Reimbursement Panel

1 www.vita.virginia.gov

Jeff Nelson, Policy Analyst Senior

Virginia Department of Medical Assistance Services

dmasva.dmas.virginia.gov 1

Department of Medical Assistance Services

Mid-Atlantic Telehealth Resource Summit

“Reimbursement Panel”, March 15, 2012

Charlottesville, Virginia

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Telemedicine Reimbursement- General

• Report- “Telemedicine Reimbursement: A National Scan of Current Policies and Emerging Initiatives” (2009) by the California Telemedicine and eHealth Center

• Key Findings:

– No Single, Comprehensive Resource

– Number of Players and Rules Adds Complexity and Confusion

– New Laws do not Ensure Practice

– States can Proactively Tackle the Challenges

www.vita.virginia.gov dmasva.dmas.virginia.gov 2


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Telemedicine Reimbursement- General

– States can Act Proactively and Tackle Challenges

– Limited Impetus to Change Status Quo

– T he Gordian Knot of Reimbursement



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Virginia Medicaid at a Glance

• While Medicare coverage is consistent across the country, Medicaid programs vary state to state as to eligible persons, services covered, and service reimbursement

• Virginia Medicaid enrollment in 2011 was 804,186. About 56 percent children, 6 percent in long term care

• Virginia expenditures in 2011 were $7,166,169. Medical services were 49 percent, long term care services 31 percent



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• About 63.5 percent of Virginia Medicaid recipients are under managed care coverage, which consists of 6 plans including a plan recently added.

• About 36.5 percent under fee-for-service coverage



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• Among the services covered by Virginia Medicaid are:



•Dental care for persons under age 21 •Prescription drugs •Occupational and other rehab services •Hospice •Some mental health services •Some substance abuse services •Waiver programs for persons with AIDS, other conditions

•Inpatient and Outpatient hospital services • Physician and nurse midwife services • Laboratories and x-ray services • Transportation-emergency and non-emergency • Nursing facility services • Home health • Early and Periodic Screening, Diagnosis and Treatment program

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Virginia Medicaid Telemedicine Reimbursement

• Virginia Medicaid received inquiries from providers in the 1990s about adding telemedicine to our services coverage

• Medicaid programs have had difficulties retaining providers due to low reimbursement

• Virginia Medicaid saw telemedicine as a win-win situation in the potential to retain providers to strengthen our provider capacity. Also benefits in improving access to services, cost savings potential, and a sense that telemedicine can help address medical conditions at an earlier stage of disease

• Credit to our agency leadership over the years for seeing the value of telemedicine



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• Virginia Medicaid telemedicine coverage started as a pilot project in 1995.

– Some consultations

– One psychotherapy service

– A few clinical services such as in cardiology

• Only physicians recognized as providers for both ends of telemedicine encounter

• Reimbursement is according to the Virginia Medicaid fee schedule and is the same as when the service is delivered conventionally. No telemedicine equipment reimbursed



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• Virginia Medicaid expanded telemedicine coverage July 1, 2003 from a pilot to statewide. Governor Mark Warner announced the coverage at a community health event

• Telemedicine definition as the real-time transfer of medical data and information using an interactive audio/video connection for the purposes of diagnosis and treatment

• Additional services covered

– Evaluation and management, office visits

– Range of individual psychotherapies

– Select clinical services such as in cardiology

– Mental health and substance abuse crisis intervention



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• Providers recognized by Virginia Medicaid for telemedicine:

– Physicians

– Nurse practitioners

– Clinical nurse specialists

– Clinical psychologists

– Clinical social workers

– Licensed professional counselors

– Licensed marriage and family therapists

– Licensed substance abuse practitioners



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– Certified Outpatient Rehabilitation Facilities – Community Services

Boards – Dialysis Centers – Federally Qualified Health Centers – Health Department Clinics – Hospitals



– Nursing Homes – Rural Health Centers – Program for All-

Inclusive Care for the Elderly

– Plus physicians and other providers on previous page

• Originating sites (where the recipient is located) were expanded in October 2009 to include:

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• Under fee-for-service, billing telemedicine to DMAS

involves: – Originating site (where the patient is located) typically

bills a Q3014 code for presenting patient

– Remote practitioner bills for services such as an evaluation and management code

– Reimbursement is according to the Virginia Medicaid fee schedule and is the same as when the service is delivered conventionally. No telemedicine equipment is reimbursed



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• Providers of telemedicine services are expected to fully comply with service documentation and other coverage and billing requirements described in the Virginia Medicaid provider manuals

• Providers can only bill for services using telemedicine, which are services Virginia Medicaid already covers when delivered conventionally and are on a list of Virginia Medicaid approved telemedicine services

• Virginia Medicaid telemedicine coverage is similar to Medicare coverage but is not tied to rural area definitions for the originating site



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• Additional services Virginia Medicaid has added recently:

– Cochlear implant related procedures (CPT 92601-92604, 95974) for post operative analysis and fitting of devices, measurements and adjustments

– Teledermatology, dermatology services utilizing store and forward

– “Telepractice” speech therapy services for children in special education

– Diabetic retinopathy screening, digital images of the retina are captured (stored) and forwarded to ophthalmologists for evaluation



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• Telemedicine is included in the contracts DMAS has with

Managed Care Organizations. The contract coverage parallels the DMAS coverage

• An informal DMAS survey was conducted in February of MCOs regarding telemedicine activities



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• Telemedicine “billing” has been low for Virginia Medicaid. In FY11, 3799 claims and encounters were received. This reflects approximately $183,762 of services using DMAS reimbursement amounts. Other Medicaid programs have reported low billing volume as well

• Psychiatric care was the predominant service billed. Providers with Community Services Boards, which are the point of entry in Virginia into the publicly-funded system of services for mental health, intellectual disability, and substance abuse, were the primary providers



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• Possible explanations as to why telemedicine billing is low:

– Providers not using telemedicine billing modifiers on

claims form – Telemedicine as part of the larger bundle of services

rendered to patients with particular diagnoses – Contracts for services with hospitals/clinics do not break

out telemedicine



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• Virginia Medicaid Website http://dmasva.dmas.virginia.gov/

• DMAS telemedicine coverage description (“Provider Memo”, September 30, 2009) at

https://www.virginiamedicaid.dmas.virginia.gov/ECMPdfWeb/ECMServlet?memospdf=Medicaid+Memo+2009.09.30.pdf

• Contact DMAS staff Jeff Nelson- 804-371-8857 or [email protected]



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Reimbursement Panel

Health & Medicine

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