(Medicare Claims Processing Manual)

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   The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.  Originating sites authorized by law are listed below:  The office of a physician or practitioner;  A hospital (inpatient or outpatient);  A critical access hospital (CAH);  A rural health clinic (RHC);  A federally qualified health center (FQHC);  A hospital -based or critical access hospital -based renal dialysis center (including satellites) (effective January 1, 2009);  A skilled nursing facility (SNF) (effective January 1, 2009); and  A community mental health center (CMHC) (effective January 1, 2009).   NOTE:   Independent renal dialysis facilities are not eligible originating sites.   For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.   190.3 - List of Medicare Telehealth Services  (Rev. 3476, Issued: 03 -11-16, Effective: 01 -01-15, Effective: 04 -11-16)  The use of a telecommunications system may substitute for an in- person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services.  The various services and corre sponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website at www.cms.gov/Medicare/Medicare-General -Information/Telehealth/   NOTE:  Beginning January 1, 2010, CMS eliminated the use of all consultation codes, except for inpatient telehealth consultation G -codes.  CMS no longer recognizes office/outpatient or inpatient consultation CPT codes for payment of office/outpatient or inpatient visits.  Instead, physicians and practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate hospital or nursing facility care code, as appropriate to the particular patient, for all office/outpatient or inpatient visits.   190.3.1 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits (Rev. 2354, Issued:  11-18-11 Effective: 01 -01-12, Implementation: 01- 03-12)  A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patients problem(s).  It can involve an opinion, advice, recommendation, suggestion, direction, or counsel from a physician or qualified nonphysician practitioner (NPP) at the request of another physician or appropriate source.   Section 1834(m) of the Social Security Act includes professional consultations in the definition of telehealth services. Inpatient or emergency department consultations furnished via telehealth can facilitate the provision of certain services and/or medi cal expertise that might not otherwise be available to a patient located at an originating site.   The use of a telecommunications system may substitute for an in- person encounter for emergency department or initial and follow -up inpatient consultations.  Medicare A/B MACs (B) pay for reasonable and medically necessary inpatient or emergency department telehealth consultation services furnished to beneficiaries in hospitals or SNFs when all of the following criteria for the use of a consultation code are met:   An inpatient or emergency department consultation service is distinguished from other inpatient or emergency department evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specifi c problem is requested by another physician or other appropriate source.  The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices;    A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patients medical record and included in the requesting physician or qualified NPPs plan of care in the patients medical record; and    After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.   The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professionals knowledge.   Unlike inpatient or emergency department telehealth consultations, the majority of subsequent inpatient hospital, emergency department and nursing facility care services require in -person visits to facilitate the comprehensive, coordinated, and personal care that medically volatile, acutely ill p atients require on an ongoing basis.  Subsequent hospital care services are limited to one telehealth visit every 3 days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days.   190.3.2 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)