Road to Reimbursement: Logistics

It is becoming increasingly clear that Telemedicine is growing in popularity.  As we referenced in previous articles in this series, it is being reported as a top goal in expanding practices by many healthcare practitioners. However, it is also becoming a strong factor in how consumers choose which providers they see. In a 2017 study entitled “The consumer is the new payer in healthcare”, NRC Health found that 58% of consumers found it important (in terms of their physician choices) that their current physician add telehealth in the near future and 12% actually said they would switch care providers if the one they had previously preferred didn’t offer telehealth. Unfortunately, there are many medical offices that still hesitate to offer it and if they do, it is frequently not taken advantage of by their patients.

The most often-cited reason for the lack of adoption and utilization is insurance reimbursement for virtual care services.

We have created this series to pave the way through the seemingly endless roadblocks some payers place on telemedicine reimbursement.  While these barriers to payment can appear intimidating, utilizing the principles in this “Road to Reimbursement” series can bypass many of those obstacles. The first two articles focused on concerns surrounding Licensing and Location.  For this final installment, we will be gathering the rest of the major points of resistance under the umbrella of Logistics.

The term “logistics” has a varied slew of technical and popular definitions; the one we draw on today is this:

“The planning, implementation, and coordination of the details of a business or other operation.”

As healthcare practitioners, especially those who are doctor-owners, you know the incredible number of moving parts involved in providing and practicing healthcare. It can be overwhelming to consider that any number of factors in your process can affect whether you get paid. Add to that, the number of insurance carriers (858 U.S. health insurance companies in 2016) and a 10% growth rate in the last three years. Each of the 50 states has a different Medicaid plan, and there are both Medicare and military health plans. Every single one of them has a different set of coverage policies and restrictions.

To help with the over-abundance of variables, the following narrows down the top three pieces that most affect insurance reimbursement of telehealth services.

Provider Specifics

Believe it or not, the first thing that can get in the way of getting paid is, well, you. What type of healthcare practitioner is providing the services can make all the difference in the world. Unfortunately, in what you will come to see is a common theme in all of these pieces, the providers who are eligible to provide telehealth services (and be paid for them) can differ greatly from private plans, across states, to federal regulations. Physicians are always included, but after that it can be tricky – most cover services provided by Nurse Practitioners and Physician Assistants. Nurse Midwives and providers of mental health services (psychologists, therapists, counselors, social workers, etc.) are also becoming increasingly commonplace. Some plans have no mention of provider types at all.

Another aspect of the provider themselves that can stand in the way is certain certification or registration requirements. Often health plans, especially private companies as well as some states, require that the provider register as a telehealth provider as a part of their contract with that company, or go through a certification process in order to be eligible for payment. Missing that is one of the easiest ways to lose money on telehealth.

As an important add-on to that, within this next year the DEA has been compelled to create, revise and finalize a telehealth “special registration” process. This is so that providers can be exempt from the Ryan Haight Act ban on prescribing controlled substances in alternative healthcare delivery scenarios as long as they are registered with the DEA according to their guidelines, and will obviously be required, once it exists, for any virtual encounter involving pharmacologic management services.

Finally, there are some CPT codes (which we will touch on more a little later) for some services  that can only be provided by a certain provider type – for example, Evaluation and Management services (E/M codes) can only be billed when a physician is providing those services.


Visit Details

Another factor that affects reimbursement might be the activities required to fulfill each type of appointment. When trying to decide whether a visit can be completed via telehealth, these are some questions to ask yourself:

What is the scope of services offered?

The most basic one, this refers to what the range of services is that will be provided to the patient from the start to the end of this appointment. Diagnosis and prognosis, dietary or genetic counseling, blood pressure monitoring, and medication management are all examples. Also, the broader categories such as specialty types like ophthalmology, orthopedics, palliative care and surgery follow-ups are also important to consider and check against your payer’s policy.

What type of appointment is it?

Each CPT code mentions a specific “type” of appointment: E/M, structured assessment and intervention, education and self-management training, and so on. Make sure that you are familiar with which type your payer covers via telehealth and that your visit will have the necessary elements to be considered as such.

How long do I need to complete this visit?

Most codes for office visits have a time limit on them: 15, 30, 45, or 60 minutes. If your time spent in face-to-face interaction with the patient and/or family exceeds 60 minutes, it is probably best to choose another method of delivery, though there are codes that are eligible for telehealth billing that address “prolonged preventative services” or additional time for E/M visits. Most telehealth encounters are under 30 minutes of face-to-face time with the billing provider.

How complicated is the medical problem we will be addressing/how much problem-solving will be needed?

Another factor of many of the CPT codes you will be looking at, especially in primary care settings, is the complexity of the visit. When considering what type of visit it is, you must consider how in-depth each element of the visit will need to be for your patient. For example, with codes for E/M, you have to have documentation of two of the following: a history that is detailed, comprehensive, or expanded problem-focused. Same goes for an exam (detailed, comprehensive, or expanded problem-focused). And the third is medical decision-making: low, moderate or high complexity. Not all codes reimbursable for telehealth are E/M codes, but many of them require the same type of distinction as far as the amount of effort and complexity required for the appointment.

What data (vitals, physical exam, family history, systems review, etc.) is needed to complete this appointment, and do I or the patient have the equipment necessary to do so?

The last detail of any visit that needs to be considered when trying to determine eligibility for telehealth reimbursement is whether you have the ability to collect whatever data is needed to complete the visit with the same standard of care as if the patient was in your office. That refers to things such as vitals, physical exams, family or patient history, systems reviews, medication management – sometimes it is a matter of having access to the patient’s EHR wherever you are located, and other times it is necessary to have certain medical devices or trained clinical staff present with the patient to complete any diagnostic testing or evaluation metrics. Not all types of visits need that however, it is just a matter of being thoughtful about what this visit requires when choosing whether to see the patient virtually.


Coding Intricacies

The final piece is the actual business of coding each telehealth encounter. Again, we run into a similar dilemma as there are no standardization or hard and fast rules. The following attempts to filter through the complexity of the coding policies to help you identify the most helpful resources.

The Center for Medicare and Medicaid Services

Every year CMS has a period of time where members of the healthcare community can submit codes for consideration to be included in the list of covered telehealth service for the coming year. They are in two categories: Category 1 is for codes that are similar to codes that are already on the list of approved telehealth services, and Category 2 codes are new and distinct codes for services not similar to what is already approved – those require a more extensive burden of proof as to why they should be included in the list than the first category. After that period of submission is over, CMS will release its proposed list, along with the proposed physician fee schedule for the next year. The physician fee schedule is a comprehensive list of how much the physician is paid for each service, by code, that Medicare reimburses services for. There is then a period where they accept comments from the healthcare community about the proposed list and rule, which is then finalized and published before the next year, usually in November of the year preceding.

This list of codes is often the basis for both state and private plans – there are many coverage documents that include language like, “we adhere to the same standards for telehealth as CMS” or “eligible services include the list of CY__ CMS telehealth eligible service codes.” So, even if a provider is not contracted with Medicare, it is still important to be familiar with this list. In cases where a benefit plan is more progressive, this list is still used as a starting point – it sets the low bar of the minimum coverage required for the industry as a whole.

2019 Current Procedural Terminology Manual from the American Medical Association

The other list of codes that is important to be familiar with is in the CPT manual itself. Every year the American Medical Association releases an updated version of their coding manuals, both for procedures/services and for diagnoses. The CPT codes are accepted by all payers as the standard of billing for an encounter – they are basically a way to take the encounter notes and make them into something measurable and consistent regardless of the style or type of practice of an individual physician. In the back of the book is “Appendix P” which is a list of codes that can be delivered via telehealth. This list is often referenced alongside the CMS list in policy documents as covered telehealth services for private payers and Medicaid plans alike.

The Great Modifier Debate

The most confusing aspect of coding telehealth encounters surround the use (or disuse) of modifiers, hands down. Over the years Medicare, Medicaid and private payers have stated their preferences in an inconsistent way – some prefer the older GT code denoting that the service was delivered virtually, while some (including Medicare for services on or after January 1, 2018) prefer the Place of Service (POS) code 02 to be used instead.

In addition to that difference, the AMA included the modifier -95 for the first time in the 2017 CPT manual. That modifier established that a service was delivered via live-video telehealth and can only be applied to codes listed in Appendix P. However, there is no clear standard as far as whether insurance providers accept or use that modifier or not. Medicare, for example, does not.

When it comes to these modifiers the general rule of thumb is to call each individual insurance provider that you are contracted with before submitting bills for telehealth encounters until you are sure that you are familiar with their particular rules and requirements. Some states include their coding preference in their regulatory documents (for example, Maryland wants providers to use the GT modifier), but for most you will need to speak to their adjusters directly. It is always best to do this before, because once a service is denied reimbursement, whether it is because of incorrect coding or not, it becomes infinitely harder to secure the payment in a timely manner.

Next Steps on Your Journey to Success

You chose to pursue a career in medicine because you wanted to help people get and stay healthy; but everyone needs a paycheck at the end of the day. And while the ever-evolving world of medical technology innovation can be daunting for those deep in the trenches of healthcare, the clear benefits of telehealth for both providers and patients far outweigh the concerns.

Hopefully, after reading this series, you have a greater understanding of and confidence in how to successfully get paid for the telehealth services your patients want and your practice needs. If you are ready to continue your journey of preparing your practice to offer telehealth services, join our next Webinar or visit our Resource Library for answers to more of your questions about all things telehealth. And if you are already prepared and ready to get started call us at 877-83-VISIT, email, or schedule a demo to talk to us about how SimpleVisit can help you implement telehealth with no new technology, low cost, and the most user-friendly process on the market today!

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