| Attachment | Size |
|---|---|
| dfr-order-docket-21-026-i-audio-coding.pdf (2.37 MB) | 2.37 MB |
STATE OF VERMONT
DEPARTMENT OF FINANCIAL REGULATION
IN RE: CODING AND REIMBURSEMENT )
FOR AUDIO-ONLY TELEPHONE SERVICES )
REQUIRED BY ACT 6 OF 2021 )
) Docket No. 21-026-I
)
ORDER
WHEREAS, the Commissioner of the Department (the “Commissioner”) is responsible for administering and enforcing the insurance laws and regulations of the State of Vermont;
WHEREAS, Act 6 of 2021, Section 6, required the Department to work in consultation with the Department of Vermont Health Access (DVHA), the Green Mountain Care Board (GMCB), representatives of health care providers, health insurers, and other interested stakeholders to determine:
appropriate billing and payment codes or modifiers for audio-only telephone services; and
reimbursement rates for audio-only telephone services.
WHEREAS, the Department solicited and received proposals from interested parties, including the Department of Vermont Health Access (DVHA), Cigna, MVP Health Care, Blue Cross Blue Shield of Vermont, and the Coalition of Health Care Associations as to coding and reimbursement for audio-only telephone services.
WHEREAS, the Department has consulted with Department of Vermont Health Access (DVHA), and GMCB.
NOW THEREFORE, the Commissioner makes findings and ORDERS as follows:
FINDINGS OF FACT
The Department, through its Insurance Division, is charged with administering and enforcing the State of Vermont’s insurance laws and regulations.
DVHA is responsible for administering the Vermont Medicaid health insurance program and Vermont’s State-based exchange for health insurance, Vermont Health Connect.
GMCB is an independent five-member board responsible for, among other things, reviewing requests for health insurance premium rates in the large, small, and individual insurance markets plans and maintaining Vermont’s all-payer claims database, the Vermont Health Care Uniform Reporting and Evaluation System (VHCURES), and hospital discharge database, the Vermont Uniform Hospital Discharge Data Set (VUHDDS).
On January 31, 2020, Secretary of Health and Human Services Alex M. Azar declared a public health emergency (PHE) for the entire United States to aid the nation’s healthcare system in responding to COVID-19.
On March 13, 2020, Governor Phil Scott declared a state of emergency in Vermont to help ensure Vermont had all the necessary resources to respond to the COVID-19 PHE.
Under 8 V.S.A. § 4100k, commercial health insurance plans in Vermont are required to provide coverage for health care services and dental services delivered through telemedicine, defined as “interactive audio and video over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996[(HIPAA),]” at the same reimbursement rate as the equivalent in-person service. This definition of telemedicine specifically excluded audio-only telephone.
Prior to the COVID-19 PHE, commercial health insurance plans were not required to provide coverage for health care services delivered through audio-only telephone.
Vermont Medicaid provides coverage for telemedicine, defined as two-way, real-time, audio and video interactive communication, through a secure connection that complies with HIPAA, when medically necessary, clinically appropriate for delivery through telemedicine and within the provider’s licensed scope of practice. Covered services delivered through telemedicine are "reimbursed at the same rate as the service being provided in a face-to-face setting."
Prior to the COVID-19 PHE, audio-only interactions were not considered telemedicine and were not generally covered by Vermont Medicaid with exceptions for certain services, such as telephone evaluation and management services by physicians or other qualified health care professionals who may report evaluation and management services provided to an established patient.
Beginning in April 2020, the Department adopted a series of emergency rules to ensure safe access to health care during the COVID-19 PHE in a manner that would minimize the spread of the virus.
Among other things, early in the COVID-19 PHE, the Department required commercial health insurance plans in Vermont to provide coverage of health care services delivered through audio-only telephone, including telephone triage services, at the same reimbursement rate as for the equivalent in-person service. The Department’s current emergency rule, Reg. H-2020-06-E, will remain in force until July 1, 2021.
On March 18, 2020, Vermont Medicaid implemented several changes to support Medicaid-participating providers in responding effectively to the COVID-19 PHE, including covering and reimbursing medically necessary, clinically appropriate Medicaid-covered services delivered by audio-only telephone at the same rate as Medicaid-covered services provided in-person.
On July 6, 2020, Governor Scott signed Act 140 of 2020, which required the Department to convene a working group to develop recommendations for commercial health insurance and Medicaid coverage of health care services delivered by telephone after the COVID-19 PHE has ended.
The working group convened by the Department eventually included over 80 members representing providers, health insurers, DVHA, GMCB, the Vermont Medical Society, Bi-State Primary Care Association, the VNAs of Vermont, the Vermont Association of Hospitals and Health Systems, Vermont Program for Quality in Health Care, and the Office of the Health Care Advocate.
In October 2020, the Department asked working group members for recommendations. Over a dozen working group members responded with recommendations reflecting their unique goals, points of view, and expertise relating to audio-only telephone and insurance coverage thereof.
On December 1, 2020, the working group delivered its report to the Legislature, recommending that commercial insurers continue coverage of audio-only telephone after the COVID-19 PHE utilizing value-based reimbursement where appropriate for provider type and size. The working group also found that transitioning to a permanent, value-based payment model was not practical with the data collected during the COVID-19 PHE and that implementation would likely require two years of data collection.
The working group did not reach consensus on whether audio-only health care services should be reimbursed at parity with in-person services or at some other rate.
On March 29, 2021, Governor Scott signed Act 6 of 2021, which added 8 V.S.A. § 4100l, requiring health insurance plans to provide coverage for all medically necessary, clinically appropriate health care services delivered by audio-only telephone to the same extent that the plan would cover the services if they were provided through in-person consultation. Section 4100l allows insurers to charge an otherwise permissible deductible, co-payment, or coinsurance for a health care service delivered by audio-only telephone if it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation.
Act 6 requires the Department, working in consultation with other stakeholders, to set appropriate billing codes for health care services delivered by audio-only telephone and to conduct a two-year study of audio-only telephone utilization beginning in plan year 2022. Vermont Medicaid is required to participate in the study to the extent permitted by the Centers for Medicare and Medicaid Services (CMS).
Act 6 further requires the Department, working in consultation with DVHA and the GMCB to determine reimbursement for audio-only telephone services. In doing so, the Department must “find a reasonable balance between the costs to patients and the health care system and reimbursement amounts that do not discourage health care providers from delivering medically necessary, clinically appropriate health care services by audio-only telephone.”
On April 2, 2021, The Department solicited proposals from interested parties as to coding and reimbursement for audio-only telephone services.
The Department received proposals from DVHA, Cigna, MVP Health Care, Blue Cross Blue Shield of Vermont, and the Coalition of Health Care Associations. All proposals are appended to this Order.
Coding of audio-only telephone services must utilize accepted Current Procedural Terminology (CPT) language and definitions.
Providers may code audio-only telephone services using the CPT code for in-person services with a modifier to allow the claims processing system to distinguish between services delivered by telephone and in-person services.
Providers may also code audio-only telephone services using telephone-only evaluation and management (E/M) codes, such as CPT 99441, 99442, and 99443, when use of such codes is required. Telephone-specific E/M codes do not require a modifier.
CMS maintains a list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth, including services payable as audio-only interactions. This list is used by Vermont Medicaid to determine whether a service is clinically appropriate when provided by audio-only telephone.
Based on Medicare’s Resource-Based Relative Value Scale system for determining the cost of providing services, a comparison of Vermont Medicaid reimbursement rates indicates that the appropriate reimbursement rate for audio-only delivery should fall between 53.6% - 73.7% of the reimbursement rate determined for an in-person equivalent service.
Due to fixed costs, including rent, staffing, and other overhead, healthcare providers with a physical presence in Vermont commented that the short-term expenses associated with providing audio-only telephone services are generally comparable to in-person services.
ORDER
NOW, THEREFORE, based on the above Findings of Fact, the Commissioner ORDERS as follows:
Terms used herein have the meanings given to such terms, if any, in 8 V.S.A. § 4100l and 18 V.S.A. §§ 4601 and 9402.
Between July 1, 2021 and December 31, 2021, provisions of Regulation H-2020-06-E (Access to Health Care Services During the COVID-19 Pandemic) relating to coding and reimbursement shall continue: Health insurance plans shall provide the same reimbursement rate for services billed using equivalent procedure codes and modifiers, subject to the terms of the health insurance plan and provider contract, regardless of whether the service was provided through in-person consultation with a health care provider or through telemedicine or audio-only telephone.
Beginning on January 1, 2022:
Health insurance plans shall provide reimbursement for audio-only telephone services billed using accepted CPT language and definitions including both CPT codes for in-person services and telephone-specific E/M codes.
Audio-only telephone services using the CPT code for in-person services shall be reimbursable if the claim is submitted with a V3 modifier or any more specific, nationally-recognized successor modifier that may subsequently be adopted by the American Medical Association (to indicate “service delivered via telephone, i.e., audio-only”) and a place of service code of “99 – other.”
The V3 modifier should not be used with telephone-specific E/M codes.
Commercial health insurance plans may additionally reimburse audio-only telephone claims with a V4 modifier to allow differential reimbursement.
In determining which codes are clinically appropriate for audio-only delivery, commercial health insurance plans shall consider providers’ clinical judgment, as documented in the medical record under Act 6. Commercial health insurance plans are also encouraged to align as closely as possible with codes identified by Vermont Medicaid as “telephone allowable.” Nothing in this order, however, shall be construed to require commercial payers to reimburse Medicaid-specific codes.
Health insurance plans shall reimburse providers for audio-only services at a rate no less than 75% of the rate for equivalent in-person or audio/visual telemedicine covered service. Plans are strongly encouraged to negotiate rates with providers for audio-only telephone services that reflect their clinical value. Telephone-specific E/M codes with no in-person equivalent shall be reimbursed subject to the terms of the health insurance plan and provider contract.
This Order shall remain effect until December 31, 2022, or until rescinded or superseded by the Commissioner.
This Order shall be governed by and construed under the laws of the State of Vermont.
ENTERED at Montpelier, Vermont, this 29th day of June 2021.
[Text Box: /s/ Michael S. Pieciak]
______________________________________
MICHAEL S. PIECIAK, Commissioner
Vermont Department of Financial Regulation