(Medicare Claims Processing Manual)

*Clinical psychologists and clinical social workers cannot bill for psychotherapy services that include medical evaluation and management services under Medicare.  These practitioners may not bill or receive payment for the following CPT codes: 90805, 90807, and 90809.  190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)  Claims for telehealth services are submitted to the contractors that process claims for the performing physician/practitioners service area. Physicians/practitioners submit the appropriate HCPCS procedure code for covered professional telehealth services with place of service code 02 (Telehealth). By billing place of service code 02 with a covered telehealth procedure code, the distant site physician/practitioner certifies that the beneficiary was present at an eligible originating site when the telehealth  service was furnished. By billing the place of service code 02 with a covered ESRD -related service telehealth code, the distant site physician/practitioner certifies that 1 visit per month was furnished face -to-face hands on to examine the vascular access site. Refer to section 190.3.4 of this chapter for the conditions of telehealth payment for ESRD -related services.   In situations where a CAH has elected payment Method II for CAH outpatients, and the practitioner has reassigned his/her benefits to the CAH, CAHs submit the appropriate HCPCS procedure code for the covered telehealth services with the GT modifier, and A/B/MACs (A) should make payment for telehealth services provided by the physician or practitioner at 80 percent of the MPFS facility amount for the distant site service. In all other cases, except for MNT services as discussed in Section 190.7- A/B MAC (B) E diting of Telehealth Claims, telehealth services provided by the physician or practitioner at the distant site are billed to the A/B/MAC (B).  Physicians and practitioners at the distant site bill their A/B/MAC (B) for covered telehealth services.  Physicians and practitioners offices serving as a telehealth originating site bill their A/B/MAC (B) for the originating site facility fee.   190.6.2 - Exception for Store and Forward (Noninteractive) Telehealth  (Rev. 1, 10- 01-03)  In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, store and forward technologies may be used as a substitute for an interactive telecommunications system. Covered store and forward telehealth services are billed with  the GQ modifier, via asynchronous telecommunications system. By using the GQ modifier, the distant site physician/practitioner certifies that the asynchronous medical file was collected and transmitted to them at their distant site from a Federal te lemedicine demonstration project conducted in Alaska or Hawaii.  190.7 - A/B MAC (B) Editing of Telehealth Claims  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)  Medicare telehealth services (as listed in section 190.3) are billed with POS 02. The contractor shall approve covered telehealth services if the physician or practitioner is licensed under State law to provide the service. Contractors must familiarize the mselves with licensure provisions of States for which they process claims and disallow telehealth services furnished by physicians or practitioners who are not authorized to furnish the applicable telehealth service under State law. For example, if a nurse  practitioner is not licensed to provide individual psychotherapy under State law, he or she would not be permitted to receive payment for individual psychotherapy under Medicare. The contractor shall install edits to ensure that only properly licensed physicians and practitioners are paid for covered telehealth services.  If a contractor receives claims for professional telehealth services coded with the GQ modifier (representing via asynchronous telecommunications system), it shall approve/pay for these services only if the physician or practitioner is affiliated with a Federal telemedicine demonstration conducted in Alaska or Hawaii. The contractor may require the physician or practitioner at the distant site to document his or her participation in a Federal telemedicine demonstration program conducted in Alaska or Haw aii prior to paying for telehealth services provided via asynchronous, store and forward technologies.  Contractors shall deny telehealth services if the physician or practitioner is not eligible to bill for them.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 185  RARC: N/A  MSN: 21.18  If a service is billed with POS 02 and the procedure code is not designated as a covered telehealth service, the contractor denies the service.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 96  RARC: N776  MSN: 9.4  The only claims from institutional facilities that FIs shall pay for telehealth services at the distant site, except for MNT services, are for physician or practitioner services when the distant site is located in a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to the CAH. The CAH bills its regular FI for the professional services provided at the distant site via a telecommunications system, in any of the revenue codes 096x, 097x or 098x. All requirements for billing distant site telehealth services apply.  Claims from hospitals or CAHs for MNT services are submitted to the hospital's or CAH's regular FI. Payment is based on the non-facility amount on the Medicare Physician Fee Schedule for the particular HCPCS codes.  200 - Allergy Testing and Immunotherapy  (Rev.  2997, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01- 2012 -  ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD- 10)  A. Allergy Testing   The MPFSDB fee amounts for allergy testing services billed under codes 95004- 95078 are established for single tests.  Therefore, the number of tests must be shown on the claim.   EXAMPLE:  If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004 and specify 25 units. To compute payment, the Medicare A/B MAC (B) multiplies the payment for one test (i.e., the paymen t listed in the fee schedule) by the quantity listed in the units field.   B. Allergy Immunotherapy  For services rendered on or after January 1, 1995, all antigen/allergy immunotherapy services are paid for under the Medicare physician fee schedule.  Prior to that date, only the antigen injection services, i.e., only codes 95115 and 95117, were paid for under the fee schedule.  Codes representing antigens and their preparation and single codes representing both the antigens and their injection were paid for under the Medicare reasonable charge system.  A legislative change brought all of these services under the fee schedule at the beginning of 1995 and the following policies are effective as of January 1, 1995:   1. CPT codes 95120 through 95134 are not valid for Medicare.  Codes 95120 through 95134 represent complete services, i.e., services that include both the injection service as well as the antigen and its preparation.   2. Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.    If both services are provided both codes are billed.  This includes allergists who provide both services through the use of treatment boards.   3. If a physician bills both an injection code plus either codes 95165 or 95144, A/B MACs (B) pay the appropriate injection code (i.e., code 95115 or code 95117) plus the code 95165 rate.  When a provider bills for codes 95115 or 95117 plus code 95144, A/B MA Cs (B) change 95144 to 95165 and pay accordingly.  Code 95144 (single dose vials of antigen) should be billed only if the physician providing the antigen is providing it to be injected by some other entity.  Single dose vials, which should be used only as a means of insuring proper dosage amounts for injec tions, are more costly than multiple dose vials (i.e., code 95165) and therefore their payment rate is higher.  Allergists who prepare antigens are assumed to be able to administer proper doses from the l ess costly multiple dose vials.  Thus, regardless of whether they use or bill for single or multiple dose vials at the same time that they are billing for an injection service, they are paid at the multiple dose vial rate.   4. The fee schedule amounts for the antigen codes (95144 through 95170) are for a single dose.  When billing those codes, physicians are to specify the number of doses provided.  When making payment, A/B MACs (B) multiply the fee schedule amount by the number  of doses specified in the units field.  5. If a patients doses are adjusted, e.g., because of patient reaction, and the antigen provided is actually more or fewer doses than originally anticipated, the physician is to make no change in the number of doses for which he or she bills.  The number of doses anticipated at the time of the antigen preparation is the number of doses to be billed.  This is consistent with the notes on page 30 of the Spring 1994 issue of the American Medical Associations CPT Assistant.  Those notes indicate that the antigen  codes mean that the physician is to identify the number of doses prospectively planned to be provided.  The physician is to identify the number of doses scheduled when the vial is provided.  This means that in cases where the patient actually gets mor e doses than originally anticipated (because dose amounts were decreased during treatment) and in cases where the patient gets fewer doses (because dose amounts were increased), no change is to be made in the billing.  In the first case, A/B MACs (B) are not to pay more because the number of doses provided in the original vial(s) increased.  In the second case, A/B MACs (B) are not to seek recoupment (if A/B MACs (B) have already made payment) because the number of doses is less than originally planned.  This is the case for both venom and nonvenom antigen codes.   6. Venom Doses and Catch -Up Billing -  Venom doses are prepared in separate vials and not mixed together -  except in the case of the three vespid mix (white and yellow hornets and yellow jackets).  A dose of code 95146 (the two- venom code) means getting some of two venoms.  Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms.  Some amount of each of the venoms must be provided.  Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction.  For example, a physician prepares ten doses of code 95148 (the four venom code) in two vials -  one containing 10 doses of three vespid mix and another containing 10 doses of wasp venom.  Because of dose adjustment, the three vespid mix doses last longer, i.e., they last for 15 doses.  Consequently, questions arise regarding the amount of replacement wasp venom antigen that should be prepared and how it should be billed.  Medicare pricing amounts have savings built into the use of the higher venom codes.  Therefore, if a patient is in two venom, three venom, four venom or five venom therapy, the A/B MAC (B) objective is to pay at the highest venom level possible.  This means that, to the greatest extent possible, code 95146 is to be billed for a patient in two venom therapy, code 95147 is to be billed for a patient in three venom  therapy, code 95148 is to be billed for a patient in four venom therapy, and code 95149 is to be billed for a patient in five venom therapy.  Thus, physicians are to be instructed that the venom antigen preparation, after dose adjustment, must be done in a manner that, as soon as possible, synchronizes the preparation back to the highest venom code possible.  In the above example, the physician should prepare and bill for only 5 doses of replacement wasp venom -  billing five doses of code 95145 (the one venom code).  This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the cheaper four venom code.  Use of a code below the venom treatment number for the particular patient should occur only  for the purpose of catching up.