MLN Matters® Number: MM6493
Related Change Request (CR) #: 6493
Related CR Release Date: July 24, 2009
Effective Date: January 1, 2009
Related CR Transmittal #: R1776CP
Implementation Date: January 4, 2010
Provider Types Affected
Indian Health Service (HIS) and tribal providers who bill Palmetto GBA for providing telehealth services to Medicare Beneficiaries.
What You Need to Know
CR 6493, from which this article is taken, expands the instructions for telehealth services (effective January 1, 2009) to include Indian Health Service (IHS) and tribal providers as eligible to receive the telehealth originating site facility fee. The CR also clarifies the payment basis to the distant site physician or practitioner. You should make sure that your billing staffs are aware of this new information.
Background
CR 6493, from which this article is taken, announces that the Centers for Medicare & Medicaid Services (CMS) is expanding the instructions for telehealth services to include Indian Health Service (IHS) and tribal providers.
Effective January 1, 2009, IHS and tribal providers are included in the telehealth service polices (presented below) and eligible to receive:
- The originating site facility fee (generated from an originating site facility service in which the beneficiary is presented to the distant site practitioner); and
- The payment to the distant site physician or practitioner (usually a professional consultation)
Telehealth Policies
Section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) - Revision of Medicare Reimbursement for Telehealth Services amended Section 1834 of the Social Security Act (the Act) to provide for an expansion of Medicare payment for telehealth services. With this amendment, effective October 1, 2001, coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
An interactive telecommunications system is required as a condition of payment; however, BIPA does allow the use of asynchronous “store and forward” technology in delivering these services when the originating site is a Federal telemedicine demonstration program in Alaska or Hawaii. In addition, BIPA does not require that a practitioner present the patient for interactive telehealth services.
Originating Site Facility and Distant Site Practitioner Services
The originating site facility fee is equal to $23.72 for the period January 1, 2009 through December 31, 2009. For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee is increased as of the first day of the year by the percentage increase in the Medicare Economic Index (MEI). For CY 2009, the payment amount is 80 percent of the lesser of the actual charge or $23.72. (No clinic visit is to be billed if this is the only service received.)
The following facility types are authorized by law to be eligible for payment of the telehealth originating site facility fee when a beneficiary is presented to a distant site practitioner:
- The office of a physician or practitioner
- A hospital (inpatient or outpatient)
- A critical access hospital (CAH)
- A rural health clinic (RHC); and
- A federally qualified health center (FQHC)
NOTE: Except for the Federal telemedicine demonstration in Alaska and Hawaii, eligibility of originating sites is limited to rural health professional shortage areas (HPSAs) and counties not classified as a metropolitan statistical area (MSA).
IHS/Tribal facilities should submit claims for the originating site facility fee on Types of Bills (TOB) 12x, 13x, 71x, 73x, or 85x, using HCPCS code Q3014 and revenue code 0780.
Distant site practitioners include only physicians and selected medical practitioners, specifically physician assistants (PA), nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse-midwives, clinical social workers (CSW), clinical psychologists (CP), or registered dietician or nutrition professionals.
Distant site practitioners services are payable as if they were provided face-to-face, using the Medicare Physician Fee Schedule (MPFS); and are based on 80% of the Medicare Physician Fee Schedule (MPFS) payment amount for a physician, and the appropriate step down percentages for other practitioners. The usual Part B coinsurance and deductible apply, but are waived for IHS/Tribal facilities.
Billing providers should use the following Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes on claims for distant site practitioner services:
- Consultations (CPT codes 99241 - 99255)
- Office or other outpatient visits (CPT codes 99201 - 99215)
- Individual psychotherapy (CPT codes 90804 - 90809)
- Pharmacologic management (CPT code 90862)
- Psychiatric diagnostic interview examination (CPT code 90801)
- Individual Medical Nutrition Therapy (CPT codes 97802 and 97803and HCPCS code G0270)
- Neurobehavioral status exam (CPT code 96116) and
- Follow-up inpatient telehealth consultations (HCPCS codes G0406, G0407, and G0408).
You must include either the GT HCPCS modifier (for interactive telecommunications) on your claims, or the GQ HCPCS modifier (for the store and forward communication) if used in the Federal Telemedicine Demonstration in Alaska or Hawaii.
Additional Information
Your Medicare contractor will not search their files to find and adjust claims with dates of service on or after January 1, 2009, that were processed prior to the January 4, 2010, implementation date of CR 6493. However, they will adjust such claims that you bring to their attention.
You can find more information about the provision of telehealth services by IHS or tribal providers by going to CR 6493, located at www.cms.hhs.gov/Transmittals/downloads/R1776CP.pdf (PDF, 220 KB). You will find the updated Medicare Claims Processing Manual, Chapter 19 (Indian Health Services), Sections 100.16 (Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners), 100.16.1 (FI--Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners), 100.16.2 (FI – Telehealth Originating Site Facility Fee – Medicare Part B – Payment Policy) and ( FI – Telehealth Originating Site Facility Fee – Medicare Part B – Claims Processing) as an attachment to that CR.
You might also want to review Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Section 190 (Medicare Payment for Telehealth Services); and Medicare Benefit Policy Manual Chapter 15 (Covered Medical and Other Health Services), Section 270 (Telehealth Services) for more information on telehealth services. This manual is available at www.cms.hhs.gov/manuals/IOM/list.asp.
If you have any questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.