Can you get Medicare reimbursement for telehealth as an originate site?

The Medicare Originating Site Fee is a perk for provision of telemedicine services. State law also may provide its own rules. Let’s look below at federal law and then California law.

We address fee-splitting / kickback issues relating to various compensation arrangements between MSOs and medical ventures, elsewhere on this blog.

Medicare Originate Site Fee

The Centers for Medicare & Medicare Services (CMS) at the U.S. Department of Health and Human Services provides a Fact Sheet on Telehealth Services, in which CMS explains the originating site system:

An originating site is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located outside of a Metropolitan Statistical Area (MSA) or in a rural census tract….; or a county outside of a MSA….

The originating sites authorized by law are: Offices of a physician or practitioner; Hospitals; Critical Access Hospitals (CAHs); Rural Health Clinics (RHCs); Federally Qualified Health Centers (FQHCs); Hospital-Based or Critical Access Hospital (CAH)-Based Rental Dialysis Centers (including Satellites); Skilled Nursing Facilities (SNFs); and Community Mental Health Centers (CHMCs)….

Practitioners at the distant site who may furnish and receive payment for covered telehealth services (subject to State law) are: Physicians; Nurse practitioners (NP); Physician assistants (PA); Nurse-midwives; Clinical nurse specialists (CNS); Clinical psychologists (CP) and clinical social workers (CSW)….. [certain procedures and billing codes are excluded]; Registered dieticians or nutrition professionals.

As a condition of payment, an interactive audio and telecommunications system must be used that permits real-time communication …. Asynchronous “store and forward” technology is permitted only in Federal telemedicine demonstration projects conducted in Alaska or Hawaii….

CMS has a chart of 2014 Medicare Telehealth Services. CCH summarizes these for telepsychiatry as:

Initial inpatient consultations; Follow-up inpatient consultations; Office or other outpatient visits; Individual psychotherapy; Pharmacologic management; Psychiatric diagnostic interview examination; End Stage Rental Disease (ESRD) related services; Individual medical nutrition therapy (MNT); Neurobehavioral status exam; Individual health and behavior assessment and intervention (HBAI).

CMS advises regarding billing:

You should submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modified GT, “via interactive audioand video telecommunications systems” (for example, 99201 GT). By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when the telehealth service was furnished….

With regard to billing and payment for the originating site facility fee, CMS advises as follows:[1]

Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014.[2] You should bill the MAC [Medicare Administrative Contractor] for the originating site facility fee, which is a separately billable Part AB payment.[3]

In Chapter 15 of the Medicare Benefit Policy Manual, Section 270 covers Telehealth Services.[4] Section 270.5 provides more detail regarding how the originating site must pay; this section, and applicable statutes and regulations, set forth the originating site fee.

California Law/Medi-Cal Guidance

California law contains various statutory authorities, relevant to reimbursement of telehealth (see Appendix 2 – California Law & Telehealth Reimbursement). Statutes include those prohibiting insurers from requiring face-to-face contact for services appropriately provided through telemedicine, prompt reimbursement of appropriate telemedicine claims, and prompt procedures for payment or denial.

Medi-Cal has an online document about telemedicine reimbursement, also available through its website. This document provides guidelines for psychiatric diagnostic interview examination and selected psychiatric procedures via telemedicine, including:

• The health care provider who has the ultimate responsibility for the care of the patient must be licensed in the State of California and enrolled as a Medi-Cal provider. The provider performing services via telemedicine whether from California or out of state, must be licensed in California and enrolled as a Medi-Cal provider.
• Appropriate informed consent procedures for telehealth must be followed (as specified in the document).
• Medical information transmitted via telemedicine must be part of the patient’s medical record.
• CPT-4 codes 90785, 90791, 90792 and 90863 may be reimbursed when performed via telemedicine according to these guidelines. (Additional CPT-4 codes are provided for evaluation and management (E&M).)
• Codes Q3014 (telehealth originating site fee) and T1014 (telehealth transmission) may be used to bill transmission costs. Modifier GT must be used for E&M and psychotherapy services provided by telehealth.

Additional guidelines exist for psychotherapy services via telehealth.

Notes

[1] For more information about telehealth services, CMS references: http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/; Chapter 15 of the Medicare Benefit Policy Manual (Publication 100-02); and Chapter 12 of the Medicare Claims Processing Manual (Publication 100-04).

[2] CMS provides general information about HCPCS online, and, a quarterly update of HCPCS codes. CMS also provides Alpha-Numeric HCPCS, in which we found Q3014 listed as the telehealth originating site fee.

[3] Noridian services California (see the JE Part A site). Noridian has an article summarizing policies for 2014 regarding the telehealth originating site facility fee.

[4] These are:

• 1 – Eligibility Criteria
• 2 – List of Medicare Telehealth Services
• 3 – Conditions of Payment
• 4 – Payment – Physician/Practitioner at a Distant Site
• 5 Originating Site Facility Fee Payment Methodology

Appendix 1 – Originating Site Fee Payment Methodology

Section 270.5 from Chapter 15 of the Medicare Benefit Policy Manual, provides as follows:

The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs… The originating site facility fee is a separately billable Part payment. The contractor pays for 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 is the lesser of $20 or the actual charges. For services furnished on or after January 1 of each subsequent year, the originating site facility 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 originating site facility fee is a separately billed 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 CHAs. The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance.

The originating site facility fee payment methodology for each type of facility is clarified below:

[The rule next addresses: where the originating site is a hospital outpatient department; hospital inpatients; a critical access hospital; an FQHC or RHC.]

Where the originating site is a physician or practitioner’s 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 fee regardless of geographic location. The geographic cost index (GPCI) should not be applied to the originating site facility fee. This fee is statutorily set and is not subject to the geographic payment adjustments authorized under the MPFS.

[The rule next addresses a hospital-based or critical access hospital-based renal dialysis center, a SNF, a CMHC, and in 270.5.1, ESRD-related services.]

Note that under Section 30 (Physician Services), Subsection B (Telephone Services):

Services by means of a telephone call between a physician and a beneficiary, or between a physician and member of a beneficiary’s family, are covered under Medicare, but carriers may not make separate payment for services under the program. The physician work resulting from telephone calls is considered to be an integral part of the prework and postwork of other physician services, and the fee schedule amount for the latter services already includes payment for the telephone calls.

The publication for CMS entitled, , Summary of Policies in the Calendar Year (CY) 2013 Medicare Physician Fee Schedule (MPFS) Final Rule and the Telehealth Originating Site Facility Fee Payment Amount, states:

Section 1834(m)(2)(B) of the [Social Security] Act establishes the payment amount for the Medicare telehealth originating site facility fee for telehealth services provided from October 1, 2001, through December 31 2002, at $20. For telehealth services provided on or after January 1 of each subsequent CY, the telehealth originating site facility fee is increased by the percentage increase in the Medicare Economic Index (MEI) as defined in Section 1842(i)(3) of the Act.

In fact, the statute states:

(m) Payment for Telehealth Services.—

(1) In general.—The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary. For purposes of the preceding sentence, in the case of any Federal telemedicine demonstration program conducted in Alaska or Hawaii, the term “telecommunications system” includes store-and-forward technologies that provide for the asynchronous transmission of health care information in single or multimedia formats.

(2) Payment amount.—

(A) Distant site.—The Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this title had such service been furnished without the use of a telecommunications system.

(B) Facility fee for originating site.—With respect to a telehealth service, subject to section 1833(a)(1)(U), there shall be paid to the originating site a facility fee equal to—

(i) for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and

(ii) for a subsequent year, the facility fee specified in clause (i) or this clause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.

Appendix 2 – California Law & Telehealth Reimbursement

While this is not an exhaustive list of California law regarding telehealth, some statutory authority relevant to reimbursement includes:

• Cal Ins Code 10123.85 (no disability insurance contract for hospital, medical or surgical coverage shall require face-to-face contact for services appropriately provided through telemedicine)
• Cal Ins Code 10123.13 (requires every insurer issuing group of individual policies of disability insurance that cover medical, hospital, or surgical expenses, including telemedicine, to reimburse each claim as soon as practical but no later than 30 working days after receipt of the claim).
• Cal Health & Safety Code 1375.1 (requires all health care service plans under the Knox-Keene Act to have a procedure for prompt payment or denial of claims, including telemedicine claims).
• Cal Health & Safety Code 1374.13 (amends Medi-Cal contracts with healthcare service plans to add coverage of telemedicine and make any capitation rate adjustments).
• Cal Health & Safety Code 14132.72 (provides reimbursement for telemedicine by Medi-Cal for healthcare services otherwise covered through Medi-Cal (but excludes phone and fax)).