COVID-19 has led to many changes and updates to Medi-Cal policies, including the expansion of telemedicine. This update provides a refresher of current Medi-Cal telehealth policies for Federally Qualified Health Centers (“FQHCs”). With a clear understanding of what Medi-Cal will pay for, FQHCs can work to safely provide essential primary care services to their patients across California.
Medi-Cal’s expansion of billable telehealth services by FQHCs follows closely the requirements for a billable in-person visit. FQHCs can bill Medi-Cal at the Prospective Payment System (“PPS”) rate for the provision of covered services by a billable provider using telehealth to the same extent that those services would be billable as an in-person visit, except that the services are not provided in-person. However, telehealth, whether synchronous (two-way, interactive audiovisual communications) or asynchronous (store and forward communications), may only be used for established patients. In Fee for Service (“FFS”) Medi-Cal, established patients are those seen at the clinic within the last three years. In Medi-Cal managed care, established patients are patients assigned to the clinic by the managed care plan, even if the patient has never visited the clinic.
When providing covered services through telehealth, FQHCs and their practitioners must always ensure that providing those services through telehealth is clinically appropriate, and that the patient’s physical presence is not required.
FQHCs must document the circumstances that prevent the patient from making an in-person visit. These circumstances may include where the patient is quarantining at home, or where state or local guidance directs residents, like the patient, to remain at home. The treating practitioner must also document their intent to use the telehealth visit in the place of an in-person visit in the patient’s medical record. When billing for telehealth visits, FQHCs must use the applicable revenue code and HCPCS code. FQHCs must also include the corresponding CPT code on the UB04 Claim Form’s “informational line.”
Unlike other Medi-Cal providers, FQHCs cannot bill for e-consults or telephonic communications not meeting the requirements for a billable visit.
Questions
If you have questions about Medi-Cal telehealth policy, please reach out to one of our health care law experts listed below.
Jennifer Scott
jscott@kmtg.com | 916-321-4349