ED Coding and Reimbursement Alert

New telehealth POS 2 code for distant site from where the patient is being treated.

CMS has been struggling with how to capture practice expense for telehealth services for the originating and distant site providers. In the 2017 final rule it has decided that using the facility practice expense RVUs for telehealth is consistent with its belief that direct practice expense costs are generally incurred at the location of the beneficiary not by the distant practitioner.

As such, they will now use the facility PE RUVs to pay for telehealth serves with place of service (POS) code 2 Telehealth with the descriptor: (The location where health services and health related services are provided or received, through telecommunication technology), says David A. McKenzie, CAE, Reimbursement Director for the American College of Emergency Physicians in Irving, Texas. You will use new code for services furnished on or after January 1, 2017.

Previously, CMS instructed payers to use the place of service code that would have been reported had the service been furnished in person or the originating site in CMS terminology.

The new POS 02 will not apply to originating sites, as they will continue to use the POS code that applies to the type of facility where the patient is located. CMS added the new POS code to assist in determining proper payment and to help accurately track telehealth utilization and spending, he explains.

CMS announced in the final rule that it will pay $25.40 for HCPCS code Q3014 (Telehealth originating site facility fee), up slightly from the 2016 payment of $25.10.

Don’t Forget GT and GQ Modifiers

Under current policy, CMS requires you to use modifiers GT (Via interactive audio and video telecommunications systems) or GQ (Via asynchronous telecommunications system). In the final rule, CMS indicates that you should use POS 02 in addition to the GT and GQ modifiers; however, it may decide to eliminate their use in future rulemaking, he adds.

No Telehealth for ED or Observation Services, But Critical Care Makes the List

Process: CMS has a process in which it assigns any qualifying request to make additions to the list of telehealth services to one of two categories. The two categories are:

Category 1: Services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the list of telehealth services. In reviewing these requests, CMS looks for similarities between the requested and existing telehealth services for the roles of, and interactions among, the beneficiary, the physician (or other practitioner) at the distant site and, if necessary, the “telepresenter,”- a practitioner who is present with the beneficiary in the originating site. CMS also looks for similarities in the telecommunications system used to deliver the service; for example, the use of interactive audio and video equipment.

Category 2: Services that are not similar to the current list of telehealth services. A CMS review of these requests includes:

• an assessment of whether the service is accurately described by the corresponding code when furnished via telehealth and
• whether the use of a telecommunications system to furnish the service produces demonstrated clinical benefit to the patient.

The requester must submit evidence that includes both a description of relevant clinical studies that demonstrate the service furnished by telehealth to a Medicare beneficiary improves the diagnosis or treatment of an illness or injury or improves the functioning of a malformed body part, including dates and findings, and a list and copies of published peer reviewed articles relevant to the service when furnished via telehealth.

In an extensive discussion on the final rule, CMS explains that it did not add the ED E/M codes or observation codes to the list of approved telehealth services for either a category 1 or category 2 basis, McKenzie says.

The proposal for including the ED codes (99281-99285) on the telehealth list was based on the assumption that the services they represent can be similar to the office or other outpatient visit codes (99201-99215); however, CMS noted while the acuity of some patients in the emergency department might be the same as in a physician’s office; it decided that, in general, more acutely ill patients are more likely to be seen in the emergency department, and that difference is part of the reason there are separate codes describing evaluation and management visits in the Emergency Department setting. The practice of emergency medicine often requires frequent and fast-paced patient reassessments, rapid physician interventions, and sometimes the continuous physician interaction with ancillary staff and consultants. CMS believes this work is distinctly different from the pace, intensity, and acuity associated with visits that occur in the office or outpatient setting. Therefore, it did not propose to add these services to the list of approved telehealth services on a category one basis.

As noted above, consideration for a category 2 basis requires provision of studies supporting the clinical benefit of managing emergency department patients with telehealth. Since CMS did not receive any such studies, it did not propose to add these services to the list of approved telehealth services on a category two basis.

Similarly, CMS considered a request, but did not propose to add, the observation codes (99217-99220) to the list of Medicare telehealth services on a category two basis. While the request included evidence of the general benefits of observation units, it did not include specific information demonstrating that the services described by these codes provided clinical benefit when furnished via telehealth, which is necessary for CMS to consider these codes on a category two basis. Therefore, it did not propose to add these services to the list of approved telehealth services either, he explains.

Critical Care Consult Codes Were Approved

CMS has changed its policy on including critical care codes to the telehealth service list. Previously, CMS considered the acuity of critical care patients was not similar to codes in the office setting so it would not meet category 1 criteria for inclusion. However, CMS was persuaded of the potential benefit of critical care consultations furnished remotely based on submitted literature support. It makes the distinction that a consult for a critical care patient, such as a stroke presentation, is different from a telehealth consultation to other hospital patients.

So in 2017, CMS proposes to make payment through new HCPCS codes G0508 (Telehealth consultation, critical care, physicians typically spend 60 minutes communicating with the patient via telehealth; initial) and G0509 (Telehealth consultation, critical care, physicians typically spend 50 minutes communicating with the patient via telehealth; subsequent). These new codes provide a mechanism to report an intensive telehealth consultation service, initial or subsequent. For instance, suppose a qualified health care professional has in-person responsibility for the patient, but the patient benefits from additional services from a distant-site consultant specially trained in providing critical care services.

Note: CMS will limit these services to reporting once per day per patient, McKenzie says. The work values assigned to the codes and payments in the facility setting are as follows: