Category Archives: Health Care

Telehealth

This post will teach you how to incorporate video conferencing programs into your practice. And to get paid for those visits. If you hate my intros then skip down to the fourth paragraph. It happens, I’m not mad, you are busy people.

Insurances WANT to pay for telehealth visits. Video conferencing for medical care helps keep costs down by keeping people out of urgent cares and emergency rooms. Two of my providers recently started using Skype and Facetime to see a couple of their patients. The psych was seeing a patient who was living in another country and the Internal Med was treating a patient who was recently left without transportation and has a condition that needs careful management. After the patient missed two appointments in a row,  the Internal Med decided it was better to have a Facetime visit than to for the patient to run out of medicine that causes severe issues if you stop taking it suddenly. Both doctors actually assumed they wouldn’t get paid and didn’t give me the superbills for those visits.  That was fun. 

It took several hours of research and some new terminology to get the whole story on telehealth/telemedicine. Good news is, most of you can get paid for telehealth visits from most insurances. Medicare is the exception and will only pay for telehealth visits when a patient is either outside of a metropolitan statistical area or in a rural health professional shortage area. If your patients fall into those categories you can bill regular E&M codes. Here is the Medicare guide on telehealth if you would like more detailed information. 

The laws regulating telehealth also vary by state. There are no states that specifically  disallow using video conferencing to treat your patients, but some states restrict required reimbursement to specific specialists, some states require written consent, some need you to be licensed in the state the patient is being seen in as well as the state you normally practice in, and some states have no laws regarding telehealth at all. Below is a list of the basic information for each state. Press CTL + F and type your state in the search box that pops up to jump right to the information relevant to you. At the end of the article, I’ll discuss some of the reasoning behind the various requirements and what you can do if you don’t like your states telehealth laws.

Alamaba – No laws in place, but Medicaid and private insurances will cover telehealth. For commercial insurance, check the benefits of the patient’s plan. Most resources regarding Alabama regulations refer to it as telemedicine. Because there is no law, there is no mandate for parity in reimbursement, so it would be worth your while to call the insurances and check the fee schedule for those visits. In most other states, telehealth visits are billed with regular E&M codes. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill.

Alaska – Telehealth regulations revised 2017. The state requires private insurances to pay for telehealth for mental health as of 2016, and Medicaid has a very comprehensive reimbursement policy for remote visits. Use modifier GT for live videochats. Check benefits on the patient’s plan for specialties other than mental health.

Arizona – The law requires private insurances to pay for telehealth, but only for a limited number of conditions (trauma, burn, cardiology, infectious diseases, mental health disorders, neurological diseases including strokes, dermatology, pulmonology). Telehealth for other conditions may be covered at the discretion of the insurance provider.

Arkansas – Arkansas makes telemedicine very easy. And the regulations are incredibly easy to find and easy to read. The rules fall under Regulation 38. Please check out the link. Basically, the doctor is required to keep the same standard of care, keep detailed records, and cannot prescribe controlled substances for new patients. There are no specific requirements about written or verbal consent for the service.

California – Telehealth regulations in California have been evolving quickly. The most current law, AB 809, was passed in 2015, and states that the standard of care is the same whether the patient is seen in-person, through telehealth or other methods of electronically enabled health care. Physicians need not reside in California, as long as they have a valid, current California license. California providers are required to obtain and document verbal or written consent for the visits. California also very specifically states that only video conferencing counts as telehealth and specifies that only “real-time two-way communication” (or live video) will qualify. Controlled substances may only be prescribed if the patient has had a previous in person visit. The CA Medical Board website has a very succinct guide.

Colorado – House Bill 1029 governs telemedicine reimbursements in Colorado and, as with most things, Colorado is quite progressive. Insurers are required to reimburse providers for telehealth services. Doctors are not required to have an in-person visit before establishing care via video conferencing, there are no rules regarding “originating sites”, but providers do need to be licensed in the state of Colorado. Informed consent is required to be obtained and documented in the note. Medical marijuana is not allowed to be prescribed or even recommended during a telehealth visit.

Connecticut – SB-467 took effect on 01/01/16 and regulates telehealth in Connecticut. Insurers are required to reimburse providers for telemedicine the same way they reimburse for in office visits. Connecticut also takes a very broad view of telehealth and allows providers to use “store and forward” video to provide services to a patient, unlike most other states with telehealth laws that restrict visits to live video. Consent is required to be obtained and documented in the medical record. Insurances can also authorize telehealth visits the same way they authorize in person visits. The text of SB-467 is a bit of a slog, but is fairly straightforward and worth a read if you want more specific information.

Delaware – HB-69 unanimously passed in 2015, and while it allows telehealth, does have some specific restrictions on providers and patients. The regulation has quite a few factors required to “create a valid doctor-patient relationship,” and providers are only allowed to prescribe once that relationship has been established. This article on http://www.healthcarelawtoday.com was very helpful. Insurers are required to cover telehealth the same way they do regular office visits, only for “real-time two-way communication”.

Florida – Florida legislature has not passed any laws regulating telehealth, but the state medical board has issues rules 64B8-9.0141  and 64B15-14.081. Florida does not specify what type of video conferencing counts as telemedicine, but they do state that telephone, fax, and online questionnaires do not qualify. Providers are not allowed to prescribe controlled substances with a telehealth visit. Because Florida does not have a law, insurances are not REQUIRED to pay for telehealth services. Many of them allow these visits and want patients and providers to use them, as it lowers costs, but it will depend on the patient’s plan. Call and check the benefits for each patient before providing services.

Georgia – The Georgia Telemedicine Law went into effect in 2006 and insurers are required to cover telehealth visits the same way they cover in person visits. Patients are required to have at least one in person visit annually in order to be eligible for visits via video conferencing, and an in person exam must be done prior to any telehealth services. Georgia Medicaid requires providers to obtain written consent, but verbal consent is acceptable for other insurers.  Providers are also required to give the patient clear instructions on follow up in the event a patient needs emergency care and cannot prescribe controlled substances. The Georgia Medical Board put out this article with updated regulations in 2014.

Hawaii –  Senate Bill 2395 was passed in Hawaii in 2016 and went into effect on 01/01/17 and requires Medicaid and commercial insurances to pay for telehealth visits as they would in person visits. The Hawaii bill is unique in that it also includes requirements for malpractice coverage regarding telehealth. Your malpractice insurance would be able to help you with the specifics of your coverage. A face to face visit is not required to provide telehealth to a patient and there are no longer any geographic restrictions to providing remote services to Medicaid patients.

Idaho – Idaho regulates telehealth with HB189 also known as the Idaho Telehealth Access Act. A provider does not have to see a patient in the office in order to provide telehealth services and can prescribe with two restrictions. Controlled substances are limited to in person visits and no drug may be prescribed through telehealth services for the purpose of causing an abortion. Idaho Medicaid will cover limited physician-provided mental and behavioral health services, as well as some services for children with developmental disabilities. Providers are required to obtain either verbal or written consent and document that properly in the note. Both live video and “store and forward” video are acceptable for telehealth in Idaho. According to this Idaho Medicaid Policy telehealth services are covered for mental health and primary care.

Illinois –  SB1811 governs provider-patient relationships regarding telehealth in Illinois and was recently passed in 2017. Unlike other states, this law is simply a series of definitions. It outlines a providers responsibility in terms of establishing a doctor-patient relationship and has no requirement that insurers cover telehealth visits. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There are no laws regarding consent or prescribing, but it is always safe to document consent and adhere to the same standard of care for telemedicine as you would for in person visits. 

Indiana – Insurers in Indiana are required to cover telehealth visits, however the law does not mandate parity in reimbursement, so it would be worth your while to call the insurances and check the fee schedule for those visits. In most other states, telehealth visits are billed with regular E&M codes. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. This article from healthcarelawtoday.com breaks down the providers responsibilities very well. The doctor has eight steps to take to establish a doctor-patient relationship and some specific restrictions on prescribing.

Iowa – The Iowa Board of Medicine has issued the following rules regarding providing telehealth services to patients in Iowa. Telehealth visits are permissible via live video or “store and forward” video and the doctor does not need to see the patient in person before seeing them over Skype, Facetime, or some other video conferencing application. Physicians are required to obtain verbal or written consent and document that timely, and have an avenue for patients to access and update their information and lodge complaints. Prescribing is allowed, with restrictions on abortificants, and providers are not allowed to direct patients to websites that advertise or promote goods or products benefiting the provider or websites offering the provider a monetary incentive for sending patients there.

Kansas – Kansas does not currently have any laws regarding telehealth. A law was proposed in 2017, and has not yet made it out of committee. Insurers in Kansas are really fighting against the parity portion of the proposed law. Most other states with telehealth laws require insurances to pay the same for telehealth as they do for in office visits. And, since insurance companies don’t like to pay for anything, they are fighting for the right to pay you less for the same amount of work. Call your representative today. Telehealth does help to lower costs for insurances, though, so many of them will already cover visits done with video conferencing. Check each patients benefits before providing the service. Kansas Medicaid pays for telehealth services for office visits, individual psychotherapy, and pharmacological management services. The consulting expert must bill with the GT modifier and 02 place of service code. Patient must be present at an eligible originating site and written consent is required.

Kentucky – Kentucky gets very specific with the regulations for telehealth. First off, while insurers are required to cover telehealth visits, they are not required to pay the same amount as they would for an in person visit. In most other states, telehealth visits are billed with regular E&M codes. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Only live video is allowed and you need to obtain written consent with very specific statements before the visit. Kentucky Medicaid has very long and detailed guidelines on who can bill for telehealth and how. Please read the article if you are a primary care doctor, mental health provider, dietitian, speech therapist, chiropractor, occupational therapist, physician’s assistant, or optometrist.

Louisiana – The Lousiana Medical Board has been diligent in keeping up with current technology and has issued and revised rules regarding telehealth several times. Currently, providers are not required to do an in person exam prior to the telehealth visit, and the “originating site” for patients can be anywhere the patient chooses. As an added bonus, Louisiana allows providers to use audio only services with online apps or with telephones to provide care to patients. You would need to be careful prescribing controlled substances to patients, but if the patient has had at least one in person visit in the last year, then it is allowed. The patient does need to give specific informed consent and can revoke consent to receive services via telemedicine at any point. Also, psychiatrists cannot prescribe amphetamines for their ADHD patients and telehealth cannot be used for treating obesity.

Maine –  Insurers in Maine are required to cover telemedicine, but there is no parity mandate. For MaineCare patients, telemedicine is allowed more broadly because so much of Maine is rural. Providers can use video conferencing, and “store and forward” video, and, when video conferencing is not available due to the lack of a broadband connection, a telephone visit will be allowed. Here is a list of FAQs for MaineCare telemedicine. Maine requires very specific consent to be documented in the patient’s chart. Please review these rules before engaging in telehealth visits. Maine does not require insurers to pay telehealth visits at the same rate as in person visits. Providers are not required to see a patient in person in order to treat them with telehealth.

Maryland – Maryland has some pending legislation regarding telehealth, so if you are reading this in a few months, the rules may be different. Currently Maryland allows live video only and both the physician and patient need to be in Maryland. The Maryland Board of Physicians have current rules on telehealth that govern physicians responsibilities, and Maryland law requires insurers to cover telehealth, although parity in payment is not required. Providers need to obtain informed consent and can use both live video and “store and forward” video. The new laws will cover prescribing and “practice standards” that the provider will need to meet before each telehealth visit.

Massachusetts – Insurers in Massachusetts are required to cover telemedicine, but there is no mandate for them to pay video visits at the same fee schedule as in person visits. There are two acts currently working their way through the state legislature, but they are both currently in committee. The Massachusetts Medical Society has released several recent opinion pieces and a telemedicine guidelines booklet to aid providers in successfully implementing telemedicine into their practices

Michigan – The telehealth law in Michigan was very recently enacted. SB 0753 took effect on 03/01/17 and does not actually require that insurers pay for telehealth visits and also does not require parity of payment to in person visits. However, insurers WANT their patients to take advantage of telemedicine, especially in states without a parity mandate, because it saves the insurer quite a bit of money. So, check the benefits of the patient’s plan. Because there are no laws, each insurance plan might have strange rules about which kind of conditions can be treated with telemedicine. Before you see the patient, do your due diligence. Michigan requires patients give consent to be treated using this technology, providers can prescribe everything but controlled substances, and telemedicine is defined as two way live video. “Store and forward” video is not payable in Michigan.

Minnesota – Minnesota has very generous telemedicine laws. Insurers are required to pay telemedicine visits at the same rate as they would in person visits and commercial plans are specifically prohibited from charging patients higher copays, coinsurances, and deductibles for these services. Physicians from outside Minnesota can provide telemedicine services to patients in the state by registering with the Minnesota Board of Medical Practice. You would simply need to fill out a one page form and pay a $100 registration fee. You are not required to see a patient in person before treating them via video technology. Patients can use either live two way video, or “store and forward” video. Medicaid limits telemedicine visits to no more than three per week.

Mississippi – Mississippi has joined the side of the provider with laws for telemedicine stating that insurers and Medicaid are required to cover telemedicine, and they must pay the same as they would an in person visit. Only live video and remote monitoring are allowed. Remote monitoring has very specific requirements and if you intend to provide services this way, please review this list. If services are rendered via remote monitoring or “store and forward” video, the modifer GQ is required. I couldn’t find anything regarding requiring specific consent, but it wouldn’t hurt to document in the chart that the patient consents to receive services through telemedicine.

Missouri – There is currently legislation pending in Missouri that would change the landscape of telemedicine in that state, however this post will cover existing laws. An in person visit is required before a patient can receive care via telemedicine, and only health plan approved programs such as LiveHealth online can be utilized. Only live two way video is reimbursable. Providers are allowed to prescribe all medications, even controlled substances. Telephone visits and internet questionnaires are specifically disallowed and providers are not allowed to make any prescription without an in person or video conferencing visit. None of the laws require specific patient consent.

Montana – Insurers in Montana are required to cover telehealth visits at the same rate as in person visits. Both live video and “store and forward” technology can be used for telehealth visits. Providers are not required to obtain specific consent. Montana commercial insurers may have restrictions regarding which platform or software can be used for video conferencing, so check with the patient’s plan before proceeding. In person visits are not required prior to treating a patient via telehealth and you would use the GT modifier.

Nebraska – The Nebraska State Board of Health has a very handy guide to the telehealth statutes in that state. Nebraska providers are required to provide the patient with certain written statements that need to be then signed and a copy needs to be kept in the patient’s chart. The guide I provided above has the requirements clearly laid out. Both live video and “store and forward” video is acceptable for telehealth in Nebraska. Insurers are required to pay the same for telehealth visits as they do for in person visits and telemonitoring is also reimbursable. In order to prescribe, the physician would need an in person visit “to establish care”. There are additional requirements for providing behavioral health services to children and those rules are also in that guide linked above.

Nevada – AB 292 governs telehealth in Nevada. Insurers are required to cover telehealth visits the same as in person visits and providers can use both live two way video and “store and forward” video. Nevada also includes Workers Compensation as covered under the telehealth law with the same requirements as commercial and Medicaid insurers. Use the GT modifier when you bill and prescriptions for telehealth services must follow standard online prescribing rules for the state. Providers must obtain specific written consent. Medicaid requires an in person visit before seeing patients via telehealth, but the state law does not require it for commercial insurers.

New Hampshire – Physicians in New Hampshire can establish a doctor patient relationship via telehealth visits without having an in person visit first, but cannot prescribe any Schedule II -IV drugs. The law specifies that only “real-time two-way communication” (or live video) will qualify. This inclusive guide has billing codes and policies. New Hampshire mostly follows Medicare rules for CMS, without the restrictions on how rural the patient has to be.

New Jersey – New Jersey passed a telehealth law in 2017 and, while insurers are required to cover telehealth visits, they are not required to pay parity. This law is also unique in that it requires live two way video to establish care, but “store and forward” video may be used for subsequent visits if the provider determines that they can provide the same standard of care as they would with in person or live video. Establishing a doctor patient relationship has a specific list of information the provider would need to verify and review. This article at healthcarelawtoday.com breaks down what you need quite clearly. As far as prescribing goes, New Jersey is again unique. Schedule II drugs are not allowed without a prior in person exam, with one exception. A provider may prescribe Schedule II stimulants to minor patients under the age of 18 as long as the visit was with live video and the minor’s parent or guardian has consented to waiving the in-person examination requirement in writing. Patient consent is not specifically required in most cases, but Medicaid does require it for certain specialties.

New Mexico – Commercial insurers in New Mexico are required to pay for telehealth, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. An in person visit is not required to begin treating patients with telehealth and prescribing is allowed under the same regulations that govern online prescribing.

New York – Commercial insurers and Medicaid in New York are required to pay the same for telehealth as they do for in person visits, as long as providers are using live two way video. Insurers MAY pay for “store and forward” video visits, but are not required to. New York also has a special requirement that the camera used in the provider-patient connection be able to tilt and zoom so that the provider can be as observant over video as they would be in person, even for things the patient may not notice or intend to disclose. Written consent is not typically required with the exception of patients receiving mental health services. Bill using the GT modifier. Medicaid does require that the patient be at specific “originating sites”. Here is a list of acceptable originating sites for Medicaid.

North Carolina – Insurers in North Carolina are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The North Carolina Medical Board has a clear and comprehensive guide on a provider’s responsibilities and options for telehealth. Please note, North Carolina requires staff specifically be trained to use the technology properly.

North Dakota – Insurers in North Dakota are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The North Dakota Board of Medicine has a short guide on a provider’s responsibilities regarding standard of care and patient consent. An in-person exam is not required to start treating a patient via telehealth and providers can prescribe just as they would in person. The only exception being, providers are not allowed to prescribe opioids at all through telehealth. Two way video and “store and forward” video are both acceptable for telehealth in North Dakota. 

Ohio – Ohio is very concerned about prescribing via telehealth and verifying the identity of the both the patient and the provider. The regulations are quite involved and would take up much more space than I have here. So please go read the informed consent requirements and the prescribing regulations. In Ohio, only Medicaid is required to reimburse providers for telehealth, commercial insurers are not required by law to do so. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill.

Oklahoma – I have to say, I am so impressed with the Oklahoma Medical Board right now. This page is amazingly well organized and informative. The Telemedicine Act (SB726) states that an in person visit is not required to establish care, however, a provider does need to have access to the patient’s medical records prior to the visit. Insurers in Oklahoma are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Providers are not allowed to prescribe either opioids or benzos through telemedicine visits, but other medications can be prescribed as long as the provider is utilizing the same standard of care. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video).

Oregon –  Insurers in Oregon are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Also, some diagnosis may not be covered by telemedicine, or have specific restrictions on under what conditions you can provide telemedicine services. So, please check your patient’s benefits. There are no laws regarding consent or prescribing, but it is always safe to document consent and adhere to the same standard of care for telemedicine as you would for in person visits. 

Pennsylvania – There is currently legislation pending in Pennsylvania. I am writing this in April 2018, so if you are reading it in 2019, please double check the laws in your area. Or email me to update this article. As of the time of this writing, PA does not have any law regarding telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There are some guidelines that providers wishing to utilize telehealth need to follow. Specific consent must be obtained and documented and two way live video is preferred. 

Rhode Island – Insurers in Rhode Island are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The law also contains language regarding originating sites that insurances may be able to use to limit a patient’s access to telehealth. Please call to check benefits before you provide telehealth services. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). Patient consent is required and the patient needs to consent to some fairly specific things

South Carolina – As of the time of this writing, SC does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. South Carolina law does state that in order to provide services via telehealth, physicians and staff must be “trained in the use of telemedicine equipment and competent in its operation.” There are no standards to this training or any recommendations on where to be trained. Prescribing is allowed with three exceptions. Providers are not allowed to prescribe any Schedule II or Schedule III drugs, any erectile dysfunction medication, or any abortificants. Medicaid will not compensate providers for “store and forward” telehealth visits. 

South Dakota – As of the time of this writing, SD does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Medicaid will reimburse at parity with in person visits. I have also not been able to find any information about any pending legislation. There are no laws regarding consent or prescribing, but it is always safe to document consent and adhere to the same standard of care for telemedicine as you would for in person visits. 

Tennessee – Insurers in Tennessee are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Consent is required, but may also be “implied consent.” It is probably a good idea to get verbal consent and document that in the chart. Prescribing is allowed to the same standard of care as in person exams. Medicaid will compensate providers for telehealth visits if the patient is in crisis. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). 

Texas – Texas has recently enacted a new law easing the restrictions on providers for telehealth, but the wording of the current law is more vague. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). Consulting doctors need to provide a report to the primary care doctor within 72 business hours. Physicians are not required to see the patient in person to provide services with telehealth. Both two way live video and “store and forward” technology is payable with specific requirements for “store and forward”. The provider needs clinically relevant photographic or video images, including diagnostic images, the patient’s relevant medical records, and a HIPAA conforming technology to comply with the standard of care. The first visit must be with qualified medical staff present at the “originating site” or an in person visit. The Texas Medical Board has a good FAQ on telemedicine

Utah – As of the time of this writing, UT does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Medicaid will pay for telehealth for two way live video only. “Store and forward” video is not reimbursable. Providers can prescribe with telehealth as long as they can obtain and document patient’s relevant clinical history and current symptoms, be available for subsequent care related to the initial telemedicine services, be familiar with available medical resources, including emergency resources near the originating site, in order to make appropriate patient referrals when medically indicated, and make the patient’s medical records available to them. 

Vermont – Insurers in Vermont are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Providers need to obtain the patient’s verbal or written consent and document that in the chart. Providers may prescribe via telehealth as long as they keep to the same standard of care as in person visits. Patients are not required any longer to be in a healthcare facility as the originating site. Vermont has specific wording in their new law stating the telehealth consultations cannot be recorded and only live two way video is allowed. 

Virginia – The Virginia Department of Health Professions has issued Guidance document: 85-12 in regards to a physician’s responsibilities regarding treating patients via telehealth. It is a five page document and contains the information regarding consent (needed, specific), privacy (practice needs written policy), and prescribing. Insurers in Virginia are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. 

Washington – Insurers in Washington are required to cover telehealth visits, but there is no mandate to pay parity with in person visits. Since insurances are not required to pay the same amount for telehealth as they are for in office services, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There is no specific requirement for consent and prescribing is held to “the same standard of care” as in person exams. An in person exam is not required in order to treat a patient via telehealth. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). 

West Virginia – As of the time of this writing, WV does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. Medicaid currently only covers live video and not “store and forward” technology. Patient consent is required to be obtained and documented, and prescribing is allowed, but any scheduled pain relieving drugs are not permitted to be prescribed via a telehealth visit. In person visits only. While an in person visit is not required, the provider has a very specific list of things to do to “establish care” with a telehealth visit. Please see this article for the complete list. 

Wisconsin – As of the time of this writing, WI does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. The medical board has issued brief guidelines for providers utilizing telehealth. Patient consent is required to be obtained and documented, prescribing is allowed, and you do not need an in person visit first in order to establish care. Both two way live video and “store and forward” technology is payable, as long as the recording conforms to HIPAA (so Skype would not qualify for recordings but would for live video). 

Wyoming – As of the time of this writing, WY does not have any law regarding requiring payment for telehealth on the books. But, like I said in the introduction, insurances want patients to use telehealth, because it keeps patients out of emergency rooms and urgent care, and, if there are no parity laws, they can often pay less for a telehealth visit. Since insurances are not required to pay, they might have policies or codes specific to telehealth and you would need to look that up for each insurance you would like to bill. There is no specific requirement for consent and prescribing is held to “the same standard of care” as in person exams. An in person exam is not required in order to treat a patient via telehealth. The Northwest Regional Telehealth Center has a page on telehealth in Wyoming and they also have an easy way for you to ask more questions if you have them. 

Two quick things. “Originating site” is wherever the patient is. Previous incarnations of many state laws required patients to be in a healthcare facility to receive telehealth services. Those requirements are basically a thing of the past. Also, many states are concerned about patient consent, because of the slight risk to patient privacy during telehealth visits. In your office, you can room a patient and close the door, giving the patient a reasonable expectation of privacy. When they are at home, or in their office, or walking around the grocery store, you can’t control the privacy of the information on their end. So, they need to consent to be responsible for their own privacy since you are not there to ensure it. 

As always, contact me if you need any help or have any questions. We will be adding a telehealth topic into the roster of our available online webinars, so email me at newgenerationbilling@gmail.com if you would like to sign up. The landscape of medicine is changing very quickly, and the more information you have, the better you can decide what is right for your practice. 

 

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Filed under Billing, Health Care, Medical Billing, Medicare, Office policy, Telehealth

Every practice does it…

I was debating continuing the joke into inappropriate-land, but my professionalism got the better of me.

By “IT” I mean, no matter how careful the front desk is, the doctors occasionally see a patient that has an insurance the doctor is not contracted with. If you have a lot of non-contracted patients slipping through, please read my post on how to run a tight ship at the front desk. The purpose of this article is not to cast blame, but to help you deal with the inevitable insurance fight that will result when this does happen.

Just like all posts, this will have a detailed article and a summary wrap up at the end, and a downloadable guide. If you are looking for particular information, try pressing CTL + F and a little search box will pop up. Put a one to two word search query there and press enter. You should jump directly to the part of the post that applies to you.

The BEST case scenario when you end up with an out of network patient, is that they have a PPO, Managed Care (MC), or Place of Service (POS) plan with out of network benefits. The patient will end up paying more toward their coinsurance or deductible, which, you know, sucks for them, but the allowed amount for the provider will be the same as the in network rate.

If the non-contracted insurance is an EPO, the patient has no out of network benefits. No matter how much you appeal, you will not get any payment from this insurance. Now you have to break out your flow chart. If the patient doesn’t have anything secondary to their EPO, you bill them your cash price. Or the full price. Whatever. You do you. If the patient does have a secondary, you send a claim to the secondary with a copy of the primary denial and hopefully you are contracted with them.

Here is where it gets a little complicated. If the patient has a commercial HMO, there are a ton of rules the IPA will cite in order to deny your claim. And, if the patient does not have a secondary insurance, you can decide how much effort you are going to put in trying to get the insurance to pay your claim. You can bill the patient right away or you can appeal the charge to the non-contracted IPA. I, personally, will fight with the insurance company for a couple of rounds before I bill the patient. A patient who has insurance is very unlikely to pay your bill, even if they legitimately owe it. A patient who has an HMO generally has less money in their budget then someone who has a PPO or EPO and is even less likely to pay your statement. Here are your options with a commercial HMO patient.

  1. You are a family practice/internal med contracted with the IPA, but you are not the PCP. Unfortunately, in this case, there is probably not much you can do. You can try sending a claim to the claims department with the medical records and a letter requesting retro authorization. Here is an example of a letter requesting retro authorization. You would update the letter to explain what happened in your case. I have not had much success in convincing the insurance to pay in this situation. Mostly because the IPA has ALREADY paid the other provider their cap for that patient for the month. They are not going to pay you another cap payment, and they REALLY don’t want to pay you fee for service. 
  2. You are a family practice/internal med and you are not contracted with the IPA. You have a better shot in this situation getting a retro auth from the insurance. You would use the same type of letter as in the above example. I have about a 70% success rate when this happens. 
  3. You are a specialist and you did not get an authorization. Whether or not you are contracted, you have about the same chance of getting paid if you did not get a prior auth or single case agreement. You write a letter to convince the insurance that the services were medically necessary, or urgent. 

One of the most complicated situations arises when a patient comes in and hands you a Medicare card, but it turns out they actually have a Medicare Risk HMO plan. If the patient does not have a secondary, you would handle the charge in one of the ways outlined above. However, most of our patients with MR Risk HMO plans, also have Medicaid secondary (called Medi-Cal here in California). If your provider is contracted with Medi-Cal you are not allowed to bill a patient under any circumstances. It does NOT matter that the patient went to the wrong doctor, it does NOT matter that they gave you the wrong insurance, it does NOT matter that they specifically withheld information regarding a primary insurance, it does NOT matter that the insurance they became effective with on the first of the month when you saw them is not one you are contracted with, it does NOT matter that you requested an urgent auth and the insurance denied it. Medi-Cal does not care. My out of state readers will have to let me know if your Medcaid works the same way, but that is how it works here. Also, Medi-Cal has been forcing people into HMOs as well. So what often happens, is that a supposedly straight MR patient comes in, you bill MR and they deny it stating the patient has an HMO. You can’t send that denial to Medicaid because the secondary is also an HMO and you are not the PCP. And, unlike in the previous situations, you are not allowed to bill the patient. 

Here is an example of a letter that I have successfully used to get payment from an IPA in this exact situation. 

I have added all the letters to the links and tools page, and I have created this Downloadable non-contracted patient guide, to help you easily determine what you need to send where in which situation. If you need help with your specific patient, and your specific situation, send me an email.

If your office needs training or consulting or an audit, or if you decide that all of this is too much hassle and you want to pay someone else to do it for you, you can give me a call (909) 374-5439. I am awesome at this stuff. All the partners in New Generation are awesome at this stuff, actually, and we will train, consult, or bill, well, awesomely.

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Filed under Accounts receivable, Authorizations, Billing, Denials, Doctor's Office, Follow up, Health Care, HMO, Medical Billing

Medicare Unlikely Edits – or – The Rules Private Insurances Quote to Deny Your Claims

I recently billed an extended ophthalmoscopy to Blue Cross. What does this have to do with the Medicare Unlikely Edits you ask? Not much, just an intro. If you want to get right into it, skip down to the second paragraph. OK, back to the story. As those of you who bill for an ophthalmologist know, we used two line items of the 92225 with the RT/LT modifiers. Blue Cross paid the 92225 RT but denied my charge for the 92225 LT stating that according to the Medicare Unlikely Edits, only one unit of that code was allowed per day.

OK. Two things.

  1. Why is it ALWAYS Blue Cross? Seriously, Aetna doesn’t give me these kinds of problems.
  2. I am 100% sure that the Medicare Unlikely Edits realize that people have TWO eyes and TWO units of that code are allowed per day. Now I need to look up the table, verify that information, and deconstruct the CMS terminology to write my appeal letter.

The Medicare Unlikely Edits (MUE) are a table of guidelines that CMS puts out to indicate how many units of any given service are allowed for a single date of service. Here is a link to the MUE page on the CMS site. And, to make your life much easier, here is the MUE Table. The table has the CPT/HCPCS code in the first column, the Practicioner Services MUE Values in the second column, the MUE adjudication indicator in the third column, and the “MUE Rationale” in the fourth column. There is a fair amount of terminology that CMS made up specifically for these guidelines, and there is a PDF file 43 pages long that explains what that terminology means. But I am going to give you the cliff notes version, directly from the CMS manual.

Practicioner Services MUE Values = Maximum number of units allowable for a single beneficiary on a single date of service.

MUE adjudication indicator = Claim line or date of service edit. 1 = claim line edit, 2 & 3 = DOS edit.

  • A claim line edit means that appropriate modifiers ( e.g. 59, 76, 77, 91, anatomic) can be used to report the same code on separate lines of the claim. Example: A patient is in the emergency room with an asthma attack and he gets a breathing treatment. You use 94644 for the first hour, and up to two units of 94645 for the next two hours and the patient is no longer wheezing. However, before being discharged, he starts having another attack. You bill an additional line item of 94645 with the 76 or 77 modifiers with up to two additional units.
  • Indicator 2 means that there is no situation ever in which more than the indicated number of units would ever be payable. For example, in my situation, the code 92225 has an indicator of two. That is because every person in the world has a maximum of two eyes and there is no situation in which an insurance would need to pay for more than two units for a single patient one one visit.
  • Indicator 3 means that it is “possible but medically highly unlikely that higher values would represent correctly reported medically necessary services.” So, you do have some room to appeal with these codes if you can prove the services were medically necessary.

MUE Rationale = The criteria CMS used to determine the number of units allowed for each service. **Warning* Giant list of terminology ahead**

  • Anatomic considerations – A limit on the number of units based on anatomic structures. Ex: CPT 24357 – Tenotomy of the elbow, This code has a max of two units allowable, because each person has a max of two elbows.
  • Code descriptor/CPT Instruction – A limit on the number of units based on coding instructions directly from the CPT manual. Ex: CPT 73565. The CPT description says “Radiologic examination, knee; both knees, standing, anteroposterior” and the total number of units allowed is one. The one code already includes both knees for a single unit, so no additional units are payable. Unless the test had to be re-done for some medically necessary reason. Which you would then have to prove.
  • CMS Policy – A limit on the number of units based on established CMS guidelines. Those policies and guidelines can be found on the Medicare Coverage Database
  • Nature of an analyte – A limit on the number of units based on one of the following three factors:
    1. The nature of the specimen may limit the units of service – Ex: a test requiring a 24-hour urine specimen
    2. The nature of the test may limit the units of service – Ex: a test that requires 24 hours to perform.
    3. The physiology, pathophysiology, or clinical application of the analyte is such that a maximum unit of service
      for a single date of service can be determined. Ex: the MUE for RBC folic acid level is one since the test would only be necessary once on a single date of service.
  • Nature of service/procedure – A limit on the units of service, determined in general by the amount of time required to perform a service. Ex: an overnight sleep study
  • Nature of equipment – A limit on the units of service, determined in general by the number of items of equipment that would be utliized. Ex: cochlear implants

So, when I look up the code 92225 here is what I see:

CPT     MUE Values     MUE Adjudication Indicator    MUE Rationale

92225                   2                   2 Date of Service Edit: Policy         CMS Policy

This means that for CPT code 92225 a provider can bill two units of the service, and that is per CMS policy. So, now I can write an appeal to Blue Cross, with a copy of that line of the table, and a letter stating “As you can see, per CMS policy, two units of 92225 are reasonable and customary. Since you are adhering to the Medicare Unlikely Edits, please reprocess and pay line item 92225 LT.”

I hope you can use this as an additional weapon in our never ending war against the insurance companies. As always, if you need any additional help, want to set up a training for your office, or are so touched by my helpfulness and eloquence that you would like to thank me personally (j/k) please call (909) 374-5439 or email newgenerationbilling@gmail.com.

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Modifiers 24 and 79

A few months ago we had to do some training on our ophthalmologist account regarding when to bill the 24 modifier versus the 79 modifier in the global period to a surgery or in-office procedure. I figure, if our employees are having questions, some of you might be too, and I want you to get the maximum reimbursement for your services. First, the exact descriptions of the modifiers from the CPT book:

24 – Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Post-operative Period:
The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:
The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

Many of our doctors do both minor and major surgeries, and we all know that patients need to come back in for follow up care on their various incisions, wounds, and ulcers to make sure everything is healing properly. The insurance companies will not pay for these follow up visits, or any visit done in a certain amount of time after the procedure without the proper modifiers as they consider the follow up visit to be an integral part of the original procedure. This time period is called the global period and the length of time varies depending on the procedure performed.  The issue with this no-payment rule comes in when the doctor diagnosis the patient with something additional during the follow up visit, or the patient needs another procedure. At that point, the doctor needs to do a complete visit including review of systems and exam and make a medical decision, and we can all agree that she should be paid for that. Here is how you get her paid. Modifier 24 goes on the office visit and you make sure you have a primary diagnosis that is different than the diagnosis on the original procedure. If the patient needs any in-office procedures, put a 79 on the procedure and make sure the diagnosis is different than the one on the original procedure. If the patient needs another major surgery in that time period, unrelated to the original, use modifier 79 as the first modifier on the surgery.  Just to avoid confusion, whether you use the modifier 24 or the modifier 79, the modifier would go on the visit subsequent to the surgery or in-office procedure.

To answer a popular question, yes, you can use modifier 79 when you are billing for the same surgery on a different body part. For example, if the patient had a cataract surgery on the left eye in January and he is getting cataract surgery on his right eye in February, you can use the same diagnosis of cataracts, the same CPT code for the surgery, and add the 79 modifier. Here is how that would look:

Date                          ICD9 code            CPT Code    Modifiers

01/13/14                 366.17                    66984             LT

02/18/14                366.17                    66984              79    RT

As for using the 24 modifier, there are all kinds of good, justifiable reasons to bill with that modifier and get your office visit paid separately. Here are just a few:

1) Patient is requesting a refill on medication for her chronic condition (hypertension, diabetes, hypothyroidism, migraines, neuralgia)

2) The patient came in with an unrelated chief complaint on his follow up visit

3) Patient came in for the follow up and the doctor identified symptoms of something else during the exam

This is by no means a comprehensive list, so if you are not sure whether or not your particular patient meets the requirements for using a 24 on the office visit, send me a quick email and I’ll let you know how I would bill it. Here is an example of how a charge like that would look.

Date                          ICD9 code                             CPT Code    Modifiers

01/13/14                  366.17                                    66984             LT

02/18/14                 250.60    362.01                  99214             24

I also have another chart for you (I love charts!) detailing the global period for each procedure. It is LONG. I do not suggest you print this one out, but save it on your own computer for reference. Oh, and, the global period for any given code is either going to be 10 days or 90 days, if it has one at all. FYI. As always, I saved the chart to my Links and Tools page for you.

EDIT: Just a quick FYI, global surgery rules do not apply to assistant surgeons. So, anyone who is billing a code for a provider assisting with a surgery, these rules don’t actually apply to you. Just go ahead and use modifiers 80-82 the way you’ve been doing. In fact, if we do send in a claim with modifier 79 (or 78 for that matter), the claim will actually be returned as unprocessable. Thank you, Adam, for helping to clear up the confusion.

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Filed under Billing, Claims, CPT, Doctor's Office, Follow up, Health Care, ICD9, Medical Billing, Modifiers, Office Visit

Quick Workers Comp Tools

Have you ever wished that you could have a list of all the lists and tools and links you need for Workers Comp in one place? Well now you can! You’re welcome.

Doctor’s First Report

PR-2 Report

OMFS Schedule

OMFS DME Prices

NDC Numbers for substances

OMFS Fee schedule for pharmeceuticals

EAMS

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Filed under Claims, CPT, Doctor's Office, Follow up, Health Care, Medical Billing, OMFS, Workers Compensation

Everything you ever wanted to know about pap smears

**DISCLAIMER**  

***This post was written in 2014 and the rules have changed since then. I am going to be putting up a new post with the new rules updated to ICD10 very soon. There are some major changes to the way the insurances accept the charges and this an old post with the old rules. If you have any questions, and can’t wait for the new post, please email me directly and I will try and help you out.*** 

The first thing about paps is that every insurance pays them differently. To tell the truth, I don’t have most of it memorized. What I do have is a binder, with one page per insurance, and all of the pap rules are laid out there, in alphabetical order.

Of course, I’m going to give those to you. I suggest you do what I do and put them all in a three ring binder. However, I can only give you the PPO pap smear rules, because your HMO contracts will not be the same as the contracts for my doctors. I can show you a few of my HMO rules, though, so when/if you make your own reference sheets you know what the necessary information is.

You CAN get an office visit and a pap smear paid on the same date on the same claim. You just need to use proper modifiers. Also, most insurances allow patients to self refer for their annual exam, so you shouldn’t have to worry about authorizations.

Here are the Pap rules for PPO insurances. For your HMO insurances, all you need to do is call the provider relations department and get a copy of the doctor’s contract. The contract will be fairly short, and very clear about which codes are paid. However, you will need to ask the provider relations people which diagnosis they need to see on the claims.

If you want to review the high risk rules you can find those on the MR website. Here is a link, for the curious.

Remember to follow the blog; you’ll get an email every time I get a new post up. Also, if you have a specific question, please don’t hesitate to email me.

 

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Filed under Billing, Claims, CPT, Doctor's Office, Health Care, ICD9, Medical Billing, Modifiers, Pap smears, Well woman exam