Telehealth and the Impact of ICD-10-CM

CMS announced on Friday a proposed rule to expand telehealth access for patients.

Hospitals, doctors, and other providers seeking an edge in today’s highly competitive healthcare environment would do well to consider a smart telehealth strategy. It’s not an option anymore to think that telemedicine doesn’t fit into your practice. It is a delivery method of medicine into which many physicians and providers across the world have bought.

There’s no one-size-fits-all approach to developing a telehealth strategy. While one system may be struggling with access issues, another may face the challenge of serving a specific population group or demographic. The right solution, with a tuned operational plan behind it, can solve either of those issues. It starts with taking an inventory of the pain points for which you want to solve.

First, stop thinking in terms of return on investment or revenue created, and instead begin thinking about the value created by your telehealth strategy and virtual care solutions. There are different ways to create value, but you’ll have to decide on the right mix for your patient and practice needs.

This could include options such as self-triage, nurse advice, and asynchronous virtual care for common ambulatory conditions (frequent UTI recurrence, “pink eye,” simple injuries, and behavioral health issues, for example). For higher-acuity issues it should also include video visits. In-person visits can be reserved for conditions for which multiple co-morbidities exist (diabetes and flu, for instance), or when a physical procedure is required (such as for cancerous lesion removal).

But the reality is, you still need to find value in this new delivery method of medicine. Below are some important points to consider as you make a case for your venture into the telemedicine world.

Telehealth is an extremely broad category. It encompasses everything from managing complex, high-risk conditions such as stroke through remote monitoring and consultation, to providing high-quality, “on-demand” convenience care (or virtual care) for a range of acute, episodic, and non-emergent conditions in an effective, rapid, and cost-effective manner.

Telemedicine is not a new concept. Its proponents say it will reduce costs and improve access to medical care. In other words, it’s intended to be inexpensive and convenient. Unfortunately, that promise has only been partially realized.

It’s estimated that telehealth is an $18 billion industry today, with significant growth projected. Telemedicine has become an especially established option with specialty consultations for follow-up care, and it is increasingly used for monitoring patients with chronic conditions, in both rural and urban areas. To be safe and effective for patients, telemedicine needs to adhere to a few core principles:

• Licensure: The practice of medicine must occur where the patient receives treatment, not where the physician is located.
• Adherence to established standards of care: The standards of care for telemedicine are the same as for in-person care.
• Payment: A medically necessary and covered service should be paid for, regardless of how it is provided.

Even under the new Texas and California laws, payment remains a stumbling block, as health plans argue that telemedicine is a service rather than a mode of delivering a service that is already covered. The counterargument is this: a covered service provided to an enrolled patient by a contracted physician should be paid for, as long as the physician is licensed in Texas (or the state where the patient is receiving treatment) and the physician has access to the relevant clinical data necessary to make a diagnosis in accordance with accepted standards of care.

The following are some of the specialties that have proactively recently added telemedicine to their medical practices:

• End-stage renal disease (ERSD)-related services
• Psychiatric diagnostic evaluation
• Psychoanalysis
• Medical nutrition therapy (MNT)
• Diabetes outpatient self-management training services
• New and/or established patient office visits
• Subsequent hospital care
• Second opinion consultations
• Smoking and tobacco use cessation counseling
• Annual depression screening
• Alcohol and/or substance abuse structured assessments and follow-up
• CHF remote monitoring patients
• Chronic care management services
• TCM services

For the most part, an interaction — whether in person, via telemedicine, or on the phone — between a patient and a physician can be beneficial; however, the ongoing sticking point is the issuance of a prescription medication to a previously unknown person the doctor has never examined and for whom the doctor has no access to the medical record.

Typically, during a telemedicine visit, the patient is seen by the provider. A “patient presenter” is with the patient, in most cases, and follows the directions of the remote provider in placing a stethoscope or exam camera on the patient’s body, providing both sounds and images.

The remote provider also has the benefit of an array of other medical devices to gather patient information. Telemedicine consultations are often performed by medical specialists such as cardiologists, dermatologists, and pulmonologists. These often occur when the patient is in an underserved rural community and the specialist is in a large urban area.

The distance makes it difficult to make and keep appointments otherwise. Some telemedicine deals with minor primary care issues over the course of the phone/video conference.

If deemed to be a more serious health concern, the patient is told to make an appointment with a specialist or to proceed to a hospital emergency room.

Careful! Coding Counts

Providers must keep in mind, however, that not everyone has payment coverage, and there are strict government rules for billing these services. For Medicare, by billing claims with POS 02 (place-of-service designation), the provider is certifying that both the broad and code-specific telehealth requirements have been met. This includes all the statutory requirements for telehealth service coverage under Medicare and Medicaid (e.g., rural area, originating site, interactive audio and video telecommunications system, etc.).

If a provider delivers a telehealth service while a Medicare patient is located at home, the service would not meet the Medicare statutory requirements, and the provider should not append POS 02 to that code. False or erroneous coding of claims can expose providers to audits, overpayments, and potential liability under the False Claims Act.

For commercial payers, each contract has its own set of rules for payment and policy provisions. We recommend you review those contracts for specific instructions.

CPT® has designated a “star” symbol to reflect telemedicine potential coverage. The ICD-10-CM guidelines are specific to accuracy and certain details, so a lot of work must be done during a “virtual visit” to ensure that those are in place as they would be for an in-person visit. Physicians will need to “virtually” make decisions on diagnosis coding without the benefit of actually assessing a patient in front of them, but through digital interaction.

The Government is Paying Attention

The rapid growth of telehealth has also caught the attention of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), which recently announced two new projects to audit billing of telehealth services under Medicare and state Medicaid programs.

• Under the first project, OIG will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements. An eligible originating site must be the practitioner’s office or a specified medical facility, not a beneficiary’s home or office. This project is underway and is expected to be completed by the end of the year.
• Under the second project, OIG will determine whether states’ Medicaid payments for services delivered using telecommunication systems were in accord with Medicaid requirements. Medicaid pays for telemedicine, telehealth, and telemonitoring services delivered through a range of interactive video, audio, or data transmission (telecommunications). Medicaid programs are seeing a significant increase in claims for these services and expect this trend to only continue.

In general, response from providers in the telemedicine industry has been overwhelmingly positive. Most stakeholders appreciate CMS’s attempts to reduce administrative burdens on billing and coding, although certainly, some billing software teams will need to reprogram their interfaces to accommodate the new coding processes. Providers and hospitals that take steps to really understand which services are (and are not) covered under Medicare and Medicaid when delivered via telehealth will be in a good position to scale up their services and reach more patients with confidence.

The bottom line is that telehealth and telemedicine as a delivery method of existing medical services are increasingly integrating themselves into the healthcare community as technology advances.

Program Note:

Listen to Terry Fletcher report on this topic today on Talk-Ten-Tuesdays, 10 a.m. EST.