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Learning Community:July 25, 2011        Jorge Cuadros, OD, PhD    University of California, Berkeley              Digital ...
 Please select the “Raise Hand” button on  your control panel, or send an instant  message, email, or chat message during...
 FQHC as originating site  Does not qualify as an FQHC encounter as a stand   alone service    Considered an incident-t...
 AB 354 and AB 175 approved Medi-Cal  coverage for store-and-forward telemedicine by  ophthalmologists and optometrists ...
 Eye care providers at distant site  Reimbursable services, depending on scope   of service & setting       99241 – 992...
 FQHC as originating site  Varies depending on contract  Standard Medi-Cal Fee-for-Service (FFS)   rules would be    O...
 Specialist at distant site  Check with individual payers regarding   specific instructions  Standard Medi-Cal FFS guid...
 Previously only reimburses for store-and-  forward DRS services when provider is  participating in the federal telemedic...
 DRS reimbursement qualifies for:   County Medical Services Program (CMSP) with claims    administered by Anthem   Blue...
 FQHC as originating site  Evaluation & management (E/M) code    May bill preparation for the service as a part of the ...
 Specialist at distant site   Specialists must be approved    providers/locations   Billing for distant site services  ...
 CMSP program administered by Anthem  Blue Cross Follows the same guidelines as Anthem Blue  Cross for CalPERS Importan...
 FQHC must participate in the Public Private  Provider (PPP) program PPP clinics are instructed to contract directly  wi...
 What to bill     Claim Form: CMS 1500     CPT Code: 92250     Modifier: None     Diagnosis Code: Diabetes related code
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Lc 07-2011-reimbursement

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Transcript of "Lc 07-2011-reimbursement"

  1. 1. Learning Community:July 25, 2011 Jorge Cuadros, OD, PhD University of California, Berkeley Digital HealthCall In Number: 800.747.5150 Access Code: 9438735
  2. 2.  Please select the “Raise Hand” button on your control panel, or send an instant message, email, or chat message during the conference We will un-mute your line & your question will be heard by the presenters & the group
  3. 3.  FQHC as originating site  Does not qualify as an FQHC encounter as a stand alone service  Considered an incident-to service  Viewed similar to an X-ray or EKG  FQHC may apply for PPS rate re-determination based on change in scope  Some clinics have already done this  Some do not wish to incur recalculation of reimbursement
  4. 4.  AB 354 and AB 175 approved Medi-Cal coverage for store-and-forward telemedicine by ophthalmologists and optometrists Requires justification– examples:  Local provider unavailable  Local provider wait time unacceptable  Local provider would not accept Medi-Cal  Local provider unable to address language or cultural needs of patient  Transportation unavailable  Time off work for travel creates a financial or personal hardship
  5. 5.  Eye care providers at distant site  Reimbursable services, depending on scope of service & setting  99241 – 99243 (Office Consultation)  99251 – 99253 (Inpatient Consultation)  99211 – 99214 (Established Patient Office Visit)  99231 – 99233 (Subsequent Hospital Care)  Must add “GQ” modifier
  6. 6.  FQHC as originating site  Varies depending on contract  Standard Medi-Cal Fee-for-Service (FFS) rules would be  Originating Site Fee: HCPCS Code „Q3014‟  Any reimbursement received by the FQHC would have to be reported on the Medi-Cal Reconciliation Request form & would subsequently reduce the reconciliation amount from Medi-Cal
  7. 7.  Specialist at distant site  Check with individual payers regarding specific instructions  Standard Medi-Cal FFS guidelines  Only ACGME trained Ophthalmologists qualify  Reimbursable services depending on scope of service & setting  99241 – 99243 (Office Consultation)  99251 – 99253 (Inpatient Consultation)  99211 – 99214 (Established Patient Office Visit)  99231 – 99233 (Subsequent Hospital Care)  Must add “GQ” modifier
  8. 8.  Previously only reimburses for store-and- forward DRS services when provider is participating in the federal telemedicine demonstration project  Project currently only active in Alaska & Hawaii New codes:  92227: Remote imaging for detection of retinal disease  92228: Remote imaging for monitoring and management of active retinal disease
  9. 9.  DRS reimbursement qualifies for:  County Medical Services Program (CMSP) with claims administered by Anthem  Blue Cross Life and Health Insurance Company  Healthy Families Program coverage from Anthem Blue Cross  Medi-Cal plans from Anthem Blue Cross Partnership Plan FQHC as originating site  Originating site fee  Claim form: UB-04  HCPCS Code: Q3014  Revenue Code: 780  Bill Type: 130
  10. 10.  FQHC as originating site  Evaluation & management (E/M) code  May bill preparation for the service as a part of the primary care physician‟s office visit. Consider total time & scope of services provided to determine appropriate code.  Claim form: UB-04  HCPCS Code: Appropriate E/M code  Modifier: GQ  Revenue Code: 780  Bill Type: 130
  11. 11.  Specialist at distant site  Specialists must be approved providers/locations  Billing for distant site services  HCPCS Code: Appropriate E/M code  Modifier: GQ
  12. 12.  CMSP program administered by Anthem Blue Cross Follows the same guidelines as Anthem Blue Cross for CalPERS Important note: FQHCs qualify for an originating site fee outside of their standard PPS reimbursement. Originating site services reimbursement occurs quarterly
  13. 13.  FQHC must participate in the Public Private Provider (PPP) program PPP clinics are instructed to contract directly with an Optometrist or Ophthalmologist for services  PPP bills for both technical & professional components of DRS  PPP responsible to pay specialist  Contract with specialist must be approved by the Department of Ambulatory Care of the LA County Health Department
  14. 14.  What to bill  Claim Form: CMS 1500  CPT Code: 92250  Modifier: None  Diagnosis Code: Diabetes related code

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