Published on April 17, 2014
Regional Telemedicine Conference Heartland TRC
GAlloway@HeartlandTRC.org 1-877-643-HTRC (4872) http://www.HeartlandTRC.org Gordon Alloway Project Director, HTRC
HTRC PARTNERS Since 2010 University of Oklahoma Health Sciences Center Started 1993 Store-and-Forward expertise University of Kansas Medical Center Started 1991 2,000+ clinical consults/yr University of Missouri Health System Started 1994 Public/Private Network
Telehealth / Telemedicine: The Delivery of Care Technology-Assisted
What Telemedicine is: 1. A method of delivering care that is available for use when appropriate. 2. A care delivery method with proven efficacy and insurance reimbursement, in general, equal to in-person care.
What Telemedicine is: Not: 1. Significantly different way of providing care 2. An additional level of care 3. A replacement for face-to-face care 4. A departure from clinical protocols 5. Tele-surgery or Robotic surgery 6. Virtual care / Checklist medicine
Telemedicine Benefits: 1. Increased community satisfaction – Meeting a community need – Keeping patients in community » Additional revenue (Rx, food, gas) 2. Increased patient satisfaction – Access to specialists – Keeps patients in community – Time is key for stroke – Family access – Reduced transp.
Telemedicine Benefits: 3. Increased Board satisfaction – Efficient addition of services at your facility – Technology available for admin. needs 4. Increased staff satisfaction – Fill available capacity – Available for CME & CE training 5. Enhanced Continuity of Care – Increases practitioner avail.
Relationship of Technology Terms What About mHealth?
Two Common Forms of Telemedicine 1. Asynchronous or “Store-and-forward” Example: Radiology X-ray image/CAT scan/MRI Sent to different location Radiologist reads image and responds to PCP/patient
Two Common Forms of Telemedicine 2. Interactive or “Real Time” Example: Clinical Consultation Scheduled appointment Patient at clinic, hosp, CAH “Normal” exam room Presenter/provider remains with patient in exam room Operates equipment, assists provider Specialist/Provider/Practitioner on video monitor
Good News! There Is Reimbursement • Medicare (2001) • Medicaid varies by state, but generally follows Medicare guidelines – Kansas (2004) • Reimbursement available from all health insurance providers (no need for KS legislative mandate) • Also, Federal grants & loans available
2014 Medicare CPT / HCPCS Codes – Telehealth Services TelehealthService CPT / HCPCS Codes Emergency departmentor initial inpatient consultations HCPCS codes G0425 – G0427 Follow-up inpatient consultations (hospitals or SNFs) HCPCS codes G0406 – G0408 Subsequent hospital care services, limitation 1 telehealth visit every 3 days CPT codes 99231 - 99233 Subsequent nursing facility care services, limitation 1 telehealth visit every 30 days CPT codes 99307 - 99310 Office or other outpatient visits CPT codes 99201 -- 99215 Individual and group diabetes outpatient self- managementtraining (DSMT) services, with a minimum of 1-hr. of in-person instruction to be furnished in the initial year training period to ensure effective injection training HCPCS codes G0108 and G0109 Individual and group Kidney Disease Education (KDE) services HCPCS codes G0420 and G0421 End Stage Renal Disease (ESRD) related services CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961 Individual and group Medical Nutrition Therapy HCPCS code G0270 and CPT codes 97802 -- 97804 Individual and group health and behavior assessment and intervention (HBAI) services CPT codes 96150 - 96154 Psychiatric diagnostic interview examination CPT code 90791 and 90792 Individual psychotherapy CPT codes 90832 -- 90834 and 90836 -- 90838 Pharmacologic management CPT code 90862 Neurobehavioral Status Exam CPT codes 96116 Smoking cessation services HCPCS codes G0436 and G0437, and CPT codes 99406 and 99407 Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS codes G0396 and G0397 Annual alcohol misuse screening, 15 minutes HCPCS code G0442 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS code G0443 Annual depression screening, 15 minutes HCPCS code G0444 High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performedsemi-annually, 30 minutes HCPCS code G0445 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS code G0446 Face-to-face behavioral counseling for obesity, 15 minutes HCPCS code G0447 Transitional care managementservices CPT code 994951 and 994962 Telehealth originating site facility fee (short description: “telehealth facility fee”) Q03014
Medicare Benefit Policy – Telehealth Services NEW for 2014 (Effective 01/01/14) Transitional care management services CPT code 994951 and 994962 1. Communication with patient and/or caregiver within 2 business days of discharge; face-to-face visit within 14 calendar days of discharge and moderate complexity of medical decision-making during service period 2. Communication with patient and/or caregiver within 2 business days of discharge; face-to-face visit within 7 calendar days of discharge and high complexity of medical decision-making during service period
Telehealth Guidelines • Patient location: –Physician/Practitioner’s office –Hospital (inpatient or outpatient) –Critical Access Hospital (CAH) –Rural Health Clinic (RHC) –Federally Qualified Health Center (FQHC) –Skilled Nursing Facility (SNF) –Hospital-based or CAH-based Renal Dialysis Centers –Community mental health center (CMHC) –HPSA county outside metro area
Telehealth Guidelines • Physician/Provider location (“Distant Site”) – No limitation on location – Must be licensed in state where patient is located • Who may receive payment – Physician, PA, – Nurse practitioner, Nurse midwife, – Clinical nurse specialist, Clinical Psychologist, Clinical social worker – Registered dietitian/nutrition professional
Telehealth Guidelines • Interactive audio and video telecommunication must be used in real-time communication – Patient must be present and participating • Payment is equal to the current Physician Fee Schedule amount • Telehealth Facility Fee (for Originating Site) – Billable separately under Part B
Kansas-Specific Reimbursement • Included in Kansas Medical Assistance Program (KMAP) policy • Three KanCare MCOs • Amerigroup • Sunflower • UnitedHealthCare • Private Insurance – most major carriers
State Telehealth Mandate • Mental/Behavioral Health – Kansas - SB 175, HB 2395 and HB 2317 – Mass – Nebraska
Telemedicine in the 1990’s
Telemedicine in Kansas: 1991 Hays AHEC Kansas City
Telemedicine in Kansas Clinical Consults: 1993-2001 1993 1994 1995 1996 1997 1998 1999 2000 2001 0 500 1000 1500 2000 2500 3000
Telemedicine Technology KUMC 1993 - 2010 1993 2010
Telemedicine Today • Smaller, less expensive equipment • High quality, high definition (HD) technology • Less expensive internet connectivity • Mobile, wireless capability
Specialty Consultation via ITV
Group Sessions and Educational Events
Telestroke / Physician-to-Physician
Intra-Oral Scope (Tele-Sleep Study)
What Tele-Sleep Presenter Sees
Electronic Otoscope for Pediatrics
Oncology Care (Hospital Exam Room)
Telemedicine on Smaller Scale
Interactive Tele-Video (ITV) Putting technology concerns into the past. PROVIDER’S OFFICE w/ Desk Top Computer TABLET SMARTPHONE
Telehealth Peripherals http://www.telehealthtac.org/toolkits/patient-exam-cameras-technology- overview#Patient_Exam_Cameras Digital Stethoscopes
Telehealth Peripherals http://www.telehealthtac.org/toolkits/patient-exam-cameras-technology- overview#Patient_Exam_Cameras Total Exam Camera Advantages Same Features Less expensive Easily Available Digital Camera/Camcorders Features Digital Records image Has own lighting HD VS
Technical Advances • Smaller, less expensive equipment • From analog to digital • From telephone lines to internet lines • Wireless • Encryption • Integration
Technical Advances • Next generation:
• Two Sections 1. Privacy Rule 2. Security Rule Health Insurance Portability Accountability Act (HIPAA)
Privacy/Security Issues • Generally, all videoconferencing systems are secure • All include encryption • Log-in at both sites • Privacy • Telemedicine room should be private just like any other clinic room • Telemedicine patients same rights
HIPAA Security Rule • “The standards and specifications of the Security Rule are specific to electronic protected health information (e-PHI). . . E-PHI does not include paper-to-paper faxes or video teleconferencing or messages left on voice mail, because the information being exchanged did not exist in electronic form before the transmission. In contrast, the requirements of the Privacy Rule apply to all forms of PHI, including written and oral.” US Dept. of Health & Human Services http://www.hhs.gov/ocr/privacy/hipaa/faq/securityrule/2010.html
Insurance & Licensure
Insurance & Licensure • Standard malpractice insurance covers telehealth • Very low risk service to date – 3-4 known cases (2 were online prescribing) – 2 New Mexico cases bring up telehealth use – If available and not used, there may be liability • No national physician license – A few states require telemedicine license • Supplemental licensing
Insurance & Licensing • State Licensing Boards regulate practitioners – Physician/Practitioner must be licensed in state where patient is located. – No limits on practitioner location
Credentialing & Privileging
CREDENTIALING & PRIVILEGING • Where patient is located is place of service • Providers need to be credentialed / privileged/ licensed at each place of service • Effective July 2011 – hospital’s governing body still responsible for all privileging decisions, but can accept credentials from distant-site Medicare hospital CMS
TELEMEDICINE WORKS BOTH WAYS 1. Bring additional services into your site. Refer to specialists not currently available Patient remains onsite 2. Extend your services to other sites. Expand outreach activities Distant sites have access to your staff’s expertise Additional outpatient activity without additional traffic
Kansas Best Practices – Telehealth / Telemedicine
Telemedicine Services at Goodland Regional Medical Center Kansas Best Practice - Telehealth / Telemedicine
Kansas Best Practice - Telehealth / Telemedicine Hays Daily News By KALEY CONNER 10/25/2013
KUCTT • Over 60 sites interacted with KUCTT • 16 specialties provided Total KS activity unknown
Stormont-Vail & Mayo Clinic Care Network
Telemedicine in U.S. Multiple Federal Funding Resources – HRSA – Network Planning and Network Development • Grant assistance for upfront planning and initial development – http://www.grants.gov/web/grants/search-grants.html – USAC – Rural Health Care Support • Will pay for % of Internet access cost – http://wireless.fcc.gov/outreach/index.htm?job=funding – Dept. of Commerce – National Telecomm. and Information Admin. • Expanding broadband Internet access • State Broadband Initiative & Tech Opp. Pgm. • http://www.ntia.doc.gov/grants-combined
Telemedicine in U.S. Multiple Federal Funding Resources – USDA – Rural Development (RD) – Grants & Loans • Community Facilities (CF) Program - $70 million Direct Loans / $10 million Grants – Areas/towns up to 20,000 pop. – Construction or renovation of hosp., NF, Clinic (inc. necessary equipment) – Purchase of specific equipment (new CT scanner), technology, software • Application is once a year (end of May/early June) • Announced 60 days in advance of due date • RD staff assistance available for application process • http://www.rurdev.usda.gov
Telemedicine in U.S. Multiple Federal Funding Resources – USDA – Rural Development (RD) – Grants & Loans • Distance Learning and Telemedicine (DLT) Program - $15 million – Areas/towns up to 20,000 pop. – 15% matching requirement – Minimum grant award: $50,000; maximum: $500,000 – Purchase of computer hardware/software, computer network components, terminal equip., inside wiring, and inside equip. warranties • Application is once a year (end of May/early June) • Announced 60 days in advance of due date • RD staff assistance available for application process • http://www.rurdev.usda.gov
Telemedicine in U.S. Federal Funding Support - Kansas USDA – Rural Development (RD) – CF Program Onaga, KS Area: 410 acres Pop: 707 (2012) $5 million CF Direct Loan Bundled variety of needs: • EMR hardware/software in hosp. & clinics • Renovations/enhancements to existing hospital • Purchased diagnostic equipment • Refinanced existing debt USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc
Telemedicine in U.S. Federal Funding Support - Kansas USDA – Rural Development (RD) – CF Program WHO: Great Plains Health Alliance, Inc. WHAT: 24-Hospital Network WHERE: Phillipsburg, KS $2.2 million bank loan guarantee $3 million CF Direct Loan Acted as borrower for hospital network: • EHR hardware/software for 22 CAHs • Enabled them to provide telemedicine services, virtual consults, diagnostic exams and imaging, and remote monitoring of patients. USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc
Telemedicine in U.S. Multiple Federal Funding Resources – FCC – Broadband funding (Formerly Univ. Serv. RHC Program) • Healthcare Connect Fund – Supports broadband connectivity and networks – Provides 65% discount on broadband services, equipment, connectivity, construction, if shown to be most cost-effective – Requires 35% contribution • Started January 1, 2014 • Encourages use of consortiums • KHA is leading initiative in Kansas • FCC website: http://www.fcc.gov/health
Telemedicine in U.S. Multiple Federal Funding Resources Eligible to participate in Healthcare Connect Fund – Public or not-for-profit hospitals, rural health clinics, community health centers, health centers serving migrants, community mental health centers, local health departments or agencies, post- secondary educational institutions/teaching hospitals/medical schools, or a consortia of the above – Non-rural HCPs may participate in Healthcare Connect Fund if they belong to a consortium that has a majority rural HCPs – The largest HCPs (400 + patient beds) are eligible, but support is capped if non-rural.
Connectivity in Kansas Hospitals* • 66% - Have videoconferencing equipment • 31% - Using telemedicine (2010) – Daily 55% – Weekly 20% • 23% - Receiving reimbursement for telemedicine (25% - Not sure) • 50% used same equipment for education and training * Kan-ed Telemedicine Capacity and Readiness Survey, KS Office of Edu. Innovation & Evaluation / Kan-ed , 2010
Connectivity in Kansas • Internet access via Internet Service Provider (ISP) is available throughout Kansas • ISP Internet connectivity is adequate for high- quality videoconferencing • Multiple Internet-based videoconferencing services now available via ISP connectivity Source: Kansas Board of Regents: Evaluating the Effects of Eliminating the Kan-ed Program, Legislative Post Audit Committee, Legislative Division of Post Audit, State of Kansas, January 2012.
http://www.HeartlandTRC.org GAlloway@HeartlandTRC.org 1-877-643-HTRC (4872)
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