Provider Types Affected
Physicians, practitioners and providers submitting claims to Medicare carriers, fiscal intermediaries (FI), and/or Part A/B Medicare Administrative Contractors (A/B MAC) for telehealth services provided to Medicare beneficiaries

Provider Action Needed

Impact to You
This article is based on Change Request (CR) 5628 which adds the neurobehavioral status exam (as represented by HCPCS code 96116) to the list of Medicare telehealth services.

What You Need to Know
Effective January 1, 2008, the telehealth modifiers “GT” (via interactive audio and video telecommunications system) and modifier “GQ” (via asynchronous telecommunications system) are valid when billed with HCPCS code 96116.

What You Need to Do
See the Background and Additional Information Sections of this article for further details regarding these changes.

Background

The Centers for Medicare & Medicare Services (CMS) announced in CR 5628 that the neurobehavioral status exam (Healthcare Common Procedure Coding System (HCPCS) code 96116) has been added to the list of Medicare telehealth services (see the final rule for the calendar year (CY) 2008 physician fee schedule (CMS-1385-FC)). Previously, CMS determined that, if the eligibility criteria, and conditions of payment are satisfied, the use of a telecommunications system may substitute for a face-to-face, “hands on” encounter for consultation, office visits, individual psychotherapy, pharmacologic management, psychiatric diagnostic interview examination, end stage renal disease related services, and individual medical nutrition therapy. CR5628 added neurobehavioral status exam to the list of telehealth services (bolded). Medicare telehealth services are listed below.

• Consultations (CPT codes 99241 - 99275) - Effective October 1, 2001 – December 31, 2005;
• Consultations (CPT codes 99241 - 99255) - Effective January 1, 2006;
• Office or other outpatient visits (CPT codes 99201 - 99215);
• Individual psychotherapy (CPT codes 90804 - 90809);
• Pharmacologic management (CPT code 90862);
• Psychiatric diagnostic interview examination (CPT code 90801) – Effective March 1, 2003;
• End Stage Renal Disease (ESRD) related services (HCPCS codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318) – Effective January 1, 2005;
• Individual Medical Nutrition Therapy (HCPCS codes G0270, 97802, and 97803) (Effective January 1, 2006); and
• Neurobehavioral status exam (HCPCS code 96116) (Effective January 1, 2008).

In addition, effective January 1, 2008, the following modifiers are valid when billed with HCPCS code 96116:

The expansion to the list of Medicare telehealth services does not change the eligibility criteria, conditions of payment, or payment or billing methodology applicable to Medicare telehealth services as set forth in the Medicare Benefit Policy Manual (Publication 100-02, Chapter 15, Section 270) and the Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 190).

For example, originating sites must be located in either a non- Metropolitan Statistical Area (non-MSA) county or rural Health Professional Shortage Area (HPSA) and must be one of the following:

• Physician’s or practitioner’s office,
• Hospital,
• Critical access hospital (CAH),
• Rural health clinic, or
• Federally qualified health center.

Also, an interactive audio and video telecommunications system must be used permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary, and as a condition of payment, the patient must be present and participating in the telehealth visit. The only exception to the interactive telecommunications requirement is in the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii. In this circumstance, Medicare payment is permitted for telehealth services when asynchronous store and forward technology is used.

Effective January 1, 2008, CR 5628 instructs that:

• Your local Part B Carriers and or A/B MACs will pay for HCPCS code 96116 according to the appropriate physician or practitioner fee schedule amount when submitted with a GT or GQ modifier, and
• Your local FIs and or A/B MACs will pay for HCPCS code 96116 when submitted with a GT or GQ modifier, by CAHs that have elected Method II payment on Type of Bill (TOB) 85X.

Additional Information
To view the official instructions issued to your carrier, FI, or A/B MAC, see the two transmittals for CR5628 at http://www.cms.hhs.gov/Transmittals/downloads/R1277CP.pdf and http://www.cms.hhs.gov/transmittals/downloads/R74BP.pdf on the CMS Web site.

If you have any questions, please contact your carrier, FI, or A/B MAC, at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside the guide, you will find useful information on topics such as the types of RAs, the purpose of the RA, and the types of codes that appear on the RA. The RA Guide is available as a downloadable document from the Medicare Learning Network Publications Web page. To download and view, please go to http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the CMS Web site.

Posted: 12/07/2007