(Medicare Claims Processing Manual)

190.3.6  Payment for Diabetes Self -Management Training (DSMT) as a Telehealth Service  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)  Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefits initial training must be furnished in -person to allow for effective injection training.  Because injection training is not always clinically indicated, we are revis ing this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow -up training to be furnished via telehealth in those cases when injecti on training is not applicable.  The in-person injection training , when provided,  may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the GT or GQ modifier with HCPCS code G0108 (Diabetes outpatient self- management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests  that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar years 2 hours of follow -up training .   As specified in 42 CFR 410.141(e) and stated in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 300.2, individual and group  DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.  190.3.7  Payment for Telehealth for Individuals with Acute Stroke  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)  Section 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Act by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatme nt of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary.  Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke  telehealth services can be furnished.  Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determ ined appropriate by the Secretary, in addition to the current eligible telehealth originating sites.  Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the u sual telehealth restrictions under section 1834(m)(4)(C) of the Act.  These are identified in Section 190.1 of this chapter.   Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informat  HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for  purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:    Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals,   CAH method II (revenue codes 096X, 097X, or 098X); or    Telehealth originating site facility fee, billed with HCPCS code Q3014.    190.4 - Conditions of Payment  (Rev. 1, 10- 01-03)  1. Technology  For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real -time communication between the distant site physician or practitioner and the Medicare beneficiary.  As a condition of payment, the patient must be present and participating in the telehealth visit.   2. Exception to the interactive telecommunications requirement   In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, Medicare payment is permitted for telemedicine when asynchronous store and forward technology in single or multimedia formats is used as a substitute for an interactive telecommunications system.   The originating site and distant site practitioner must be included within the definition of the demonstration program.   3. Store and forward defined   For purposes of this instruction, store and forward means the asynchronous transmission of medical information to be reviewed at a later time by physician or practitioner at the distant site.  A patients medical information may include, but not limited to, video clips, still images, x -rays, MRIs, EKGs and EEGs, laboratory results, audio clips, and text.  The physician or practitioner at the distant site reviews the case without the patient being present.  Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real -time.   NOTE:  Asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail).  Photographs must be specific to the patients condition and adequate for rendering or confirming a diagnosis and or treatment plan.  Dermatological photographs, e.g., a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this instruction.   4. Telepresenters   A medical professional is not required to present the beneficiary to physician or practitioner at the distant site unless medically necessary.  The decision of medical necessity will be made by the physician or practitioner located at the distant site.   190.5 - Originating Site Facility Fee Payment Methodology  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   1. 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.  For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.    2. Facility fee for originating site    The originating site facility fee is a separately billable Part B payment.  The contractor pays it outside of other payment methodologies.  This fee is subject to post payment verification.    For telehealth services furnished from October 1, 2001, through December 31, 2002, the originating site facility fee was the lesser of $20 or the actual charge.  For services furnished on or after January 1 of each subsequent year, the originating site fac ility fee is updated by the Medicare Economic Index.  The updated fee is included in the Medicare Physician Fee Schedule (MPFS) Final Rule, which is published by November 1 prior to the start of the calendar year for which it is effective.  The updated fee for each calendar year is also issued annually in a Recurring Update Notification instruction for January of each year.   3. Payment amount:    The originating site facility fee is a separately billable Part B payment.  The payment amount to the originating site is the lesser of 80 percent of the actual charge or 80 percent of the originating site facility fee, except CAHs.  The beneficiary is res ponsible for any unmet deductible amount and Medicare coinsurance.    The originating site facility fee payment methodology for each type of facility is clarified below.    Hospital outpatient department.  When the originating site is a hospital outpatient department, payment for the originating site facility fee must be made as described above and not under the OPPS. Payment is not based on the OPPS payment methodology.    Hospital inpatient.  For hospital inpatients, payment for the originating site facility fee must be made outside the diagnostic related group (DRG) payment, since this is a Part B benefit, similar to other services paid separately from the DRG payment, (e.g., hemophilia blood clotting factor).    Critical access hospitals.  When the originating site is a critical access hospital, make payment separately from the cost -based reimbursement methodology.  For CAHs, the payment amount is 80 percent of the originating site facility fee.    Federally qualified health centers (FQHCs) and rural health clinics (RHCs).  The originating site facility fee for telehealth services is not an FQHC or RHC service.  When an FQHC or RHC serves as the originating site, the originating site facility fee mus t be paid separately from the center or clinic all -inclusive rate.    Physicians and practitioners offices.  When the originating site is a physicians or practitioners office, the payment amount, in accordance with the law, is the lesser of 80 percent of the actual charge or 80 percent of the originating site facility fe e, regardless of geographic location.  The A/B MAC (B) shall not apply the geographic practice cost index (GPCI) to the originating site facility fee.  This fee is statutorily set and is not subject to the geographic payment adjustments authorized under the MPFS.    Hospital -based or critical access -hospital based renal dialysis center (or their satellites).  When a hospital- based or critical access hospital -based renal dialysis center (or their satellites) serves as the originating site, the originating site facility  fee is covered in addition to any composite rate or MCP amount.    Skilled nursing facility (SNF).  The originating site facility fee is outside the SNF prospective payment system bundle and, as such, is not subject to SNF consolidated billing.  The originating site facility fee is a separately billable Part B payment.    Community Mental Health Center (CMHC).  The originating site facility fee is not a partial hospitalization or intensive outpatient  service.  The originating site facility fee does not count towards the number of services used to determine payment for partial hospitalization  or intensive outpatient  services.  The originating site facility fee is not bundled in the per diem payment for partial hospitalization or intensive outpatient programs .  The originating site facility fee is a separately billable Part B payment.    To receive the originating facility site fee, the provider submits claims with HCPCS code  Q3014, telehealth originating site facility fee; short description telehealth facility fee.  The type of service for the telehealth originating site facility fee is 9, other items and services.  For A/B MAC (B) processed claims, the office place of  service (code 11) is the only payable setting for code Q3014.  There is no participation payment differential for code Q3014.  Deductible and coinsurance rules apply to Q3014.  By submitting Q3014 HCPCS code, the originating site authenticates they are lo cated in either a rural HPSA or non -MSA county.    This benefit may be billed on bill types 12X, 13X, 22X, 23X, 71X, 72X, 73X, 76X, and 85X.  Unless otherwise applicable, report the originating site facility fee under revenue code 078X and include HCPCS code Q3014, telehealth originating site facility fee .    Hospitals and critical access hospitals bill their A/B/MAC (A) for the originating site facility fee.  Telehealth bills originating in inpatient hospitals must be submitted on a 12X TOB using the date of discharge as the line item date of service.