We all know the story well. Before Steve Jobs introduced the iPhone in 2007, we were all perfectly happy to have a simple flip phone in our pockets. The purpose of a cell phone, afterall, was simple: make (somewhat) reliable calls, then send a few texts. And maybe take a few low quality photos. Then, everything changed.
Since the launch of the smartphone, technology has been on an accelerated growth path. Today, our smartphones allow us to share our photos to millions of people around the globe, hail an Uber or Lyft, trade stocks, count our calories, and even give and receive personal health care. In fact, today, rural patients can save hours of travel time and see a specialist in an urban area, directly from their phone or tablet.
But while even healthcare has caught the technology buzz, it has not been without countless laws, policies, regulations, and guidelines.
To catch up on this phenomenon, we interviewed Jake Geertsen, a Technical Manager in the documentation and coding, who specializes in telehealth. First question of telehealth: What is it, exactly? According to Geertsen, telehealth is “a collection of means or methods for enhancing healthcare, public health, and health education delivery and support, using telecommunication technologies.”
But that’s just the tip of our conversation iceberg. Check out our latest podcast “How to Provide Access to Telehealth, While Maintaining Compliance,” where we talk about all sorts of topics that will help you:
- Understand the History and Evolution of Telehealth
- Implement Proper Coding and Billing Compliance Practices
- Stay Current with Ever-changing Medicare Regulations and Payer Policies
CJ: Welcome everybody to another episode of Compliance Conversations. I'm CJ Wolf, Healthicity's Senior Compliance Executive. Today our guest is Jake Geertsen, who worked with Intermountain Healthcare. Welcome, Jake.
Jake: Well hello.
CJ: Jake is a Technical Manager in the professional documentation and coding department of Intermountain Healthcare, which is a large health system in the intermountain west here, with many hospitals, hundreds maybe thousands of doctors, and health plans as well. It's a very large system, and Jake works in a department that I used to work in many, many years ago. I hate to admit how many years ago. Jake, tell us a little bit, before we get into the topic, today we're going to talk about tele health services a little bit, but tell us a little bit about yourself, how did you get into the department and doing what you're doing? Because we all kind of comes from different pathways into this.
Jake: Yeah. My education was in healthcare management.
Jake: I have Master of Public Health and a previous job was in a field related, but as I became acquainted with someone in the department, and they introduced me to services that are provided here, and it sounded interesting. I applied and was accepted.
Jake: It's a very enjoyable department to work in. You get to interact with all the many different people, physicians, APPs, and a lot of different people in administration.
CJ: Yeah, that's great, and how long have you been in your current role or let's just say in your department?
Jake: In this department, a little over six years now.
CJ: Well great, well we appreciate your expertise in telehealth. It's a topic that we hear a lot about, but I'm guessing that there's probably some misinterpretation about what it is and what it isn't, and that sort of thing. Maybe we could just kind of start there, what is telehealth? There are these varying definitions, how do you keep the language clean and pure when you're talking about it?
Jake: In regard to these definitions, it's really important to identify a common definition when you're talking with someone about telehealth. Unfortunately, so many different people have varying definitions. Some of these originate from industry, others originate from sort of a payor prospective. The payors usually take the approach of what is telehealth from what we cover, and not necessarily what the broader definition is.
Jake: Varying healthcare organizations, healthcare providers will have different definitions that coincide with what a pair covers. When you approach a payor and ask them if they cover telehealth, it's important to understand what their version of telehealth is.
CJ: Yeah, that's a great point, because they are concerned with what they are going to pay out, where telehealth is kind of an emerging, every year it's expanding into new areas. From a clinical perspective, it might just be what can we do appropriately from a quality standpoint in a telehealth manner, and they might be pushing the envelope on what you can actually do versus payors may lag sometimes behind on what they actually pay. Is that something that you see?
Jake: Yes, we see that regularly across the board. We, Medicare, as many may know, has a very specific definition of telehealth.
Jake: That is limiting to what can be payed for. However, talk with another payor their definition might be a bit broader, and a bit more comprehensive. Because Medicare relies on the social security act for their telehealth guidelines, any expansion of their definition of telehealth is dependent on what congress passes.
CJ: Right, it's legislative action.
CJ: It's interesting. Tell me, just from maybe a laymen's perspective, some people, what's the difference between telehealth and tele-medicine, or is there even a difference, do you hear people using both those terms interchangeably.
Jake: Yes. It again depends on the organization you're talking to, or the person, or the payor. Some use them interchangeably; some use them as very different terms.
Jake: There is one payor, for example, that has a very specific definition of telehealth and identifies specific services that they call telehealth. And they have other services that they call tele-medicine.
Jake: It's not the same across the industry.
CJ: I guess the lesson here, as you're having conversations, maybe coders or compliance folks, having conversations with doctors, with payors, or even enforcement agencies, is making sure everyone is clear on what you're talking about when you're talking about it, who's the payor, you know, what parameters are we talking about here instead of using general terms that can confuse people.
Jake: Exactly, yeah, identifying the common foundation for telehealth is very important.
CJ: Yeah. Basically you, kind of correct me here if I'm going to throw out, this is not necessarily a Medicare definition, but if we're thinking about it in a broad sense, telehealth is some sort of remote medical service, right? You're either communicating via some sort of audio, or audio visual, or some means by which, you know, treating provider and patient are not in the same room. Does that kind of work for most of this?
Jake: Yeah. That definition will work for most of it. Telehealth in the broadest sense possible is just a collection of means or methods, and I'm actually going to, I should tell you I'm quoting the center for connected health policy, because this definition is the broadest that I've been able to find. They said that telehealth is a collection of means or methods for enhancing healthcare, public health, and health education delivery and support, using telecommunication technologies.
Jake: This could involve a video, where the patient sees a provider, and it's interactive. It could be over the telephone. It could be something called remote patient monitoring.
Jake: Where you may be having vital signs taken that are electronically sent to your provider. So, there isn't actual interaction, but the provider receives the data electronically and may give you a call if your blood pressure is a little higher than it should be and is able to apply medication right away.
CJ: And you know, what fascinates me on all of this, ten years ago none of us were carrying around these phones, and in just ten short years look at what's changed. That general movement is going to happen and be effective in healthcare as well, right? We're going to try and use technology to advance convenience, cut down costs. How much better is it to monitor someone remotely if you can do it accurately. Instead of bringing that person into an emergency room, where they must have it done in person. So, there could be a lot of advantages to humanity, and for medicine, moving forward in this area.
Jake: Exactly. There are cost savings to be found. Patients can save hours of time if they don't have to travel two hours, if they live in a rural area and they need to see a specialist in an urban area. They might be able to save two, three, sometimes more hours, if they can utilize telehealth, and providing, of course, that those services are medically appropriate to be done with telehealth.
CJ: Well that's great, you could probably talk all day about these definitions and stuff. I kind of like that stuff, but some of our listeners are probably like "All right, CJ, shut up, let's get to some things about what's covered." Maybe we could talk about coverage, and maybe some of your experiences. Maybe we start with there are some state private payor parody laws that are out there, can you comment on that type of action that's going on?
Jake: Yeah. Various states are passing legislation to ensure that telehealth coverage is, or telehealth reimbursement happens.
Jake: Currently there are 39 states and the District of Columbia where they have some sort of pair of parody laws. Some of these vary drastically though. Some of them will mandate that payors have to pay for telehealth services that are provided to the patient in a way that mandates the paired coverage at the same rate.
CJ: Right, as if they were to have it done in person or something.
Jake: Right, exactly. Whereas other states require just the same coverage, they don't require the same payment rate.
CJ: Ahhh, okay.
Jake: So, it depends on the state, it depends on the coverage. The center for connected healthcare policy website is a great resource. They have a report that they produce each year, where they identify which states have these pair of parody laws, which states have Medicaid legislated Medicaid coverage, and then they have other resources as well.
CJ: And that is called, say that again, center for . . .
Jake: Center for Connected Healthcare Policy.
CJ: Connected Healthcare Policy, okay, just wanted that to be nice and clear for our listeners. You mentioned it a couple times already, sounds like it could be a great resource for people trying to learn and stay up to date on information. Is that one of your primary resources?
Jake: That is one of my resources, yeah. I utilize that as well as the individual payors' websites to identify what they cover, what they don't cover, in an absence of a private pair parody law then I have to go to the individual's website.
CJ: Let's talk about that a little bit, about these payor policies. What is the variety that you've been seeing in the payor policies? What types of things are you seeing that are similar, what things are maybe different?
Jake: Yeah, that's a good question. Medicare, I think, is the start of where a lot of people, well, it is where everyone starts. Medicare has very strict guidelines, some of which include geographic requirements, they only cover patients who present from a non-metropolitan statistical area, or a health professional shortage area. They have a website where you can put in your address to see if you have coverage.
Jake: And it's not the address of where you actually live, it's the address of where you actual present. So, Medicare does not cover direct to consumer telehealth. The patient must, in a clinical setting, whether that's a hospital, a clinic, or, they have a short list a various settings that they present from, whether they can present from for coverage, but the home is currently not one of those areas.
CJ: Okay, are there some payors that do cover from home? Like maybe private payors?
Jake: Some private payors do. The majority of our national payors, at least in our market here, I have not found great coverage. United healthcare follows Medicare closely, in that the patient must present from a clinical setting. However, they do not have the rural, or the age of the health professional shortage area non-msa coverage.
Jake: So, they can present from any clinic, or any hospital, but they still have to present from those clinical settings.
CJ: Okay. I've seen--you and I are both in the same local region--I've seen some ads and some marketing for call us on your phone, or do face time on your phone, and if we don't, if you have to come in anyway, then we won't charge you for that phone call, it will just be bundled into some sort of in person visit. Have you seen these types of things? Does this ring a bell?
Jake: Yes. Yes, this is something that we, this is a service that we at Intermountain provide. The direct to consumer over the phone or on your laptop or on your tablet depending on where you're at, and you can see a provider and have anywhere from a five to ten minute wait with no travel time, as long as your insurance company covers it.
Jake: We have had to individually negotiate those contracts with the payors.
Jake: That's a little bit difficult in terms of expanding these services, but that's something that we've had to do.
CJ: Yeah, but I really appreciate that kind of innovation in general. I know it might take some years for it to come into mainstream, but you know, somebody has a lesion on their skin, or a cut, or something, and they go, "Do I need to come in for this, or can I let it heal, it looks like it's getting worse?" I'm thinking more along the innovation lines, I'm thinking how much more healthcare could improve if these telehealth principals could be adopted, and that reimbursement could follow, and so that innovation can truly kind of flourish. I think there could be a lot of benefits there.
Jake: There are definitely a lot of benefits, both to the patient, to the healthcare organization who's looking to cut costs, to insurance companies who are also looking to cut costs. In many scenarios this is an area of innovation and improvement.
CJ: Yeah, it's exciting to me. Jake, we have maybe five or six minutes left, I wanted to save some time for this for this last topic here, about documentation, coding, modifiers, place of service. Can you tell us a little bit about the nuts and bolts of that and how that relates to telehealth?
Jake: Sure. About two years ago, maybe two and a half years ago now, Medicare came out with a new place of service. We'll start there. They created place of service 02, and that was to go on all professional claims for professional services. Now as time has gone on, and in fact just in the last six weeks, well, most payors adopt, have adopted this place of service, however there are a few handful of payors that have resisted to take on place of service 02, so this is an area in which identifying the pair of policies will be very important in submitting a claim.
Jake: So now we have place of service 02, in terms of modifiers there are four, maybe five modifiers depending on the payor that you have to take into consideration. Historically the GT modifier is the telehealth modifier, and that is identifying services that are provided via interactive two-way audio video communications.
Jake: That modifier has bene in place for over a decade now. It may date back even to around 2000, 2001, 2002, somewhere around there. Recently the AMA, so the GT modifier is a MCPCS modifier, created by Medicare. Most recently, either the beginning of 2017, or 2018, the AMA came out with the 95 modifier, which is very similar in terms of definition and scope, as the GT, and it was created so that those payors who don't recognize the HCPCS modifiers will have a modifier that they can put into their system.
Jake: Most recently, January 01 of this year, the GOmodifier was created, for, by Medicare for tele-stroke services. The reason they created the GO modifier was to identify those claims that are for tele-stroke, as part of the bi-partisan budget act of 2018 congress made one exception to the geographic requirement and that was for tele stroke services. As long as patient presents from a hospital, a critical access hospital, or a mobile stroke center, they will pay for tele-stroke services, but all of those need to be identified with the GO modifier. But that is just for Medicare. If you go to the other private payor, they will either want the GT modifier, or the 95 modifier, depending on their policy.
Jake: Across the board, and this goes for more than just tele-stroke, but telehealth in general, different payors want different modifiers or different codes for the exact same service.
CJ: Oh boy.
Jake: It's a little bit difficult. We've had to create modifier flexes and coding flexes in our EMR to help account for this, so that the providers don't have to take this into consideration when they are coding for these services.
CJ: Is there an example that comes to mind where you might be able to illustrate that, is it an ENM code or something like that?
Jake: Yeah, most-regularly it's ENM codes, especially on the end patient side. Most services on the in-patient side are provided, most of these services are consultative services. So Medicare has created the G0425 through G0427 codes, and those are in patient and emergency room telehealth consultations.
CJ: Ah, okay.
Jake: And payors cover those codes, however, there are a handful of payors out there, and these may be more of your local payors, that say we don't cover consultation codes, so we don't want you to report a consultation code for this service, we want you to report just an initial in patient code with the GT modifier.
Jake: Report code 99221 through 223 with the GT, as apposed to the G0425 through G0427 with the GT modifier.
CJ: That's a great example where the exact same clinical service being provided would be coded and reported with different codes and modifiers depending on the payor.
CJ: Yeah, interesting. Well that is great. We're kind of coming to the end here, but I want to give you the last minute or two. Anything in telehealth, where you think people would just really like to know about, or something that you really want to share that would really ring true to our listeners?
Jake: Yeah. I think there is a lot of movement in the industry for further coverage for telehealth, Medicare not withstanding their very strict definition of telehealth, Medicare is trying to expand where they can within their scope.
Jake: So, without having to get permission from congress, without and act from congress, they are trying to identify certain services, which recently they did as part of this bipartisan budget act of 2018. They expanded a whole host of services that most people would call telehealth, that Medicare says this is not telehealth, and because they say it is not telehealth, they don't need to follow the restrictions in the social security act.
Jake: There are a number of new services that are identified. Most recently in the Medicare physician piece final rule for 2019, that was released, I believe, in November of 2018, they outlined those services, and that is now part of the federal registrar.
CJ: Great. Really interesting. Jake, I feel like we could probably have this topic covered every year and there would be a lot of new information, because there's advances and changes in policy and legislation and coding and all of that, because it's one of those area's that tends to be moving forward a lot, I sense.
Jake: Yeah. Yeah, there's some, to be brief, there are some payors that revise their telehealth policy three to four times a year, and you have to continually recheck their website once a quarter to make sure they have not changed it.
CJ: What you just said, I think that is great advice. In this area, in some things that we do we check it once a year, because it's never changed in the last ten years, because that's a great point that you make, is that, anyone listening, if you're involved in telehealth services, you've got to kind of up the anti a little bit and checking quarterly, is what you're saying, for any changes.
CJ: Well, Jake, thank you so much for your expertise. You obviously live and breath this stuff, and it's so great to talk to somebody that knows the ins and outs. Thank you for your time.
Jake: Thank you, I appreciate the opportunity to chat with you. It's an area that I'm very passionate about.
CJ: Absolutely, and we appreciate that. Thank you for all our listeners for listening in, and until next time take care.