1. REIMBURSEMENT FOR TELEHEALTH SERVICES

2. AFHCAN Alaska Federal Health Care Access Network
Began in 1998 to improve access to health care for federal beneficiaries
Veterans Administration, Department of Defense, US Coast Guard, Indian Health Service, and the Alaska Native Tribal Health Consortium (managing partner)

3. Version 3 Basic Cart: Extras: Otoscope Digital Camera Scanner ECG
Tympanometer/Audiometer
Spirometer
Vital Signs Monitor (pulse
oximeter, blood pressure,
temperature and pulse)
VTC Equipment
Dental (Intraoral) Camera
Version 3 Cart
Audiometer
Tympanometer
Dental (Intraoral) Camera
Digital Camera
ECG
Scanner
Spirometer
Video Otoscope
Vital Signs Monitor

4. What is Telemedicine?
Telemedicine is a health care delivery method that links a patient and a provider who are not at the same location and is identical to a traditional healthcare visit except for the mode of delivery:
Via real time video or by
Sending clinical information or picture images to a provider for evaluation, consult or treatment via store and forward.

5. What is Telemedicine?
No telemedicine CPT codes because telemedicine is not a service provided, it is a MODE OF DELIVERY.
There are TM modifiers that alert payers of telemedicine presentation.

6. Telehealth and HIPAA

7. HIPAA cont. Treatment, Payment, and Health Care Operations;
Permitted Uses and Disclosures.
A covered entity is permitted, but not required, to use and disclose protected health information, without an individual’s authorization, for the following purposes or situations:
To the Individual (unless required for access or accounting of disclosures);
Treatment, Payment, and Health Care Operations;
Opportunity to Agree or Object;
Incident to an otherwise use and disclosure
Public Interest and Benefit Activities

8. Definition of Interactive
Two-way, real-time (live) interactive communication between the patient and the distant site (consulting) practitioner via audio/video (Polycom or VTC) equipment.
Examples: psychiatric assessment or counseling.
Photo credit:

9. Definition of Store & Forward
Store and Forward is:
asynchronous (not live) transmission of medical information to be reviewed at a later time by a health care provider at the distant (consulting) site.
Photo credit

10. Definition of Store & Forward (cont.)
Medical Information may include, but is not limited to:
Video clips
Still images
X-rays (not currently on AFHCAN system)
EKG’s
EEG’s
Audio clips

11. Requesting Provider (sending site-where the patient is located)
Face to Face visit. Provider evaluates a patient, determines the need for a consultation, and arranges services of a consulting provider for the purpose of diagnosis and treatment.
Procedure (CPT) Code
Required Telemedicine Modifier
Appropriate covered
procedure code for provider type
None required – nothing changes with telemedicine

12. Presenting Provider (Where the Patient is Physically Located)
Introduces a patient to consulting provider during an interactive telemedicine session
This provider type is not required and would only be billable during a live interactive session.
Required Telemedicine Modifier
Procedure Code
Covered procedure code for
Brief/minimal evaluation and
Management service for an
Established patient GT

13. Distant Site (Consulting) Provider
Evaluates the patient and/or medical data/images using telemedicine mode of delivery upon recommendation of the referring provider
Required Telemedicine Modifier
Procedure Code
GT (Interactive Method)
GQ (Store-and-Forward Method)
APPROPRIATE COVERED PROCEDURE CODE FOR PROVIDER TYPE

14. PROVIDER TELEMEDICINE ROLES

15. Provider Telemedicine Roles
Store-and-Forward Mode of Delivery
Interactive Mode of Delivery
Referring Provider
Consulting
Provider
Digital images, sounds,
previously recorded video
Referring Provider
Presenting Provider
(Patient is Here)
Consulting
Provider
Live Interaction with patient
using camera, video, or audio
conference equipment

16. Provider Telemedicine Roles EXAMPLE
Store-and-Forward Mode of Delivery
Interactive Mode of Delivery
REMOTE
CHA/P
HUB
CONSULTING
PROVIDER
Digital images, sounds,
This could also be a CHA/P
Previously recorded video
HUB
PROVIDER
The patient is here.
REMOTE
CHA/P
Live Interaction with patient
ANMC
CONSULTING MD
Using camera, video, or audio
Conference equipment

17. Referring Provider Type (sending site)
Performs face to face evaluation of patient
Determines need for further consultation with another healthcare provider
Develops media presentation (store and forward) including complete information of evaluation

18. Presenting Provider (Where the Patient is Physically Located)
Introduces a patient to consulting provider during an interactive telemedicine session (example: CHA/P at a remote site)

19. Distant Site (Consulting) Provider
Evaluates the patient and/or medical data/images using telemedicine mode of delivery upon recommendation of the referring provider (example: MD at ANMC or Regional Hub)

20. DOCUMENTATION

21. Provider Documentation
Follow same requirements as face to face to meet CPT standards for coding – remember SOAP notes!
Do not utilize the AFHCAN system as ! Always remember that the information you send/receive becomes part of the patient’s medical record!
As with all medical records, it is important to clarify the encounter so that coders aren’t making judgment calls (don’t assume anything)!

22. TM 4
This is an ongoing communication between a remote provider and a specialist at ANMC.
NO CONSULT!

23. IMPORTANT!
When the AFHCAN system is used for communication between two or more providers regarding a specific patient, the AFHCAN form needs to be printed out and incorporated into the medical record!
This could mean that a visit would have a PEF and an AFHCAN form, or a PCC and an AFHCAN form.

24. This statement alone is not sufficient for requesting a consult.
TM 1
EXAMPLE
This statement alone is not sufficient for requesting a consult.
A statement is also required for why they are requesting a consult.

25. PROBLEMS: EXAMPLE OF WHAT NOT TO DO! Appears that ANMC
TM 2
PROBLEMS:
Appears that ANMC
physician initiated this
(no one has requested
a consult).
There is evidence of
a prior communication
that coder doesn’t have
access to. Each record
needs to be a stand
alone document.
ANMC cannot code as a
consult because there is no
statement about why the remote
site is requesting a consult.
Additionally, the “consulting”
provider is assuming treatment
of the patient, so does not meet
criteria of consult. ANMC also
cannot code an E/M because
patient is not present (no exam).
This is more like an ongoing
communication.
EXAMPLE
OF WHAT
NOT TO
DO!

26. EXAMPLE OF WHAT TO DO Assuming this form would be used
TM 3
Chances are, this visit will meet the requirements for a 99213, but impossible to code without the PCC or PEF
Assuming this form would be used
to bill the consult, the documentation
provided here meets the criteria for a
99242 Level II Office Consultation:
Expanded problem focused history
Expanded problem focused exam
Straight forward medical decision making
EXAMPLE OF
WHAT TO DO

27. Guidelines to Remember
* Evaluation/Management

28. New Patient vs. Established Patient

29. Definition
New Patient – A new patient is one who has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.
Established Patient – An established patient is one who has received professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.

30. New Patient

31. Established Patient

32. Consultations
99241 Office consultation for a new or established patient, which requires these three key components:
A problem focused history;
Problem focused examination; and
Straightforward medical decision making.

33. Consultations
99242 Office consultation for a new or established patient, which requires these three key components:
An expanded problem focused history;
An expanded problem focused examination; and
Straightforward medical decision making.

34. Consultations
99243 Office consultation for a new or established patient, which requires these three key components:
A detailed history;
A detailed examination; and
Medical decision making of low complexity.

35. Consultations
99244 Office consultation for a new or established patient, which requires these three key components:
A comprehensive history;
A comprehensive examination; and
Medical decision making of moderate complexity.

36. Consultations
99245 Office consultation for a new or established patient, which requires these three key components:
A comprehensive history;
A comprehensive examination; and
Medical decision making of high complexity.

37. Three R’s of Consultations
Requesting a consult
Rendering an opinion
Reporting back to the requesting provider

38. PAYOR SPECIFIC REIMBURSMENT

39. STATE OF ALASKA MEDICAID

40. Service Requirements Telehealth services must
Be within the scope of Medicaid’s coverage provisions
Be within the scope of the practitioner’s license
Be a service that is appropriate for using a telemedicine method
MEDICAID

41. Service Requirements cont.
Provider must ensure telemedicine transmission meets all federal and state privacy regulations and requirements
Alaska Medical Assistance does not cover medical services provided by telephone or fax machine
MEDICAID

42. Medicaid Providers
Most healthcare practitioners who are currently eligible for reimbursement by Alaska Medical Assistance may participate in telemedicine. However, the following provider types cannot be reimbursed for telemedicine delivery:
MEDICAID

43. Ineligible Providers Home and Community-based Waiver Pharmacy
Durable Medical Equipment (DME)
Transportation
Accommodation
End-stage Renal Disease
Private Duty Nursing
Personal Care Attendant
Vision (includes visual care, dispensing, or optician services)
MEDICAID

44. STORE & FORWARD EXAMPLES

45. CHA/P Visit at a Remote Site
TM 4
CHA/P Visit at a Remote Site
Visit meets
the criteria
for a
Established
Patient OV
PF HPI
PF Exam
Low Comp
Dec Making
Example of
WHAT TO DO
Store & Forward
Document that this is a store and forward telemedicine case.
CHA/P at a
remote
site sees
patient in a
face-to-face visit
and requests
consult from a
hub provider.
Important to note provider credentials
MEDICAID

46. This is the claim billed to FHSC (MEDICAID) for the CHA/P
TM 5
No telemedicine modifier for the face-to-face visit, just use the U1 modifier to signify CHA/P as provider.
This is the claim billed to
FHSC (MEDICAID)
for the CHA/P
end of the visit only.

47. TM 6
Example of
WHAT TO DO
This is a problem focused exam, so is the consultation code to bill with a GQ modifier for the telemedicine mode of delivery.
The consulting
provider at the
hub clinic reviews
the case.

48. Example of how to bill FHSC (MEDICAID) for the consult if provider
TM 7
Example of how to bill
FHSC
(MEDICAID) for the
consult if provider
is in a
clinic.

49. Store and Forward FNP Visit at a Remote Site
TM 9
Store and
Forward
Requesting telemed consult
Sending 3 images signifying store and forward.

50. No modifier required for the face-to-face visit.
TM 10
Bill FHSC
For Referring
Provider FNP
No modifier required for the face-to-face visit.
99212 for face-to-face visit

51. TM 11
Example of
WHAT TO DO
This is a problem focused exam, so is the consultation code to bill with a GQ modifier for the telemedicine mode of delivery.
The consulting
provider at the
hub clinic reviews
the case.

52. GQ Modifier for Store and Forward
TM 12
Billing FHSC
(MEDICAID) for
the consult (at
ANMC or Hub).
GQ Modifier for Store and Forward
Consult 99241

53. INTERACTIVE EXAMPLE

54. Example of Interactive
TM 13
CHA/P is Referring Provider. Pt will be presented in Interactive Session tomorrow. This visit meets guidelines for 99212
Example of
Interactive

55. Visit is coded as a 99212 for the face-to-face visit with patient
TM 14
Visit is coded as a for the face-to-face visit with patient
Bill FHSC
(MEDICAID) for
CHA/P as
Referring
Provider in
Interactive
Session
No Telemedicine Modifier for the Referring Provider
U1 Modifier for CHA/P

56. It is the next day, the patient returns to the This visit
TM 15
It is the next
day, the patient
returns to the
clinic and is
presented by
the same CHA/P
for interactive
telemedicine
session with
Dr. Ortho at
Hub. The CHA/P
now is the
Presenter.
This visit
meets the
criteria for
99211.

57. GT Modifier for Interactive Telemedicine Visit
This is how to
bill the Presenter
to FHSC
(MEDICAID).
GT Modifier for Interactive Telemedicine Visit
U1 Modifier for CHA/P

58. Consult code with a GT modifier for Interactive Telemedicine Session
This is how the
Consulting end
Is billed to FHSC
(MEDICAID)

59. What if the CHA/P refers and presents on the same day?
FHSC (State of Alaska Medicaid) will only pay on one of the bills, the second will most likely be denied as “incident to” the first visit.

60. Multiple Consultation Roles
Store-and-Forward Mode of Delivery only
Referring
Provider
Consulting
Provider
Consulting
Provider
Example: CHA/P forwards a request for consult to a healthcare provider (audiologist, NP, physician, etc) who then evaluates the information and requests further consultation from another healthcare provider (ENT, specialist, etc)
MEDICAID

61. Multiple Consultation Roles Example
Store-and-Forward Mode of Delivery only
Referring
Provider
REMOTE CHA/P
Consulting
Provider
HUB FNP
Consulting
Provider
ANMC MD
Example: CHA/P forwards a request for consult to a healthcare provider (audiologist, NP, physician, etc) who then evaluates the information and requests further consultation from another healthcare provider (ENT, specialist, etc)
Both Hub FNP and ANMC MD
can bill for consults
MEDICAID

62. Multiple Consultations/Referrals
Multiple consultations covered
(scope of practice is greater than or equal to the referring)
Multiple referrals not covered
MEDICAID

63. BILLING AND REIMBURSEMENT
Billed on 1500 for professional services provided in a tribal free-standing clinic setting
Billed on UB for professional services provided in tribal outpatient hospital clinic
Services are reimbursed at the regular Medicaid rate
85% Medicaid physician fee schedule for CHA/P services
Current year encounter rate published in the Federal Register for services provided under CL_____ or OP Hospital clinic HS__OP
Mental health services and all other services under the appropriate published Medicaid fee schedules
MEDICAID

64. Exclusions to Required Modifiers
Currently accepted practices within an industry not affected
Example: teleradiology consults will not need to use telemedicine modifiers GT and GQ; these providers should continue to use modifiers -26 (Professional Component)
MEDICAID

65. Telemedicine for Dental Providers - Medicaid
Store and Forward Application (sending x-ray image) to a Dentist for interpretation is currently reimbursed
Live (interactive) consults by the distant site dentist can be reimbursed as if face to face
Presenting providers use CDT-4 code D0140 – Limited Exam for reimbursement
Use your standard dental claim form
There are NO telemedicine dental modifiers

66. MEDICARE

67. Medicare Reimbursement
Tribal sites permitted to bill store and forward consultations due to participation in federal demonstration project – AFHCAN
CHA/P originating site referrals not billable (Medicare does not recognize CHA/P as a provider)
Originating site can NOT bill a facility fee with CHA/P referral since Medicare does not recognize CHA/P as a provider)
Consulting Provider has to bill as an office visit, not consult with CHA/P referral
MEDICARE

68. This visit cannot be billed to Medicare CHA/P Visit at a Remote Site
TM 18
CHA/P Visit at a Remote Site
Visit meets
the criteria
for a
Established
Patient OV
This visit cannot be
billed to Medicare
Document that this is a telemedicine visit.
CHA/P at a
remote
site sees
patient in a
face-to-face visit
and requests
consult from a
hub provider.
Important to note provider credentials
MEDICAID

69. HOWEVER….

70. TM 19
Medicare can be billed for the consulting side, although an E/M code will be used instead of a consult code. Since Medicare does not recognize CHA/P’s as providers, there is no request for consult. The consulting provider bills as a face-to-face visit.

71. Consulting MD bills an E/M. In this case 99212.
TM 20
Consulting MD bills an E/M. In this case
Use the GQ modifier to document store and forward telemedicine as mode of delivery.
Meets criteria for
99212:
PF HPI
PF Exam
DM Low Complex

72. TELEHEALTH SERVICES INCLUDE:
Office Visits
Other Outpatient Visits
Consultation
Individual Psychotherapy
Pharmacologic Management Services
Gwen will change Medicaid to match this.

73. DEFINITIONS
Distant Site – where the person delivering the service is located at the time telecommunications service is provided
Originating Site – where the eligible Medicare beneficiary is located at the time telecommunications services are furnished
Per Medicaid – Originating site (MCR) is “Presenting provider” and/or “Referring provider” – this is the face-to-face with the patient.
Distant Site (MCR) is Consulting provider with Medicaid

74. DEFINITIONS, cont.
Asynchronous Store & Forward Technologies – patient’s information is transmitted from an originating site to a practitioner at a distant site for review without patient’s presence
Interactive Technologies – involve audio and video multimedia communication equipment for two-way, real-time interactive communication between the patient and the distant site practitioner
Interactive is also “live” with Medicaid

75. TELECOMMUNICATION SERVICES NOT COVERED
Telephones
Facsimile Machines
Text Messages
Same w/MCD

76. Qualified Practitioners
Distant Site
Physician
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Nurse-Midwife
Clinical Psychologist
Clinical Social Worker
Nutritionist
For Medicaid, UNQUALIFIED –
Home & community based waiver svcs
Pharmacy svcs.
DME
Transportation svcs
Accommodation svcs
Esrd
Direct-entry midwife services
Private-duty nursing svcs
Personal care attendant svcs
Visual care dispensing svc or optician svcs
Eligible for MCD – services provided by a treating, consulting, presenting or referring* provider for a Medicaid covered service that is provided within the scope of the practitioner’s license.

77. QUALIFIED ORIGINATING SITE (where the patient is located)
Practitioner’s Office
Critical Access Hospital
Rural Health Clinic
Federally Qualified Health Center
Hospital
(Does NOT include a CHA/P clinic)
MCD – no limitations on POS for originating or referring

78. REIMBURSEMENT – DISTANT SITE (where the consulting provider is located)
Payment to the distant site practitioner is equal to the current fee schedule amount paid for such services without telecommunications
Distant site practitioner should choose from the following CPT codes:
99241 through 99275
99201 through 99215
90804 through 90809
And 90862
MCD 100% of fee schedule
Includes:
Initial visit
F/u visit
Confirming consultation
Diagnostic, therapeutic or interpretive service
Psychiatric or substance abuse assessment
Individual psychotherapy or pharmacological mgmt svcs

79. REIMBURSEMENT – ORIGINATING SITE
The originating site receives a facility fee equal to 80% of the lesser of the actual charge or $22.94 (2007) unless CHA/P
HCPCS code Q3014 – Telehealth Originating Site Facility Fee
Payments made to a distant site practitioner (including deductible and coinsurance) may not be shared with the originating site.
Type of Service 9 – other items and services
Medi is face-to-face
No facility fee

80. COMMERCIAL PAYORS

81. Commercial Payors Many private payors are covering telemedicine
Make certain the payor is aware that they are paying a telemedicine delivery.

82. Questions? Cheryl A. Skiffington, CCA cskiffington@anmc.org