Telemedicine & Apheresis

Telemedicine & Apheresis: Use of 2-way Remote Video Communication and New Coding/Reimbursement Considerations:

An Evolving Field in the COVID-19 Era & Beyond

Created by COVID Taskforce Telemedicine & Apheresis Subcommittee (4/29/21): this is a third draft which will be updated and expanded by 5/30/21.

Jan Hofmann, MD, MPH Sarita Joshi, MD Susan Knight, MBA, CNMT Therapeutic Apheresis (TA) Coverage and Reimbursement (2021): Brief Overview

• Inpatient (inpt) TA procedures: covered and paid under MS-DRG or per diem policies • Hospital outpatient (outpt) TA procedures (ie, OIC): are reimbursed per treatment • Private insurance MD apheresis supervision reimbursement is similar or higher than Medicare (CMS) reimbursement (may be 10-30% or up to 2-3X higher). • Guidelines exist to advise when to bill for MD evaluation & management (E&M) consultation and/or MD apheresis supervision. • MD apheresis supervision: • CPT procedure codes for TA treatments • 2021 Medicare MD average payment rates • “A Guide to Billing & Securing Appropriate Reimbursement (2021 Edition)”: Public Affairs & Advocacy Committee, ASFA; will be available on the ASFA website. • “Apheresis Reimbursement: Guide to Billing and Securing Appropriate Payment (5/24/13)”: https://cdn.ymaws.com/www.apheresis.org/resource/collection/485AE27F-A69D-452F- A69F-07A2A7716736/Friday_Windows_1600_Berman.pdf (slides 23-45).

2 Reimbursement Terminology/Definitions

• MS-DRG (Medicare Severity-Adjusted Diagnostic-Related Group): inpt TA procedures covered and paid under MS-DRG coding and policies. • CPT codes: used to identify (and bill for) specific outpt procedures, MD services, lab services • HCPCS codes: identifies drugs, biologicals, blood products, medical equip, selected procedures • ICD-10-CM diagnostic codes: identifies diseases and injuries (comprise 3-7 digits) • ICD-10-PCS procedure codes: identifies procedures in the hospital inpt setting • RVU: Relative Value Units (MD work RVUs; non-hospital practice exp. RVUs; malpractice RVUs) • APC: Ambulatory Payment Classification (for CMS payment of hospital outpt procedures) • UB-04: hospital claim form (to facilitate payment for technical service, incl. non-MD procedure staff, supplies, equipment and space costs, etc.). • CMS-1500: physician (office/clinic) claim form (to facilitate payment for MD professional services) • Revenue codes: similar to hospital services (and items by the same service) • Place of service codes: informs insurer where apheresis procedure was performed

ICD-10 codes: Int’l Classification of Diseases, 10th Revision; diagnosis & procedure codes. Billing codes: CPT (Current Procedural Terminology) codes; and HCPCS-II (Healthcare Common Procedure Coding System) codes. ASFA PAA Committee. Therapeutic Apheresis: A guide to Billing and Securing Appropriate Reimbursement, 2021 Edition. Hofmann JC, Andrzejewski C et al (eds.). Vancouver, BC. American Society For Apheresis; 2021; 1-34. Will be available on ASFA website: https://www.apheresis.org/?page=ApheresisReimbursement. 3 Introduction: The Insurance Billing Process

• The mechanics of insurance billing process for apheresis services can be subdivided on the basis of: • The treatment setting in which the service is performed (hospital vs. physician office/physician- directed clinic). • The provider that is submitting a service claim (physician or hospital).

• When therapeutic apheresis services are provided in the hospital inpatient or outpatient setting generally involves separate submission of two claim forms: • The CMS-1500 by the physician, to facilitate payment for the physician’s professional services associated with the procedure; and • The UB-04 by the hospital, to facilitate payment for the technical service itself (including non- physician procedure staff, disposable supplies, equipment costs, space costs, etc.).

• When the procedure is performed in a physician office or clinic, only a single CMS-1500 claim form is required.

UB-04 CMS-1500 CMS-1500 Hospital claim form Physician office/clinic claim form Physician office form 4 Physician Billing on the CMS-1500 Claim Form

• The physician can separately bill an Evaluation & Management (E/M) code for a history and physical exam to determine the appropriateness of the therapeutic apheresis procedure, as long as the E/M service is performed on a different day than the physician supervision of the apheresis procedure.

• However, a physician may bill an E/M code on the same date as supervision of an apheresis procedure only when: 1) the E/M code is for a separately identified service that involves more than the E/M portion of the apheresis procedure, and 2) the E/M service involves a different diagnosis than the diagnosis for which the apheresis procedure is being performed (add a “-25” modifier to the E/M code).

• Physician supervision during TA procedures (per CMS): 1) CMS definition of “direct” versus “personal” MD supervision 2) H/o CMS evolution in MD supervision parameters (CMS currently requires “direct” MD supervision defined as MD being available [not present] during the TA procedure).

ASFA PAA Committee. Therapeutic Apheresis: A guide to Billing and Securing Appropriate Reimbursement, 2021 Edition. Hofmann JC, Andrzejewski C et al (eds.). Vancouver, BC. American Society For Apheresis; 2021; 1-34. Will be available on ASFA website: https://www.apheresis.org/?page=ApheresisReimbursement. 5 Current CPT Procedure Codes (TA procedures) CPT Description 36511 Therapeutic apheresis; for white blood cells (leukocytapheresis) 36512 for red blood cells (RBC exchange) (erythrocytapheresis) 36513 for platelets (thrombocytapheresis) 36514 for plasmapheresis (therapeutic plasma exchange; TPE) 36515 with extracorporeal immunoadsorption/plasma reinfusion with extracorporeal immunoadsorption, selective adsorption, 36516 or selective filtration and plasma reinfusion (LDL apheresis) 36522 Photopheresis, extracorporeal Blood-derived hematopoietic progenitor cell (HPC) harvesting for 38205 transplantation, per collection; allogeneic 38206 Blood-derived HPC harvesting for transplantation; autologous

• Since 3/6/20, and for the duration of the COVID-19 Public Health Emergency (PHE), CMS has been making payment for professional telehealth services furnished to beneficiaries in all areas of the country and all settings (inc. any healthcare facility, and in patients’ homes).

• These visits are considered the same as in-person visits, and are paid at the same rate

• CMS coinsurance and deductibles generally apply, but may be reduced or waived

• Use of “non-public facing” remote, two-way, encrypted video communication products (allowing only intended parties to participate), including platforms such as: Skype for Business, Zoom for Healthcare, Doxy.me, Google G Suite Hangouts Meet, Updox, GoToMeeting, Amazon Chime, and Cisco Webex Meetings, which employ HIPAA- compliant end-to-end encryption; and similar encrypted texting applications. 7 Medicare (CMS) Telehealth Services (2): 1135 Waiver Authority and Coronavirus Preparedness and Response Supplemental Appropriations Act

• Medicare telehealth services: visit using telecommunication systems (usually real-time, 2- way video telephony) between new (or established) patient (pt) and provider (>225 codes).

• Virtual check-in: a brief (5-10 min) check-in with patient’s provider via telephone (or other device) to decide if office visit or other service is needed (established pts only).

• E-visit: communication between pt and provider via online pt portal (established pts only)

• E & M (apheresis) telehealth consultation (replacing in-person: office, other outpatient, ED, inpatient, & inpt follow-up visit in hospital or SNF) is covered by CMS telehealth services.

• Apheresis procedure telehealth supervision is not currently covered by CMS telehealth services (not on the list of Medicare telehealth services [updated 3/30/21]).

8 CMS Telehealth Services (effective 3/1/20; updated 3/30/21) Type of Service Description of Service HCPCS/CPT Code

CMS Telehealth Visit: Provider using tele- • 99201-99205 (new patient, office or outpatient visit) • office or outpatient communication with pt: • 99211-99215 (established patient, office or outpatient visit) (outpt) visit with - need audio & visual - add GT modifier (via interactive audio/video telecommuni- new* or established - not temporary addition cations system; for CMS). [estab] patient, during for COVID-19. - add 95 modifier (most commercial insurance) *PHE). - Add Place of Service code (POS 02 – Telehealth)

CMS Telehealth Visit: Telehealth consultation • G0425 (Inpt/ed teleconsult 30) • inpatient (inpt) tele- (ED or inpatient consult): • G0426 (Inpt/ed teleconsult 50) consultation. - not need visual (audio only sufficient). • G0427 (Inpt/ed teleconsult 70) - not temporary addition for COVID-19. CMS Telehealth Visit: Follow-up inpt consult • follow-up inpatient (hospital or SNF): • G0406 (Inpt/tele follow up 15) teleconsultation. - not need visual (audio • G0407 (Inpt/tele follow up 25) only sufficient). • G0408 (Inpt/tele follow up 35) - not temporary addition for COVID-19. 9 Other CMS Remote Services (some not designated as Telehealth) Type of Service Description of Service HCPCS/CPT Code

CMS Virtual Check-In: 5-10 minute check-in with • G2012 (brief communication by MD, or qualified non- • occas. pt initiated provider by telephone or MD, who can report/follow-up on E&M services, provided • established pt only video telephony to decide to established patient). whether office visit/other • not designated as service needed. • G2010 (remote evaluation of recorded video and/or CMS telehealth service - not temporary addition images submitted by established pt (eg, store-and-forward), for COVID-19 including follow-up with pt within 24 business hours).

CMS E-Visit: Communication between • 99421 (5-10 min., cumulative time over 7 days) pt and provider through • often patient initiated • 99422 (11-20 min., cumulative time over 7 days) secure online pt portal: • not CMS telehealth • 99423 (≥21 min., cumulative time over 7 days) - email; smartphone • online digital E&M • G2061 (5-10 min., qualified non-MD online assessment) - not temporary addition for estab pt, cumulative • G2062 (11-20 min., qualified non-MD online assessment) for COVID-19 time over 7 days. • G2063 (≥21 min., qualified non-MD online assessment) CMS Telehealth Visit: Telephone E&M (MD  • 99441 (phone e/m phys/qhp 5-10 min. medical discussion) • telephone E&M to estab pt, not origin- • 99442 (phone e/m phys/qhp 11-20 min. medical disc.) • MD or qualified non- ating from E&M in • 99443 (phone e/m phys/qhp 21-30 min. medical disc.) MD (qhp) initiated. prior 7 days): - audio only sufficient - temporary addition for COVID-19 10 Physician peer-to-peer virtual consultation Physician coding & reimbursement for professional services

• Interprofessional telephone/internet consultation: defined as E&M service in which a pt’s treating physician requests the opinion and/or treatment advice of a consultant with specific specialty expertise to assist the treating physician in diagnosis and/or management of pt’s problem without the need for the patient’s face-to-face contact with consultant.

• Consultant CPT codes: 99446-99449 (5-10; 11-20; 21-30; ≥31 minute consultation): - reported only by the consultant (when requested); for new or estab pt/new or exacerbated problem - cannot be reported >1X per 7 days, or if request for face-to-face consult occurs w/i next 14 days

• Potential “non-CMS” models for payment of MD peer-to-peer virtual consultative services: • Monthly subscription fee paid by hospital based on TA volume/complexity • Per patient fee paid by hospital based on diagnostic & treatment complexity • Per hour fee paid by hospital for video telephony patient “virtual visit” • Consulting salary paid by institution or company providing TA service

. 11 Summary

• Inpatient TA procedures are covered under DRG policies, whereas hospital outpatient (OIC) procedures are reimbursed per treatment.

• Guidelines exist to advise when to bill for physician E&M consultation and/or MD apheresis supervision.

• Current CMS guidelines indicate “direct”, not “personal”, MD supervision of TA treatments.

• Since 3/6/20, CMS has authorized telehealth services (>225 codes) for visits using primarily video telephony between new (or established) patients and providers.

• E & M (apheresis) telehealth consultations replacing in-person office, other outpatient, ED, inpatient, & inpt follow-up visits are currently covered by CMS telehealth services.

• Apheresis procedure telehealth supervision is not currently covered by CMS telehealth services (not on the list of Medicare telehealth services).

12 References

• CMS list of 2021 telehealth services and codes (effective 3/1/20; updated 3/30/21): https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

• Medicare telemedicine healthcare provider factsheet (3/17/20): https://cms.gov/newsroom/factsheets/medicare-telemedicine-health-care-provider-fact-sheet.

• Medicare telehealth frequently asked questions (3/17/20): https://edit.cms.gov/files/document/ medicare-telehealth-frequently-asked-questions-faqs-31720.pdf.

• Additional background: sweeping regulatory changes to help U.S. healthcare system address COVID-19 patient surge (3/30/20): https://www.cms.gov/newsroom/factsheets/additional- background-sweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient.

• AMA quick guide to telemedicine in practice (4/23/20): https://www.ama-assn.org/practice- management/digital/ama-quick-guide-telemedicine-practice.

• FAQs on telehealth and HIPAA during the COVID-19 nationwide public health emergency: https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf.

13 References (2)

• FAQs on telehealth and HIPAA during the COVID-19 nationwide public health emergency: https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf.

• MATRC telehealth resources for COVID-19 toolkit: https://www.matrc.org/matrc-telehealth- resources-for-covid-19/.

• CMS COVID-19 telehealth policy updates to Medicare – update 5/1/20: Center for Connected Health Policy: https://www.cchpca.org/resources/covid-19-telehealth-coverage-policies.

• CMS physician fee schedule: https://www.cms.gov/Medicare/Medicare-General- Information/Telehealth/index. https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/PFS-Federal-Regulation.

• HHS telehealth resources: https://www.telehealth.hhs.gov.

• Medicaid & CHIP telehealth toolbox: https://www.medicaid.gov/medicaid/benefits/ telemedicine/index.html.

• Arizona telemedicine program, American College of Physicians webinar series: https://www.acponline.org/practice-resources/business-resources/health-information- technology/telehealth. 14 References (3)

• AMA telehealth implementation playbook: https://www.ama-assn.org/system/files/2020- 04/ama-telehealth-playbook.pdf.

• Special coding advice during COVID-19 public health emergency: https://www.ama- assn.org/system/files/2020-05/covid-19-coding-advice.pdf.

• COVID-19 emergency declaration blanket waivers for health care providers: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf.

• Physicians and other clinicians: CMS flexibilities to fight COVID-19: https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf.

• Hospitals: CMS flexibilities to fight COVID-19: https://www.cms.gov/files/document/covid- hospitals.pdf.

• Virtual care management services: https://www.caravanhealth.com/CaravanHealth/media/ Resources-Page/VirtualCare-CareManagementServices_ForPrint.pdf.

• Telemedicine reimbursement and licensure (AAFP): https://www.aafp.org/dam/AAFP/ documents/advocacy/health_it/telehealth/BKG-Telemedicine.pdf 15 References (4) • Centers for Medicare and Medicaid Services (CMS). Medicare Program: CY 2021 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Final rule. Federal Register, Vol. 85, No. 248, December 28, 2020: Available at: https://www.cms.gov/medicaremedicare-fee-for-service-paymentphysicianfeeschedpfs-federal- regulation-notices/cms-1734-F; and https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf /2020-26815.pdf.

• Centers for Medicare and Medicaid Services (CMS). Medicare Program: Hospital Outpatient Payment and Quality Reporting Programs; Final rule. Federal Register, Vol. 85, No. 249, December 29, 2020: Available at: https://www.cms.gov/medicaremedicare-fee-for-service- paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1746-FC; and https://www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf.

• Padmanabhan A, Connelly-Smith L, Aqui N, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice – Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eight Special Issue. J Clin Apher 2019;34:171-354.

• MLN Matters. Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long- Term Care Hospital (LTCH) PPS Changes. CR Release Date: January 15, 2021. Available at: https://www.cms.gov/files/documentation/mm11879.pdf.

16 References (5)

• ICD-10 resource page. Centers for Medicare and Medicaid Services. Available at: https://www.cms.gov/Medicare/Coding/ICD10/ICD-10Resources/html.

• MLN Matters. The Importance of Correctly Coding the Place of Service by Physicians and Their Billing Agents. May 15, 2013: https://www.cms.gov/MLNMattersArticles/ Downloads/ SE1104.pdf.

• Andrzejewski Jr C, Linz W, Hofmann J et al. American society for apheresis white paper: considerations for medical staff apheresis medicine physician credentialing and privileging. J Clin Apher 2012;27(6):330-335.

• Linz W, Andrzejewski Jr C, Wu DW et al. Apheresis medicine in the era of advanced telehealth technologies: an American Society for Apheresis (ASFA) position paper. Part I: Understanding the basic technologies and apheresis medicine practice models. J Clin Apher 2020;35(5):460-468.

• ASFA PAA Committee. Therapeutic Apheresis: A Guide to Billing and Securing Appropriate Reimbursement, 2021 Edition. Hofmann JC, Andrzejewski Jr C, et al (eds.). Vancouver, BC: American Society For Apheresis, 2021; 34 pages. Will be available on the ASFA Website at: http://www.apheresis.org/?page=ApheresisReimbursement.