Telehealth for Vulnerable PopulationsBilling and Technology in TelehealthJune 18, 2020

PANELISTSSarah E. Warren, Aud, PhDRachel Lauletta, MS, BCBA, LBASharon Lusk, JD, CPA, CMC, CMCOMODERATORMarian Levy, DrPH, RD, FAND

June 18CEUHelper check in and outcodes for Behavior Analysis CEU:Check-in: 6695Check-out: 4208

Technology Platforms and AccessSarah E. Warren, Au.D., Ph.D., CCC-AAssistant Professor, University of Memphis School ofCommunication Sciences and Disorders

Questions to ask beforeimplementing atelehealth platform: Do you have the basicsneeded to provide telehealthservices? What types of services areyou looking to provide? What is your budget? What other questions shouldyou be considering?

Do you have the basicsneeded to providetelehealth services? Are your services eligible forreimbursement through telehealth? Basic equipment LaptopTabletTelephoneOther accessories (carts, webcameras, speakers, wall mounts, etc) Internet Connection

Bandwidth &Connectivity1 Practitioner– 4 Mbps2-4 Practitioners—10 MbpsLarge (up to 25 practitioners)—25 MbpsLarge Medical Center—1,000 MbpsHow to estimate your bandwidth requirements?Check with your local Regional Extension Center

What type of servicesare you looking toprovide? Types of systems: Integrated system with EMR A stand-alone solution Delivery method Telephone Video Specialized equipment Must be HIPAA compliantIf you don’t know what your needs are yet, that’s ok!

What is your budget? How many licensed professionals willbe using this software? How much training and support willyou need? Do you have internal IT support staff,or will you need support from avendor? What training do you and your staffneed? What specialty equipment do youalready have? What would you need?In the long-run, you may see a reduction of overall costs.

Other questions toconsider: What is your timeline? What are your goals? How will these be tracked? How will you measure success? Who will take primary responsibility ofmanaging the implementation? Who will manage telehealth in thelong-term? How might your needs change overtime?

Resources National Consortium ofTelehealth Resource Centers American Telehealth Association The Office of the NationalCoordinator for Health InformationTechnology

Billing and Providing ClinicallyAppropriate ABA Telehealth ServicesRachel Lauletta, MS,BCBA,LBAExecutive Director/Adjunct ProfessorHarwood Center/ University of Memphis

TopicsCovered: Requesting Insurance Providers to Pay for ABA RBTs, BCBAs, Parent Training Determining Clinical Appropriateness of Service Schedule Goals Caregiver Needs & Involvement Recommended Tasks Prior to Beginning Service Consent Forms- Discuss Limits to HIPAA Welcome Call with Families- Decide goals,etc. Staff Training and Supervision plan Billing the Insurance Provider

Requesting InsuranceProviders to Pay for ABA Reach out to your representativefor any insurance provider you arecredentialled with Will they pay for Telehealth? If yes: Will they pay for Supervision by aBCBA? Will they pay for direct therapyfrom an RBT? Will they pay for parent training bya BCBA? Can you concurrently bill?This Photo by Unknown Author is licensed under CC BY-SA

Determining Clinical Appropriateness of theserviceMeet with the family and talk aboutwhat struggles they are havingMay not work on the same goals as in-personbased therapyMay be more functional skills or attending to a screen to talk with familymembers during pandemicSome clients may not be appropriate due to behaviors or skill levelDetermine length of SessionMultiple short sessions per day?First half parent training and the 2nd half therapy?

Company Handbook for both Parents andPersonnel include Telehealth Does your Company Liability Insurance coverTelehealth? Develop Consent Forms for Telehealth Limitations with HIPAA Recording Consent Social Skills Group Consent Establish Plan for Staff Training and Supervision Financially BudgetRecommendedTasks Prior tobeginning theservice

Limitations to HIPAA Ensure you are paying for a HIPAA compliantZoom or other platform Consent Forms articulate Limits to HIPAA Family members/children may overhear thecall Group Therapy Sessions, sharing informationwith other clients Higher risk of a Breach due to being allelectronic Consent to record sessions for training purposes

Billing the Insurance Provider Ensure you are using the correct ServiceLocation: 02 Telehealth Must document every session and write aclear and precise session note Convert notes within 24-hours Determine what individuals are on thecall, who is billing and for what Only bill for the services provided. Ifthe BCBA only did parent training,an RBT cannot bill for therapy, evenif they were on the call. Review insurance authorizations.Some insurances may not approveservices delivered by an RBT.

TeleMedicine –Documenting & BillingSharon Lusk, JD, CPA, CMC,CMCOCo-owner, KLA Healthcare Consultants

Then and now Types of TeleMedicine Service TeleHealth Visit Virtual Check-in TelemedTopicsCovered: Online Digital Portal Remote Evaluation Recorded Data Remote Monitoring Providing and Documenting Services Consents Medical Decision Making vs. Time CPT Time CMS Time Billing the Insurance Provider

TeleHealth – It’s a wholenew ball game!Then – Medical providers at both endsof the visit. Now – Visit can occur withboth patient and provider sheltering athome.Then – Strict HIPAA rules governedvisit. Now – HIPAA rules relaxed.Technologies such a Facetime, Zoomand Skype may be used.Then – Telephone calls, if reimbursedat all, were reimbursed poorly. Now,telephone calls reimbursed similarly toin-office visits BECAUSE many who aremost at risk are not familiar with usingaudio-visual technologies.

What services may be reimbursed via TeleHealth?As of the preparation ofthis slide, 238 types ofhealthcare services arepayable by telehealth perCMS. You may downloadthis list formation/Telehealth/Telehealth-CodesInformation about thecode’s future status and ifaudio-only interactionqualifies is also included.

Primary TeleHealth icine%20Services%20Chart.PNG

Other TeleHealth MethodsTYPE OFSERVICEWHAT IS THE SERVICEHCPCS/CPT CODEPATIENT RELATIONSHIPWITH PROVIDERVIRTUAL CHECK- Standard evaluationINand managementservices done bytelephone only.99441 – 5 to 10 minutes - 77.9499442 – 11 to 20 minutes - 112.9999443 – 21 to 30 minutes - 151.66New or established.(Most commercial usingregular E&M codes)Patient cannot have beenseen in past 7 days.Patient cannot be seenface-to-face within 24hoursREMOTEPATIENTMONITORING99453 – Set-up, patient education 19.4999454 – Monitoring per month 65.0199457 – Clinical time 20 minutes permonth - 52.9099458 – Additional 20 minutes permonth - 43.12New (during PME) orestablished patientsRemote monitoring ofphysiologic parameterssuch as blood pressure,pulse oximetry, weight,etc(Memphis based RPMCompany – DiversifiedHealthcare Partners –503-329-0957)

Patient consent,Patient initiation: A formal patient consent is NOT requiredduring the Public Health Emergency foraudio visual visits. Consent is presumed.Consider obtaining one anyway if yourvisit is not recorded and part of yourmedical record. A formal patient consent IS required fortelephone calls. Verbal consent is OK. Awitness is strongly suggested. The patient MUST initiate the visit. If anoffice calls and gives the patient a choiceof office or telehealth and the patientselects telehealth, THIS IS PATIENTINITIATED.

Documentationbased onMedicalDecisionMaking orTime: May use CPT timesor CMS Chart CPT times are basedon times based inactive patient care.They may berounded up. 16minutes satisfies 30minutes. CMS times areThreshold times.You must meet thattime BUT it includespre and post(reviewing anddocumentation)times.

Billing the Insurance CarrierFrom the March 31, 2020 CMS update:“When billing professional claims for non-traditional telehealthservices with dates of services on or after March 1, 2020, and forthe duration of the Public Health Emergency(PHE), bill with thePlace of Service (POS) equal to what it would have been in theabsence of a PHE, along with a modifier 95, indicating that theservice rendered was actually performed via telehealth.“MOST, but not all Commercial Payors, are following CMS’sguidance. Blue Cross does use POS 02. Cigna still uses obsoletetelehealth modifiers GQ (audio visual) or GT (telephone only).Cigna will deny if POS 02 is used. Search for COVID updates on thecarrier’s webpages for current rules. MOST PROVIDER MANUALSARE rgencies/coronaviruswaivers

Use your note fieldExpect audits!Some insurance carriers have been clear to expect audits of virtualservices. Cigna, for example, has warned that visits above level 3are suspect.Use your note fields to fully discloseField 19 of the standard billing form (CMS 1500) is for “AdditionalClaim Information.” Although not required, disclosing howservices were rendered will go far to protect you in future audits.Include phrases such as “telephone, facetime, Skype” in this field.Billing electronically? Most EMRs have interfaces that will showallow you to input your electronic claim in a CMS 1500 format.

ServiceCode(s) to billCommentsVirtual screening telephone consult (5-10 minutes)G2012. CMS allows billing 99211 even ifdone by nurse Must be performed by a licensed provider Cost-share will be waived Usual face-to-face E/M code ICD10 codeZ03.818 or Z20.828Virtual or face-to-face visit for screening for suspected or Modifier CS (Only when testing orderedlikely COVID-19 exposurefor Medicare) Append with GQ, GT or 95 modifier forvirtual care depending on carrierBilling forCOVIDtesting Cost-share will be waived only when providers bill theappropriate ICD10 code and modifier CS Modifier CR or condition code DR can also be billedinstead of CS Cost-share will be waived only when providers bill the Usual face-to-face E/M code ICD10 codeappropriate ICD10 codeVirtual or face-to-face visit for treatment of a confirmed B97.29 or U07.1 Cigna will reimburse usual face-to-face ratesCOVID-19 case Append with GQ, GT or 95 modifier for Effective for dates of service on and after February 4,virtual care2020 In order to bill these codes, the laboratory must use atest that is developed and administered in accordancewith the specifications outlined by the FDA or throughstate regulatory approval Diagnostic screening tests: U0001, U0002, Reimbursement at 100% of MedicareCOVID-19 laboratory testing (including antibody testing) U0003, U0004 or 87635 Please see additional guidance for U0003 and U0004 in Antibody tests: 86328 and 86769the COVID-19 Laboratory Testing Frequently AskedQuestions section Cost-share will be waived only when providers bill one ofthese codesSpecimen collectionG2023 and G2024COVID-19 related diagnostic tests (other than COVID-19 Usual codes ICD10 code Z03.818 ortest) including, but not limited to influenza (87275,Z20.82887276, 87279, and 87804) and respiratory syncytial virus Modifier CS(87280, 87420, 87634, and 87807) Reimbursement at 100% of Medicare Cost-share will be waived when billed by a provider orfacility only when billed without any other codes For other laboratory tests when COVID-19 may besuspected Cost-share will be waived only when providers bill theappropriate ICD10 code and modifier CS Modifier CR and condition code DR can also be billedinstead of CS Paid per contract

Thank you for your attentionPlease email: [email protected] orCall: 901-377-8727 with questions.

PANELISTSSarah E. Warren, Au.D., Ph.D., CCC-AAssistant Professor, University of Memphis School ofCommunication Sciences and DisordersRachel Lauletta, MS, BCBA, LBAExecutive Director, Harwood CenterAdjunct Professor, University of MemphisSharon Lusk, JD, CPA, CMC, CMCOCo-owner, KLA Healthcare Consultants

Telehealth for Vulnerable PopulationsBilling and Technology in ProvidingTelehealth ServicesJune 18, 2020

the BCBA only did parent training, an RBT cannot bill for therapy, even . new ball game! Then –Medical providers at both ends of the visit. Now –Visit can occur with . state regulatory