The document provides guidance on billing and reimbursement for teleophthalmology and diabetic retinopathy screening services delivered through store-and-forward and live video between community health centers, specialists, and health plans. It addresses rules for qualifying encounters, applicable billing codes, and requirements that vary depending on the originating and distant sites as well as the payers involved.

1. Learning Community:
July 25, 2011
Jorge Cuadros, OD, PhD
University of California, Berkeley
Digital Health
Call In Number: 800.747.5150
Access Code: 9438735

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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.  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.  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.  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.  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.  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.  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.  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.  Specialist at distant site
 Specialists must be approved
providers/locations
 Billing for distant site services
 HCPCS Code: Appropriate E/M code
 Modifier: GQ

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.  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.  What to bill
 Claim Form: CMS 1500
 CPT Code: 92250
 Modifier: None
 Diagnosis Code: Diabetes related code