examined.

HCCInsights: How does the chart audit process work? What should a practice anticipate?

Plencner: Following the execution of a Business Associate Agreement (BAA)*, a nationally certified medical auditor will first work with you to remotely access your practice’s medical record, review a sampling of patient charts, and evaluate the quality of provider documentation and coding accuracy. Then, after a preliminary conversation with our main contact and/or the leadership at your practice, our experts will conduct a virtual meeting with your providers and practice staff to walk through the charts reviewed and discuss the findings and recommendations.

Practices also have the option of requesting that a consultant travel to their location to provide onsite coaching in coding and documentation. As needed, the consultant can also develop customized documentation tools and training plans and assist with incorporating these into the practice’s procedures. Again, the goal of all these activities is to enhance your documentation and increase your reimbursement.

*Editor’s Note: A Business Associate Agreement (BAA) is a legal document signed between a healthcare provider and contractor/vendor. A provider enters into a BAA with a contractor/vendor who might, in the course of the proposed work engagement, (e.g., HCCI) receive access to Protected Health Information (PHI).

HCCInsights: What types of things do the auditors review?

Plencner: It’s a pretty extensive list. Everything from Evaluation and Management (E/M) coding, to ensure the correct level of service is selected and the documentation supports medical necessity, to whether the necessary information is recorded, and timely signatures have been obtained. The auditor will also check whether all services provided were billed out. These are just a few examples of what’s typically reviewed.

HCCInsights: Based on your personal experience, what are the most common issues discovered during a formal HBPC chart audit?

Plencner: Among the top issues we typically discover are: (1) failure to document a complete history of present illness (HPI); (2) failure to document all services being provided, such as reviewing patient records and history, talking to other providers, ordering tests, etc., which is important for determining the correct level of Medical Decision Making (MDM); and (3) under-coding** the correct level of service, which – believe it or not – is actually more common in HBPC practices than over-coding.

**Editor’s Note: Under-coding” is reporting a lower level of service than the documentation supports.

HCCInsights: It seems like there are changes to billing and coding nearly every day – how do auditors keep up?

Plencner: Nationally certified medical auditors are required to complete a variety of continuing education requirements every year to maintain their accreditation. As experts in their field, HCCI auditors actively participate in coding and documentation “boot camps,” webinars and other credential-specific programs.

HCCInsights: Are chart audits required or optional?

Plencner: At a minimum, internal chart audits are a required component of a practice compliance plan. The industry standard is an annual audit of 10 charts per provider to determine coding accuracy and compliance. Practices without an internal billing staff, or practices desiring an unbiased third-party review, would find a lot of value from doing an external chart audit.

HCCInsights: Does HCCI offer other types of consulting services?

Plencner: Yes, HCCI can conduct practice assessments to evaluate operational standards, clinical functions, policies and procedures, and opportunities for improvement. All our consulting services are customized to the practice’s specific needs and concerns. We also can offer practices customized education, such as exclusive webinars and onsite, interactive training for the entire team.

HCCInsights: How would a practice learn more about initiating a chart audit through HCCI?

Plencner: Call us at 630-283-9222 or email  [email protected]. After an introductory call with your team, HCCI will be happy to provide you with a proposal that outlines the recommended scope of work and describes next steps. 

Editor’s Note: Those interested in coding will also want to attend our free HCCIntelligence™ webinar this month (Wednesday, February 19, 4:00 pm-5:00 pm Central Time) featuring the topic, What You Should Know about 2020 Coding Updates!