Our Results

Due to the urgency to expand the use of technology to help patients who need routine care, and to keep vulnerable patients in their homes while maintaining access to the care they need, CMS broadened access to telemedicine services effective March 1, 2020.

CMS and certain private payers have lifted the telemedicine restrictions during the pandemic and are paying the same rates for virtual care as in-person care. Though this waiver is only valid through the duration of the current pandemic, this change is expected to drive a large number of healthcare organizations to move forward with their telemedicine initiatives. The change from in-person to virtual medical care model for certain patient services is expected to be permanent thus resulting in expanded revenue generating possibilities.

The key question you need to ask then is whether your organization is ready and able to move forward with the telemedicine reimbursement model.  We believe that if you are located in a diverse demographic area, especially with technologically savvy as well as geriatric patient population, then you can leverage telemedicine platform for video and phone visit documentation to its full capacity.

There are many regions in our nation where the patients face logistical challenges in traveling to see their provider either at a practice or a hospital. With access to high-speed internet and the electronic devices necessary to perform video and phone visits, the telemedicine approach is becoming popular with patients due to its many advantages.

Some patients who need the care of a specialist must drive long distances and invest a lot of time for each visit. Telemedicine makes it possible for patients and their primary care physicians to leverage the expertise of specialists who are not nearby.

Telemedicine can not only help generate higher revenue through increased patient base but also help serve the local communities more effectively. It enhances the ability to get secondary services to patients such as testing, imaging and other ancillary services. With new advancements in imaging and optics technology, providers can avail the latest technological tools for differential diagnosis via telemedicine visits. Some of the specialty specific examples of telemedicine services are listed below:

Dermatology

High-definition video based telemedicine makes it possible to diagnose and treat many skin problems remotely.

Endocrinology

Treatment of endocrine conditions like diabetes and thyroid disease requires frequent adjustments to hormones and medications. Telemedicine reduces the burden on patients and increases the likelihood of consistent follow-up.

Gastroenterology

Patients with chronic conditions like Crohn’s disease, hepatitis C, and colitis require close supervision making telemedicine an ideal choice for monitoring and disease management.

Nephrology

Using telemedicine nephrologists can develop care-at-home plans for patients who have been through kidney replacement surgery and those with kidney disease.

Neurology

Telemedicine can help evaluate neurological signs for mental health related issues very effectively.

Psychiatry/Psychology

Telehealth is an excellent way to monitor the mental health of patients, adjust medications, and conduct cognitive behavioral therapy.

The flexibility of place of service also enhances the providers ability to see patients at location of their choice and provide services to patients during off business hours.  For instance, mobile labs and imaging stations can be easily transported into communities where organizations can provide those services and expand to meet the specific needs of the local communities.

The new model can also include hospital-at-home where an organization can provide inpatient services in limited ways for patients at home. By managing an uncomplicated patient disease without bringing the patient to the hospital, the healthcare delivery model is expected to shift out of the brick-and-mortar set-up to a large extent.

In conclusion, the current pandemic situation will cause telemedicine and remote technology to evolve more aggressively lending itself to expansion of services resulting in better patient care and higher reimbursement.

by Tej Gill, VP – Healthcare Solutions | TriumpHealth

Due to the urgency to expand the use of technology to help patients who need routine care, and to keep vulnerable patients or patients with mild symptoms in their homes while maintaining access to the care they need, under the guidance of President Trump, CMS broadened access to Medicare Telemedicine services.

Under the new 1135 waiver effective March 1, 2020, Medicare patients will be able to receive certain services at their home through Telemedicine and other virtual services, including evaluation and management visits, mental health counseling and preventive health screenings. This waiver will be valid through the duration of COVID-19 Public Health Emergency.

In order to proactively support our customers during these trying times and help them work through the COVID-19 emergency we have developed the below frequently asked questions presentation.

1. Which providers are eligible for Telemedicine services?

Please see the below list of providers who can furnish and get reimbursed for covered Telemedicine services at this time:

  • Physicians
  • Nurse Providers
  • Physician Assistants
  • Nurse Midwives
  • Certified Nurse Anesthetists
  • Clinical Psychologists
  • Clinical Social Workers
  • Registered Dietitians
  • Nurse Professionals

2. How will the Telemedicine services be paid?

The Telemedicine services will be considered the same as in-person visits and will be paid at the same rate as regular, in-person visits.

3. What technologies are available to provide Telemedicine services?

With regards to technology, the provider must use an interactive audio and video telecommunications system that permits real-time communication between the provider site and the patient at home. Considering ease-of-use and HIPAA compliance, some of the good platforms available for use (with no order of preference) include:

Having said that, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency (Source: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html).  Facebook Live, Twitch, TikTok and similar video apps that are public facing should not be used to provide care virtually.

4. What are the key methods of providing virtual services, including documentation and billing options?

Below are three main types of virtual services that providers can provide to their patients:

Service Applicable Codes Modifier POS1 Medium Patient Visit Documentation2
Telemedicine Visit 99201 – 99205
99211 – 99215
For complete list of codes, click here
95 for Medicare;

GT or other, for non-Medicare

Also check payer rules

11 •  Audio/Video •  Schedule your patients as you normally would

•  At the time of the televisit, your MA and patient may log into Telemedicine platform to get the visit started

• Make sure to notate in the EHR that the service was performed via Telemedicine

• Indicate the location of the patient e.g. at home

• Document in the EHR as you would for an in-office visit

• For time-based 99201 – 99215 services provided via Telemedicine (real time, interactive audio/visual), a provider does not need to use the level of history or exam to select the service

•  Provider can bill by Total Time or override level based on Medical Decision Making (MDM)

•  If you are billing based on time then you must record total time spent and where that time was spent. Billable time is counted based on providers time and not staff time

•  Provider may want to document detailed assessment and plan based on complexity of the disease

•  Unlike Virtual Check-in visits, you do not need to keep the recordings for your Telemedicine visits. Your documentation for these visits is your office visit note, just as if you were completing an in-person visit

•  Per latest Medicare guidelines, if the patient does not have access to a smart phone or computer, do not bill office visit codes 99201 – 99215. Instead consider using Virtual Check-in or Phone Visit for a phone call with a patient

Virtual
Check-in Visit
• G2010
(Remote evaluation of recorded video/image e.g. via email, text etc.) 

•  G2012
(5-10 minute medical
discussion via phone)

Check payer rules 11 •  Audio
•  Image
•  Applicable to new and established patient who initiates a communication

•  Patient must verbally consent to the services

•  Not related to a visit in the past 7 days and does not lead to a medical visit in the next 24 hours

•  You must record the time spent and save any images sent to you to the patient’s chart

Phone Visit 99441 – 99443 (Physician)

98966 – 98968
(NP, PA Registered Dieticians, Social Workers, Speech Language pathologists and Physical & Occupational Therapists)

11 •  Audio •  99441 – 99443 are applicable to new and established patient who initiates a communication

•  98966 – 98968 are applicable to established patient who initiates a communication

•  Patient must verbally consent to the services

•  Not related to a visit in the past 7 days and does not lead to a medical visit in the next 24 hours

•  You must record the time spent

E-Visits
Via Patient Portal
99421 – 99423 (E&M Providers including Physician, NP, PA)

G2061 – G2063 (Non-E&M Providers e.g. Physical Therapist)

Check payer rules 11 •  Portal •  99421 – 99423 are applicable to new and established patient who initiates communication

•  G2061 – G2063 are applicable to established patient who initiates communication

• Patient must verbally consent to the services

•  Patient communicates with provider without going to the providers office by using online patient portal

•  The communications can occur over a 7-day period

•  You must record the time spent

*Notes: 

  • 1 Coding for Phone Calls, Internet and Telemedicine Consultations, click here
  • 2 Examples of documentation and billing for Virtual visits, click here
  • 3 Examples of 99202 and 99212 coding during telemedicine visits, click here
  • 4 Examples of 99213 coding during telemedicine visit, click here

5. Are there any additional documentation requirements for a Telemedicine visit?

For virtual visits involving time-based coding, evidence of time must be documented. For Telemedicine visit including a synchronous real-time and interactive video-phone call, the call data is not required to be stored. Similarly, for a Phone visit the call data is not required to be saved, you only need to document the visit and time spent. However, for Virtual Check-in visit the  asynchronous images or videos and related data must be stored.

6. Does the provider need to obtain consent from the patient for a virtual visit?

While it is not required that an informed consent be obtained from a patient prior to the service, however Medicare recommends that the patient be notified that virtual service via third-party Telemedicine platform may have potential security and privacy risks.

7. Are new patient visits included in Telemedicine services?

For Medicare Telemedicine services, the patient must have an established relationship within the past three years but can also be a new patient. To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. For more information on establishing patient-provider relationship specific to your State, please refer to a website here.

8. Can ancillary staff bill for virtual services e.g. MA’s, Nurses and other non-Physician staff?

There are only two categories of staff that can bill for Telemedicine services. For Telemedicine and Virtual Check-in visits respectively, the provider must be able to bill for an E/M visit. A Nurse, MA or Technician performing these services would not be able to bill. In situations where the physician does not communicate directly with the patient, the service is not billable.

For E-Visits, the codes ranging from 99421-99423 can be used if the services were provided by an E/M provider e.g. Physician, NP, PA etc. The non-E/M providers e.g. Physical Therapists can use codes ranging from G2061-G2063.

 

9. Can the practitioner provide Telemedicine services from location other than their office, e.g. practitioner’s home?

Yes, a practitioner can provide services from a location other than the practitioner’s practice, such as practitioner’s home. In this scenario, such address must be listed on the claim. CMS is no longer requiring that providers enroll their home address (or other alternate address) with their MAC and will disregard discrepancies between a provider’s enrolled address and the address at which services were provided during the COVID-19 emergency.

10. Can a practitioner provide Telemedicine service out of their state?

Per waiver 1135, in order to render Telemedicine services, a provider does not have to be licensed in the state that the patient is located. However, we recommend that you refer to your state specific guidelines by clicking here.

11. Does the Medicare coinsurance and deductible apply to the virtual visits?

For Medicare, it is optional for providers to lower or waive copays. For non-Medicare payers it is recommended to check specifically with the respective payers in your jurisdiction.

12. Are there any specific requirements for Telemedicine visit documentation for Federally Qualified Health Center’s (FQHC’s) and Rural Health Center’s (RHC’s)?

For FQHC’s or RHC’s, the geographic and site restrictions still apply. In other words, the FQHC’s and RHC’s can serve as the originating site for Telemedicine services, however the patient has to be present at the site and not their home. Evaluation or discussion is not related to a visit in the past 7 days and does not lead to a medical visit in the next 24 hours. Both FQHC’s and RHC’s need to use HCPCS code “G0071” with modifier “GT”.

13. How can providers e-prescribe controlled substances during COVID-19 emergency?

As it relates to e-prescribing for controlled substances, while COVID-19 public health emergency remains in effect, DEA-registered providers may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

  • The prescription is issued for a legitimate medical purpose by a provider acting in the usual course of his/her professional practice
  • The Telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system
  • The provider is acting in accordance with applicable federal and state laws

14. How does Accelerated/Advance Payment Program help providers with cash flow?

In order to increase cash flow to providers impacted by the COVID-19 emergency, CMS has announced establishment of an Accelerated/Advance Payment Program. Under this program, providers can request advanced payments to help cover costs for a 120-day period following receipt of the advanced payment. Amounts advanced under this program will be recouped from the provider’s Medicare billings commencing at the end of such 120-day period. Details on the eligibility, and the request process are outlined here.

15. Is COVID-19 emergency going to impact MIPS reporting in 2020?

On March 22, 2020, CMS announced relief for clinicians, providers, hospitals and facilities participating in quality reporting programs in response to COVID-19. Firstly, the deadline for attestation for 2019 MIPS reporting has been extended to April 30, 2020.

Additionally, if MIPS eligible clinicians attest by April 30, 2020 on 2 or more MIPS performance categories (Quality, Improvement Activities and/or Promoting Interoperability) as an individual or group, they will be scored on those performance categories and receive a 2021 MIPS payment adjustment based on their 2019 MIPS final score.

However, for MIPS eligible clinicians who do not submit their 2019 MIPS data by the extended deadline of April 30, 2020, CMS will reweight the MIPS performance categories. These MIPS eligible clinicians will have all 4 performance categories weighted at 0 percent and will receive a MIPS final score equal to the performance threshold, resulting in a neutral payment adjustment for the 2021 MIPS payment year.

Disclaimer:

This information is provided as a tool to help you understand the latest changes in Telemedicine billing as a result of COVID-19 emergency. TriumpHealth employees and staff have created this presentation to the best of their knowledge and ability, and make no representation or guarantee that this presentation is error-free. TriumpHealth has no liability or responsibility to any person or entity with respect to any loss of revenue, or indirect damages resulting from the potential use of this information.

by Tej Gill, VP – Healthcare Solutions | TriumpHealth

The Centers for Medicare & Medicaid Services (CMS) is proactively taking steps to ensure that patients, healthcare facilities and clinical laboratories are prepared to respond to the COVID-19, a disease caused by the novel coronavirus. CMS has released several fact sheets in recent weeks on billing and coding to provide guidance for healthcare organizations on testing and treating patients for COVID-19.

Last month, CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. This month CMS announced the second HCPCS billing code (U0002), which allows laboratories to bill for non-CDC laboratory testing for COVID-19, to help increase the testing and improve tracking of this virus.

Healthcare Common Procedure Coding System (HCPCS) is a standardized code system necessary for medical providers to submit healthcare claims to Medicare and other health insurances in a consistent and orderly manner.

Medicare claims processing systems will be able to accept the U0001 and U0002 codes starting April 1, 2020, for dates of service on or after February 4, 2020. Local Medicare Administrative Contractors (MACs) will be responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates. Laboratories may seek guidance from their MAC on payment for these tests prior to billing for them.

Per CMS, when Medicare patients with COVID-19 no longer require acute inpatient care but remain quarantined in a hospital room to avoid infecting others, Medicare will pay the diagnosis-related group rate and any cost outliers until the patient is discharged.

If you are facing any billing and coding challenges or simply don’t have enough time in the day to manage your revenue cycle effectively, give us a call today to receive expert and dedicated support.

By: Tej Gill, VP – Healthcare Solutions, TriumpHealth

The Centers for Medicare and Medicaid Services (CMS) released its Final Rule for the 2020 Merit-based Incentive Payment System (MIPS) program. The Final Rule continues to gradually increase the reporting requirements and financial impact of the MIPS program. Below we share the most relevant changes that will impact your 2020 MIPS performance and help you plan for the future.

MIPS Performance Categories

In 2020, the MIPS category weights remain the same as in 2019.

2020 MIPS Categories

Quality

Promoting Interoperability

Improvement Activities

Cost

45%

25%

15%

15%

MIPS Reimbursement Overview

There will be larger incentives for 2020 performance year due to the higher thresholds and other changes to the program.  The clinicians who are taking the program seriously will see more revenue going forward.  On the other hand, those who are not taking the program seriously or have just met the bare minimum threshold in the past will have a challenging time and may see higher penalties in the future.

The lookback period is two years.  Prepare in 2020 for payment adjustment in 2022.

Performance Threshold & Financial Impact

In 2020, CMS increases the minimum performance and the exceptional bonus thresholds. Additionally, there will be greater financial implications for MIPS eligible clinicians who choose not to report.

2019 2020
30-point performance threshold 45-point performance threshold
75-point exceptional performance threshold 85-point exceptional performance threshold
Maximum payment penalty set at -7% Maximum payment penalty set at -9%
Maximum incentive prediction at +4.69% Maximum incentive prediction at +6.25%

Note: To ensure budget neutrality, positive payment adjustment is likely to be increased or decreased by an amount called a “scaling factor.” The amount of the scaling factor depends on the distribution of final scores across all MIPS eligible clinicians.

 

MIPS Timeline

Below are pertinent milestones for the MIPS program.

Milestone Date
2018 Performance Adjustment Jan 1 – Dec 31, 2020
2019 Data Submission March 31, 2020
2019 Performance Feedback July 1, 2020
2019 Target Review August 31, 2020
2020 Data Reporting Jan 1 – Dec 31, 2020
2020 Performance Adjustment Jan 1 – Dec 31, 2022

MIPS Eligible Clinicians

In 2020, the MIPS eligible clinician categories remain the same as in 2019.

2020 MIPS Eligible Clinicians
Physicians Audiologists
Physician Assistants Physical Therapists
Nurse Practitioners Occupational Therapists
Clinical Nurse Specialists Speech-Language Pathologists
Certified Registered Nurse Anesthetists Clinical Psychologists
Audiologists Registered Dieticians or Nutrition Professionals

MIPS Eligibility Criteria

To be able eligible to participate the clinician must meet the following three requirements:

Opt-in is available for MIPS eligible clinicians who are excluded from MIPS based on the low-volume threshold determination

  • If you are a MIPS eligible clinician and meet or exceed at least one, but not all, of the low-volume threshold criteria, you may opt-in to MIPS
  • If you opt-in, you’ll be subject to the MIPS performance requirements, MIPS payment adjustment,etc.

Note: You can voluntarily report if you are a clinician or group that is not MIPS eligible.If you report voluntarily, you will receive a MIPS final score but no payment adjustment.

MIPS Performance Period

The performance periods for respective MIPS categories remain unchanged.

Performance Category 2019 2020
Quality 12 months 12 months
Cost 12 months 12 months
Promoting Interoperability 90 days 90 days
Improvement Activities 90 days 90 days

Changes in Quality

In 2020, the following changes are expected in the Quality category:

  • CMS eliminated 42 quality measures and added 4 new measures
  • The data completeness requirement increased from 60% to 70% in 2020. In other words, Quality measures will need to be reported on at least 70% of eligible cases, for both Medicare and non-Medicare patients, for the entire year.  Measures that are submitted, but do not meet the data completeness threshold (even if they have a measure benchmark and/or meet the 20-case minimum), would receive 0 points (instead of 1 point in 2019).
  • Clinicians in small practices (15 or less in the TIN) would continue to receive 3 points for measures that don’t meet the data completeness requirements.
  • Several Quality measures have topped out or have been removed.
  • New specialty sets have been added including for Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietician, and Endocrinology.
  • Flat percentage benchmarks are being established for limited cases where CMS determines that the measure’s benchmark could potentially incentivize inappropriate treatment for some patients.

Changes in Promoting Interoperability (PI)

The PI category will not see any significant changes in 2020, except below:

  • A group will be considered hospital-based and eligible for reweighting if more than 75% of the clinicians in the group meet the definition of a hospital-based individual MIPS eligible clinician (it is currently 100%).
  • CMS will remove the Verify Opioid Treatment Agreement measure and keep the Query of PDMP measure as optional.
  • Clinicians will be allowed to satisfy the optional Query of Prescription Drug Monitoring Program (PDMP) measure with a yes/no response instead of a numerator/denominator (also applies in 2019).
  • The points for Support Electronic Referral Loopsby Sending Health Information measure will be redistributed to Provide Patients Access to Their Health Information measure if an exclusion is claimed (also applies in 2019).

Changes in Improvement Categories (IA)

As with Quality measures, there is a net reduction in the number of IA measures.  Here are the key changes:

  • 15 IA activities were removed, 2 new added and 7 modified.
  • CMS increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice.
  • The definition of rural area was modified to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP Code file available.

Changes in Cost

Out of the four MIPS categories, Cost category will see the most changes.  Key changes are below:

  • CMS is revising the current measures – Medicare Spending Per Beneficiary Clinician measure and Total Per Capita Cost measure.  There will be no changes to current case minimum requirements.
  • The driver for above change is to address the concern from clinicians of certain specialties that patients were attributed to them over whom they have minimal control, both in terms of their behavior and clinical outcome. This negatively impacted the Cost score of the specialist clinician.  The 2020 changes in patient attribution methodologies is expected to positively impact the Cost score for the impacted clinicians.
  • 10 new episode-based measures have been introduced, increasing the total number of such measures to 18.

MIPS Value Pathways (MVP)

In order to reduce the MIPS reporting burden on clinicians, CMS is adopting a new framework beginning in 2021 performance year called the MIPS Value Pathways. (MVPs)  Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs).The goal of MVPs is to reduce the reporting burden by moving towards an aligned set of measures more relevant to a clinician’s scope of practice across all MIPS categories for different specialties or conditions.

Here is a CMS video explaining the MIPS Value Pathways framework. (Source https://qpp.cms.gov/mips/mips-value-pathways)

Planning for 2020

MIPS eligible clinicians and groups should continue to stay on top of their 2019 MIPS data reporting, and at the same time become familiar with the changes for MIPS in 2020.The 2020 final rule establishes higher performance thresholds and payment adjustments, so more planning and reporting will be necessary to avoid any penalties.

TriumpHealth consultants help you with acquiring pertinent MIPS knowledge, planning, and monitoring performance.  To see how we can help you maximize incentives please click here or call us at (888) 747-3836 x1.

By Tej Gill – VP Healthcare Solutions, TriumpHealth

References: