(Medicare Claims Processing Manual)

See Medicare Benefit Policy Manual, Chapter 15, for general coverage requirements.   Direct payment may be made under Part B for professional services.  However, services furnished incident to the professional services of CPs to hospital patients remain bundled.  Therefore, payment must continue to be made to the hospital (by the A/B MAC ( A)) for such incident to services.  170.1 - Payment  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health treatment limitation (the limitation).  Generally, the limitation does not apply to diagnostic services.  Refer to 210 below for a discussion of the outpatient mental health treatment limitation.   Payment for the services of CPs is made on the basis of a fee schedule or the actual charge, whichever is less, and only on the basis of assignment.  CPs are identified by specialty code 68 and provider type 27.  180 - Care Plan Oversight Services  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06) The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non-physician practitioners.  Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare -covered services provided by a participating home health agency or Medicare approved hospice.  CPO services require complex or multidisciplinary care modalities involving:  Regular physician development and/or revision of care plans;   Review of subsequent reports of patient status;   Review of related laboratory and other studies;   Communication with other health professionals not employed in the same practice who are involved in the patients care;   Integration of new information into the medical treatment plan; and/or   Adjustment of medical therapy.  The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physicians time per month.  Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:   Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;  Time spent by staff getting or filing charts;   Travel time; and/or   Physicians time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.  Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patients care with the home health agency or hospice during the month for which CPO services were billed.  The physician who bills for CPO must be the sa me physician who signs the plan of care.  Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight.  These non- physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services.  These non -physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare -covered home health or hospice service.  A. Home Health CPO  Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either:   The physician and NPP are part of the same group practice; or   If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or   If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.  Billing may be made for care plan oversight services furnished by an NPP when:  The NPP providing the care plan oversight has seen and examined the patient;   The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and  The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care. NPPs may not certify the beneficiary for home health care.  B. Hospice CPO  The attending physician or nurse practitioner (who has been designated as the attending physician)  may bill for hospice CPO when they are acting as an attending physician.  An attending physician is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care.  They are not employed nor paid by the hospice . The care plan oversight services are billed using Form CMS -1500 or electronic  equivalent.  For additional information on hospice CPO, see Chapter 11, 40.1.3.1 of this manual .  180.1 - Care Plan Oversight Billing Requirements  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06)  A. Codes for Which Separate Payment May Be Made   Effective January 1, 1995, separate payment may be made for CPO oversight services for 30 minutes or more if the requirements specified in the Medicare Benefits Policy Manual, Chapter 15 are met.    Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered.  CPO services may not be billed across calendar months and should be submitted  (and paid) only for one unit of service.   Physicians may bill and be paid separately for CPO services only if all the criteria in the Medicare Benefit Policy Manual, Chapter 15 are met.   B. Physician Certification and Recertification of Home Health Plans of Care   Effective 2001, two new HCPCS codes for the certification and recertification  and development of plans of care for Medicare- covered home health services were created. See the Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100-01,  Chapter 4, Physician Certification and Recertification of Services, 10-60, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, Home Health Services, 30.  The home health agency certification code can be billed only when the patient has not received Medicare -covered home health services for at least 60 days.  The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period.  The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.   C. Provider Number of Home Health Agency (HHA) or Hospice For claims for CPO submitted on or after January 1, 1997, physicians must enter on the Medicare claim form the 6 -character Medicare provider number of the HHA or hospice providing Medicare-covered services to the beneficiary for the period during which CPO services was furnished and for which the physician signed the plan of care.  Physicians are responsible for obtaining the HHA or hospice Medicare provider numbers.  Additionally, physicians should provide their UPIN to the HHA or hospice furnishing services to their patient.   NOTE:  There is currently no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice provider number required for a care plan oversight claim.  For this reason, the requirement to include the HHA or hospice provider number on a care plan oversight claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for care plan oversight claims.  190 - Medicare Payment for Telehealth Services  (Rev. 1, 10-01-03) A3-3497, A3-3660.2, B3-4159, B3-15516  190.1 - Background  (Rev. 1635, Issued: 11- 14-08, Effective: 01-01-09, Implementation: 01-05-09)  Section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) - Revision of Medicare Reimbursement for Telehealth Services amended 1834 (go to the link and then select the applicable title) of the Act to provide for an expansion of Medicare payment for telehealth services.   Effective October 1, 2001, coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.  Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as a metropolitan statistical area (MSA).  Additionally, Federal telemedicine demonstration projects a s of December 31, 2000, may serve as the originating site regardless of geographic location.  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.  BIPA does not require that a practitioner present the patient for interactive telehealth services.   With regard to payment amount, BIPA specified that payment for the professional service performed by the distant site practitioner (i.e., where the expert physician or practitioner is physically located at time of telemedicine encounter) is equal to what w ould have been paid without the use of telemedicine.  Distant site practitioners include only a physician as described in 1861(r) (go to the link and select the applicable title) of the Act and a medical practitioner as described in 1842(b)(18)(C)  (go to the link and select the applicable title) of the Act.  BIPA also expanded payment under Medicare to include a $20 originating site facility fee (location of beneficiary).  Previously, the Balanced Budget Act of 1997 (BBA) limited the scope of Medicare telehealth coverage to consultation services and the implementing regulation prohibited the use of an asynchronous, store and forward telecommunications system. BBA 1997 also required the professional fee to be shared between the referring and consulting practitioners, and prohibited Medicare payment for facility fees and line charges associated with the telemedicine encounter.   BIPA required that Medicare Part B (Supplementary Medical Insurance) pay for this expansion of telehealth services beginning with services furnished on October 1, 2001.  Section 149 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended 1834 of the Act to add certain entities as originating sites for payment of telehealth services.  Effective for services furnished on or after January 1, 2009, eligible originating sites include a hospital- based or critical access hospital -based renal dialysis center (including satellites); a skilled nursing facility (as defined in 1819(a) of the Act); and a community mental health center (as defined in 1861(f f)(3)(B) of the Act).  MIPPA also amended1888(e)(2)(A)(ii) of the Act to exclude telehealth services furnished under 1834(m)(4)(C)(ii)(VII) from the consolidated billing provisions of the skilled nursing facility prospective payment system (SNF PPS).   NOTE:  MIPPA did not add independent renal dialysis facilities as originating sites for payment of telehealth services.   The telehealth provisions authorized by 1834(m) of the Act are implemented in 42 CFR 410.78 and 414.65.  190.2 - Eligibility Criteria  (Rev. 2848, Issued 12- 30-13; Effective 01 -01-14; Implementation 01-06-14)  1. Beneficiaries eligible for telehealth services   Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by 332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by 1886(d)(2)(D) (go to the link and select the applicable title) of the Act.   Effective January 1, 2014, rural HPSAs include HPSAs located outside of a county outside of an MSA as well as those located in rural census tracts as determined by the Office of Rural Health Policy.  Also effective January 1, 2014, geographic eligibility for an originating site is established for each calendar year based upon the status of the area as of December 31st of the prior calendar year.   2. Exception to rural HPSA and non MSA geographic requirements  Entities participating in a Federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location.  Such entities are not required to be in a rural HPSA or non-MSA.   3. Originating site defined