峰會前會議A：賬單和報銷訓練營.pdf

1、Kellie Mendoza serves as the Chief Compliance&Privacy Officer for MUSC Physicians.In this role,she has primary responsibility for the development,implementation,revision and oversight of the MUSCP Compliance Plan and activities related to privacy and access to patient health information.As the deman

2、ds of the healthcare regulatory environment increase,she and her team strive to maintain and expand the visibility of corporate compliance efforts and implement compliance initiatives that reduce risk related to professional billing practices.Kellie has over 18 years of billing and coding experience

3、 with an emphasis on telehealth billing&reimbursement policies in South Carolina.Kellie is a graduate of the Medical University of South Carolina where she earned a Bachelor of Health Science(summa cum laude)and a Master of Health Administration.She holds a Certified Professional Coder(CPC)certifica

4、tion from the American Academy of Professional Coders(AAPC),a Certification in Healthcare Compliance(CHC)and a Certification in Healthcare Privacy Compliance(CHPC)from the Health Care Compliance Association(HCCA).Amanda Gardner joined the MUSC Physicians Compliance Department in 2020 and serves as t

5、he Corporate Compliance Regulatory Manager.Amanda is responsible for research/investigation and interpretation of applicable laws and regulations for the billing and business relations of MUSC Physicians and other organizations where MUSC Physicians provides compliance oversight via contract.She ens

6、ures implementation of appropriate policies and compliance training,conducts investigations,and responds to all regulatory matters.Amanda is a graduate of The Ohio State University where she earned a Bachelor of Science in Health Information Management and Systems and a Master of Health Administrati

7、on.She holds a Registered Health Information Management Administrator(RHIA)certification and is a member of the American Health Information Management Association(AHIMA).This presentation and the content herein are solely based on information published in payer policies as of October 25,2024.The mat

8、erials provided in this presentation are for general information purposes only and do not constitute legal or other professional advice on the subject matter.The material provided in this presentation are not statements of advice,opinion,or information of the presenter.The presenter encourages one t

9、o seek the advice of your respective health care counsel and your compliance department for a more detailed explanation of this information and its application to your situation.Describe common virtual services and documentation/billing guidelines for each Understand coverage rules and current state

10、 of reimbursement for telehealth,including any Public Health Emergency(PHE)extensions Understand Teaching Physician Regulations for video visits Understand responsibilities outlined under the SC Telemedicine Act Consent requirements vary by state SC requires written informed consent be documentedoVe

11、rbal vs.written CMS Best Practices A video visit is a visit performed using live,interactive video and audio Platform used must be HIPAA Compliant Current State:Provider must select E/M code as if the service was provided in person;E/M category is based on patient status(inpatient vs.outpatient)o Ex

12、amples:99202-99215;99242-99245(Office or other outpatient visits)99281-99285(Emergency department visits)99252-99255;99221-99223;99231-99233,99238(Inpatient visits)G0425-G0427(Medicare telehealth consults,emergency department or inpatient)G2025(RHC/FQHC)Jan.1,2025:AMA will release new E/Ms for video

13、 visitso Coding will be dependent upon payer policies,CMS/DHHS have not yet issued a statement on how telehealth claims should be submitted Documentation must include the following:o A statement that the service was provided using interactive audio&video;o Location of the patient;o Location of the p

14、rovider;o Medical necessity of the visit;o Total time SC Medicaid requires start and stop time only if also required for a face-to-face service All other payers allow total time,but not time ranges o Names of all persons participating and their role in the encounter,as applicable From March to Novem

15、ber 2020,there were$1.4 billion in Medicare Part B payments for more than 19 million E/M serviceso105 of 110 sampled E/M services complied with Medicare requirements Why is this important?oLike services provided face to face,billed telehealth services must be supported by the actual performance of t

16、he serviceoPerformance of service=documentation Current StateA telephone visit(AKA virtual check-in)is a visit using telephone only,without videoBilling is based on provider type and total time of the visitCannot be billed if less than 5 minutes OR for communication of test results,scheduling appoin

17、tments,or for other communication that does not include E&M servicesReported only once for the same episode of care during a 7-day period;cannot report if originating from a related visit provided within the previous 7 days or if communication leads to a virtual visit within 24 hours or soonest avai

18、lableJan.1,2025 AMA will release new E/Ms for audio only visits for eligible E/M billing providers Non-MD/APP services will likely continue to be billed using 98966-68 A statement that the patient provided verbal consent for the billing of the service(each service)Medical necessity of the visit Tota

19、l time(actual not time range)Q:What do I do if I start a visit as a video visit,but the patient is unable to connect and the service is ultimately done via telephone?A:The service should be billed as a telephone visit and billed based on total time.An e-visit is an asynchronous communication between

20、 a patient and provider through an online patient portal This service may not be used for work done by clinical staff(i.e.,nurse,CMA)May only be reported once for the billing providers cumulative time devoted to the service for the same or related problem during a 7-day period If separate E/M servic

21、e provided during the 7-day period,time spent on e-visit must be incorporated into the separately reported E/M service.Cannot be billed if less than 5 minutes A statement that the patient provided consent for the billing of the service(annually)Medical necessity of the visit Total time(actual not ti

22、me range)An Interprofessional consult,AKA e-consult,is a time-based visit in which a patients treating physician/APP requests the opinion/treatment advice of a consulting physician/APP to assist in the diagnosis and/or management of the patients problem.The service is provided without face-to-face p

23、atient contact with the consultant.The service includes medical consultative discussion and review of pertinent medical records,laboratory studies,imaging reports,medications,and path results.Not reported if in-person visit in past 14 days,next available appt is scheduled,or transfer of care Cannot

24、report 99446-99451 more than once in 7-day period Physician to physician service A statement that the patient provided verbal consent for performance and the billing of the service(each service)Request with reason for consultation Medical necessity of the visit Total time(actual not time range)If a

25、physician provides an interprofessional consult for a patient they have never seen before,and then the patient presents a few months later for an office visit with the same physician,the patient will be considered a new patient.Provider must obtain patients consent for all RPM and RTM services and d

26、ocument it in the patients medical recordThe device must meet the definition of a medical device,as defined by the FDAThe service must be ordered by a physician or other qualified healthcare providerRPM and RTM services can be billed during the same service period as Chronic Care Management(CPT code

27、s 99487,99489,and 99490),Transitional Care Management(CPT codes 99495 and 99496),and Behavioral Health Integration(BHI)(CPT codes 99492,99493,99494,and 99484)(4)be licensed to practice medicine in this State;provided,however,a licensee need not reside in this State if he has a valid,current South Ca

28、rolina medical license;further,provided,that a licensee who resides in this State and intends to practice medicine via telemedicine to treat or diagnose patients outside of this State shall comply with other applicable state licensing boards;(4)verify the identity and location of the patient and inf

29、orm the patient of the licensees name,location,and professional credentials In S.C.,an in-person evaluation is required to prescribe new C-II and C-III narcotics except in the following scenarios:o When the practice of telemedicine is being conducted while the patient is physically located in a hosp

30、ital and being treated by a practitioner acting in the usual course of professional practiceo When buprenorphine is being prescribed as a medication for opioid use disordero For patients enrolled in palliative care or hospiceo Any other case where an exception has been approved by the S.C Medical Bo

31、ard An established patient is not required to have an in-person evaluation for the refill of a current medication as previously prescribedDefinition of telehealth created as“the use of electronic communications,information technology,or other means to deliver clinical health care,patient and profess

32、ional health-related education,public health,or health administration between a licensee in one location and a patient in another location with or without an intervening licensee”Amendment to the Nurse Practice Act that an APRN may perform medical acts and prescribe C-II and C-III medications via te

33、lemedicine and telehealth pursuant to a practice agreement without having to be licensed to practice medicine in SCOutlined by each state,but typically require providers to be licensed in the state where the patient is located.Information on individual state licensure requirements can be found on th

34、e Federation of State Medical Boards website.Audits to verify conditions of payment are met:oState licensure oProvider locality for diagnostic tests oSupervision oConsent oDocumentation of time oCharge consistent with service performed oHIPAA compliant technology Generally,telehealth coverage is bas

35、ed on:CPT code Performing provider type Originating site Medicares resource for coverage and billing rules for telehealth services can be found here Medicare coverage is currently based on the following:1)Distant site provider type2)Service(CPT or HCPCS code)Click here for a full list of CPT/HCPCS c

36、odes payable under the Medicare Physician Fee Schedule when furnished via telehealthCovered services for new and established patientsNon-covered services*Exception:Audio-only services that are permanently covered for mental health treatmentCovered services for established patients onlyCovered servic

37、es for established patients only RPM may only be provided to established patients RTM may be provided to new and established patientsCovered services Full list in Appendix T in CPT book 93 modifier required Use after Jan 1.2025 dependent upon CMS coding rules and use of new AMA E/M codes Medicare al

38、lows coverage for services that would routinely be done using video/audio to be performed using only audio(i.e.,telephone)Video Visits:POS 02(telehealth provided other than patient home);POS 10(telehealth provided in patient home)Virtual Check-ins,Telephone Visits,E-visits,Interprofessional Consults

39、:POS as if the patient presented in person Video visits:95 Stroke:G0 Audio-only:93 Mental health:FQ Asynchronous:GQAny location,including patients homeAn eligible originating site located outside of a Metropolitan Statistical Area(MSA)OR within a Rural Health Professional Shortage Area(HPSA)*Exclusi

40、ons:services for the diagnosis,evaluation or treatment of a mental health disorder or an acute strokePatient must physically be located in a hospital facility*Exception:Behavioral health services provided in the patients homeFull information regarding flexibilities for RHCs and FQHCs can be found he

41、re.Eligible to furnish telehealth to meet in person requirement Patient required to be seen in person,excluding mental health services Mental health services may be provided via telehealth if an in-person visit was furnished within the previous 6 months In general,there must be an in person mental h

42、ealth visit at least every 12 months while the patient is receiving telehealth services to diagnose,evaluate,or treat mental health disordersPatient cost sharing requirements for telehealth services enforced*Exception:Cost sharing waived preventive services furnished via telehealth in RHCs and FQHCs

43、 through 12/31/2024Practitioners can render telehealth services from their home without reporting their home address on their Medicare enrollmentPractitioners are required to report their home address on their Medicare enrollment if rendering telehealth services from their home Tele radiology is the

44、 process of transmitting medical images from one location to another for interpretation and consultation Provider locality considerations:o Rules for interjurisdictional reassignment apply to all remote practitioners or practitioners located in another MAC jurisdiction than the practice to which the

45、y have reassigned their benefits o Payment varies among localities and is determined based on the location where the service is performedo If the provider performing the professional component is not located in the same payment locality as the technical component,the service cannot be billed globall

46、yMay be virtually present and immediately available via live interactive audio/video technologyMust be physically present and immediately availableMay meet required presence and participation via live interactive audio/video technology if the service is furnished virtually(i.e.,3-way video visit wit

47、h all parties in separate locations)*Exception:For residency training sites that are located outside of a Metropolitan Statistical Area(MSA),i.e.,Orangeburg,virtual supervision is permissible even if services are performed in person by the residentMust be physically present to meet required presence

48、 and participation*Exception:May meet required presence and participation via live interactive audio/video technology for services if patient and resident are both in a Rural Health Professional Shortage Area(HPSA)E/M levels 1-3 and Welcome to Medicare/Annual Wellness Visits(G0402,G0438,and G0439)ma

49、y be provided by residents located in all residency training sites E-visits(99421 99423),interprofessional consult(99452),and virtual communications(G2010 and G2012)may be provided by residents located in residency training sites outside of a Metropolitan Statistical Area(MSA)Residents and fellows m

50、ay furnish and separately bill for services in the inpatient,outpatient,and emergency department settings that are not related to their approved GME programsNo frequency limitations on telehealth services Subsequent Inpatient Care may only be billed once every three days Subsequent Skilled Nursing F

51、acility Care may only be billed once every fourteen days Critical Care Consultations may only be billed once per day Community Mental Health(CMH)Services Provider Manual Hospital Services Provider Manual Physicians Services Provider Manual 2024-2025 Telehealth Proviso Report Final|SCDHHSFull listing

52、 of provider manuals can be found here SC Medicaids resource for coverage and billing rules for telehealth services can be found on the SCDHHS website and searching“telehealth”Current telehealth flexibilities can be found here Future state(eff.01/01/25)of telehealth coverage can be found here SC Med

53、icaid coverage is currently based on the following:1)Distant site provider type2)Service(CPT or HCPCS code)Click here for a full list of CPT/HCPCS codes payable when furnished via telehealthMedicaid allows coverage for behavioral health services that would routinely be done using video/audio to be p

54、erformed using only audio(i.e.,telephone)Covered services for established patients onlyCovered services for MD/APPsNon-covered for other eligible provider types Non-covered servicesNon-covered servicesCovered services Place of service oVideo Visits:POS 02oTelephone Visits,E-visits,and Interprofessio

55、nal Consults:POS as if the patient presented in person GT modifier(video visits only)Any location,including patient home Referring site eligible for Q3014Any location*Note:provider must be licensed in SCPhysicianNurse PractitionerPhysician AssistantPhysical TherapistOccupational TherapistSpeech Lang

56、uage PathologistClinical Psychologist*Clinical Social Worker*Licensed Professional Counselor*Licensed Marriage&Family Therapist*providers enrolled under CMHC,RBHS or LIP categoriesPhysicianNurse PractitionerPhysician Assistant Clinical Psychologist*Clinical Social Worker*Licensed Professional Counse

57、lor*Licensed Marriage&Family Therapist*providers enrolled under CMHC,RBHS or LIP categoriesMay be virtually present and immediately available via live interactive audio/video technologyMust be physically present and immediately availableMust be physically present or immediately available,as applicab

58、le,to meet required presence and participationResidents and fellows may furnish and separately bill for services in the inpatient,outpatient,and emergency department settings that are not related to their approved GME programsPsychiatric diagnostic evaluations and individual and family psychotherapy

59、 are allowable via telehealthService coordination,individualized family service plan meeting and team participation,family training and occupational therapy are allowable via telehealthService coordination,individualized family service plan meeting and team participation,family training and occupati

60、onal therapy must be provided in personNon-covered services(unless provided to a member enrolled in BabyNet)hereTRICARE coverage is based on the following:1)Originating site(also known as referring site)2)Distant site provider type3)Service(CPT or HCPCS code)The use of interactive telecommunications

61、 systems may be used to provide diagnostic and treatment services for otherwise covered TRICARE benefits when such services are medically or psychologically necessary and appropriate medical careCovered servicesNon-covered services Place of service 02 Modifier oSynchronous:GT or 95oAsynchronous:GQPa

62、yment is made only when the originating site is where an otherwise authorized TRICARE provider normally offers professional medical or psychological services.No payment shall be made when the originating site does not satisfy the requirement(e.g.,no payment will be made when the originating site is

63、the beneficiarys home).TRICARE authorized provider providing services within their scope of practice under all applicable state(s)law(s)where services provided Aetnas resource for coverage and billing rules for telehealth services can be found in their Telemedicine and Direct Patient Contact Payment

64、 Policy Aetna coverage is currently based on the following:1)Service(CPT or HCPCS code)Aetnas full list of CPT/HCPCS codes payable when furnished via telehealth are listed in their Telemedicine and Direct Patient Contact Payment PolicyNon-covered servicesNon-covered servicesNon-covered services Non-

65、covered services Place of service 02 Modifier Synchronous:GT or 95 Asynchronous:GQ Stroke:G0 Supervising practitioner present via two-way A/V communication:FRNot addressed in telemedicine policyAll participating and nonparticipating physicians,facilities,and other qualified health care professionals

66、 Medical policies found here Click on medical policies and then find“T”under alphabetical list Click on the“T”and look for the two policies:oCAM176 Telehealth oCAM 032 TelemedicineBCBS of SC coverage is based on the following:1)Referring site(also known as originating)2)Distant site provider type3)S

67、ervice(CPT or HCPCS code)Review each policy below for a full list of CPT/HCPCS codes payable when furnished via telehealth and telemedicineoCAM176 Telehealth oCAM 032 TelemedicineNon-covered servicesNon-covered servicesNon-covered servicesCovered services Place of service oPOS as if the patient pres

68、ented in person ModifieroTelemedicine:GToTelehealth:95 TelemedicineoPhysician officeoHospitaloRHC and FQHCoCommunity Mental Health CenteroPatient homeoPublic schooloAct 301 Behavioral Health CentersPhysicianNurse PractitionerPhysician AssistantClinical Nurse SpecialistClinical PsychologistClinical S

69、ocial WorkerLicensed Professional CounselorLicensed Marriage&Family TherapistSpeech TherapistOccupational TherapistPhysical TherapistProviders who meet the Plans contracting requirements and are currently contracted are eligible to submit claims for telemedicine and telepsychiatry when the service i

70、s within the scope of their practice Cignas coverage and billing rules for telehealth services can be found in their Virtual Care Reimbursement Policy Cigna coverage is based on:1)Service(CPT or HCPCS code)Full list of CPT/HCPCS codes payable when furnished via telehealth are found in the Virtual Ca

71、re Reimbursement PolicyCovered servicesNon-covered servicesNon-covered servicesNon-covered services Place of service 02 ModifieroSynchronous:GT or 95oAsynchronous:GQoStroke:G0oAudio-only:FQNot addressed in telemedicine policyPolicy only references physician and other qualified health care profession

72、als Policy very similar to Medicare CMS designated covered providers CPT code list differs based on use of GT,GQ or 95 modifieroSynchronous&asynchronous services coveredUHC coverage is based on the following:1)Originating site2)Distant site provider type3)Service(CPT or HCPCS code)CPT/HCPCS codes pa

73、yable when furnished via telehealth:Telehealth Eligible Services Codes PT/OT/ST Telehealth Eligible Codes Communication Technology-Based Services and Remote Physiologic Monitoring Eligible Codes Telehealth Audio-Only Eligible Services CodesCovered servicesCovered servicesCovered servicesCovered serv

74、icesCovered services Place of service Telehealth provided other than patient home:POS 02 Telehealth provided in patient home:POS 10 Modifiero 95 or GTo Stroke:G0o Mental health:FQo Audio-only:93 Physician office Hospital Critical Access Hospital RHC and FQHC Hospital-based or critical access hospita

75、l-based renal dialysis center(including satellites)Skilled Nursing Facility Community Mental Health Center Mobile Stroke Unit Patient home*For monthly end stage renal,ESRD-related clinical assessments or for purposes of treatment of a substance use disorder or a co-occurring mental health disorder P

76、hysician Nurse Practitioner Physician Assistant Nurse-midwife Clinical Nurse Specialist Certified Registered Nurse Anesthetist Clinical Psychologist Clinical Social Worker Registered Dietitian or Nutrition Professional Licensed Professional Counselor Licensed Marriage&Family Therapist Speech Languag

77、e Pathologist Occupational Therapist Physical Therapist If you dont understand,ask your payer!Scenarios with request for approval are best!Look for changes frequently!Share what you learn from policies with your providers;they may be able to help you advocate coverage at some point!Kellie Mendoza,MHA,CHC,CHPC,CPCChief Compliance&Privacy Officer,MUSC Physiciansmendozakmusc.eduAmanda Gardner,MHA,RHIACorporate Compliance Regulatory Manager,MUSC Physiciansgardnamamusc.edu