December 6, 2013
| posted by Renee Dustman
Telehealth services are becoming more mainstream and the Centers for Medicare & Medicaid Services (CMS) shows its continued support for remote services in the 2014 Medicare Physician Fee Schedule (MPFS) final rule, published in the Nov. 27 Federal Register.
Prior to 1999, Medicare coverage for services furnished by a telecommunications system was limited to things like X-ray interpretations, electroencephalogram tracing, and cardiac pacemaker analysis. The Medicare, Medicaid and SCHIP Benefits Improvement Protection Act of 2000 (BIPA) significantly expanded Medicare coverage for telehealth services. For example, one provision expanded the Social Security Act to require the Department of Health & Human Services (HHS) secretary to establish a process that provides for annual updates to the list of telehealth services. CMS established this policy in the 2003 MPFS final rule.
Medicare also provides payment of a facility fee to the originating site. Telehealth originating sites are those located in a designated rural health professional shortage area (HPSA) in a county that isn’t in a metropolitan statistical area (MSA), or an entity that participates in an approved federal telemedicine demonstration project.
The initial list of telehealth originating sites included the physician office, critical access hospitals, rural health clinics, federally qualified health centers, and hospitals. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) expanded the list to include hospital-based renal dialysis centers, skilled nursing facilities, and community mental health centers.
In the 2014 MPFS final rule, CMS redefines rural HPSAs as those located in rural census tracts as determined by the Office of Rural Health Policy (ORHP), defining “rural” to include geographic areas located in rural census tracts within MSAs. CMS also finalizes its proposal to establish and maintain geographic eligibility for an originating site on an annual basis.
The telehealth originating site facility fee in 2014 is increased by the 2014 MEI increase of 0.8 percent, making the 2014 payment amount for HCPCS Level II code Q3014 Telehealth originating site facility fee 80 percent of the lesser of the actual charge, or $24.63—up 20 cents from 2013.
CMS has also greatly added to the list of approved telehealth services over the years. The 2014 MPFS final rule further expands the list of approved telehealth services by adding “transitional care management.”
CMS finalized a payment policy for CPT® transitional care management codes 99495 and 99496 in the 2013 MPFS final rule. These services are for a patient whose medical and/or psychosocial problems require moderate or high complexity medical decision-making during transitions in care from an inpatient hospital setting. Transitional care management is comprised of one face-to-face visit within the specified time frames following a discharge, in combination with non-face-to-face services that may be performed by the physician or other qualified healthcare professional and/or licensed clinical staff under his/her direction.
Continue to append modifier GT Interactive audio and video telecommunications systems or GQ Asynchronous telecommunications system to the procedure code to receive payment equal to the amount the physician would have been paid if the service had been furnished without the use of a telecommunications system.
CMS is soliciting public requests to add services to the list of Medicare telehealth services. The deadline to submit requests is Dec. 31 to be considered for the next rulemaking cycle. For instructions on how to submit a request, go to www.cms.gov/telehealth.
The AMA has raised the alarm about insurers who pay providers using credits cards. When redeemed, the cards incur transaction costs of up to 5 percent, which must be borne by the provider and effectively lower reimbursement.
James L. Madara, MD, Executive Vice President and CEO of the AMA, wrote of the issue in a letter to Centers for Medicare & Medicaid Services (CMS) administer Marilyn B. Tavenner. The letter additionally noted, “that some credit card companies offer incentives of up to 1.75 percent of the claim amount to payers or their claims administrators when reimbursement is made using a commercial credit card.”
Put another way, using credit cards for payment not only shifts the costs of transferring money electronically from the payer to the practice, but also allows payers to recoup money for themselves while simultaneously shortchanging providers.
To fight against the transaction costs eroding provider reimbursement, the AMA recommended that CMS “prohibit payers from reimbursing physicians anything less than the contracted rate on their fee schedules when they pay physicians electronically,” as well as “ encourage payers to accept the newly adopted EFT [electronic funds transfer] standard prior to the January 1, 2014, implementation date if a physician requests this standard sooner than the effective date.”
You don’t have to wait for government action to counter insurers’ credit card payments, however. First, be sure you don’t agree to credit card payments from the payer as part of any new contract. Better still, insist that payments be made by check or electronic funds transfer without additional transaction costs. Also be aware of your office’s merchant credit card agreement and its associated fees. You can negotiate these contracts, as well.
If you’re already receiving credit card payments, call the insurer(s) and insist they reinstate payments via check or EFT. The healthcare electronic funds transfer standard known as ACH CCD+ is approved the Health Insurance Portability and Accountability Act (HIPAA) and costs less than credit card transactions.
When you report a CPT® “unlisted procedure” code, or one of the new technology (Category III) codes, you may be required to enclose a special report with your claim. Additionally, the CPT® manual provides instruction regarding special reports in the Radiology Guidelines, which specify, “A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature extent, and need for the procedure; and the time effort, and equipment necessary to provide the service.”
The special report should also provide information about the time, effort, and equipment necessary to provide the service. Additional information that may be helpful to the carrier includes: The complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures performed, concurrent problems, and planned follow-up care. This data gives the payer a better understanding of what the procedure is, what was required to perform it, and how it should be reimbursed.
November 27, 2013
| posted by Ronda Tews, CPC, CHC, CCS-P
The Electronic Health Record (EHR) must follow the same documentation requirements as the paper chart. It is not true that if the information is located “somewhere” in the EHR, that it may be counted toward the documentation requirements for any and all dates of service. The provider must reference within her note for that date of service if she has reviewed any information within the EHR to get credit for the information.
Here’s how Medicare carrier Wisconsin Physician Services (WPS) addresses this topic in a Q&A:
Q 17. This question pertains to an Electronic Medical Record (EMR.) We have always been taught that the progress note “stands alone.” When we are auditing physician’s notes to determine if they are billing the appropriate level of service, what parts of the EMR can be used toward their levels without requiring them to reference it? We are referring specially to Growth charts, Past, Family, & Social History, Medication Listings, Allergies, etc.
A 17. If the physician were not referencing previous material in the EMR, then the information would not be used in choosing the level of E/M service.
The old adage still applies to the EHR—If it’s not documented, it wasn’t done.
Templates are beneficial, but can create problems if documentation begins to look the same for each patient. The Office of Inspector General (OIG) has warned, “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries…. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. This does not mean that providers cannot use templates, but appropriate changes need to be made to the template based on the patient being seen and the treatment provided.
And remember: The volume of documentation doesn’t determine coding, medical necessity does. National Medicare policy asserts, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed” (CMS Transmittal 178, Change Request 2321, May 14, 2004).