Lawriter - OAC - 5160-1-18 Telemedicine.

5160-1-18 Telemedicine.

Unless stated otherwise in rule 4731-11-09 of the Administrative Code or elsewhere in the Administrative Code, the following rule applies to health care services covered by the medicaid program and delivered using telemedicine.

(A) For purposes of this rule, the following definitions apply:

(1) "Telemedicine" is the direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. The following activities are not telemedicine:

(a) The delivery of service by electronic mail, telephone, or facsimile transmission;

(b) Conversations between practitioners regarding the patient without the patient present either physically or via synchronous, interactive, real-time electronic communication; and

(c) Audio-video communication related to the delivery of service in an intensive care unit.

(2) "Distant site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telemedicine.

(3) "Originating site" is the physical location of the patient at the time a health care service is provided through the use of telemedicine. The originating site may be one of five places:

(a) The office of a medical doctor, doctor of osteopathic medicine, optometrist, or podiatrist;

(b) A federally qualified health center, as defined in chapter 5160-28 of the Administrative Code, rural health center, or primary care clinic;

(c) An outpatient hospital;

(d) An inpatient hospital; or

(e) A nursing facility.

(B) Requirements and responsibilities.

(1) The originating site is responsible for documenting the medical necessity of the health care service provided through the use of telemedicine, for securing the informed consent of the patient, and for developing and maintaining progress notes.

(2) The rendering practitioner at the distant site must be a medical doctor, doctor of osteopathic medicine or licensed psychologist or a federally qualified health center, as defined in Chapter 5160-28 of the Administrative Code. When the rendering provider is a federally qualified health center the rendering practitioner must be a medical doctor, doctor of osteopathic medicine or licensed psychologist.

(3) The distant site is responsible for maintaining documentation of the health care service delivered through the use of telemedicine and for sending progress notes to the originating site for incorporation into the patient's records.

(C) Coverage.

(1) Payment may be made for the following health care services delivered at the distant site:

(a) Evaluation and management services characterized as "office or other outpatient services";

(b) Evaluation and management services characterized as either "office or other outpatient consultations" or "inpatient consultations"; or

(c) Psychiatry services characterized as "psychiatric diagnostic procedures", "psychotherapy," "pharmacologic management," or "interactive complexity."

(2) When the originating site is located within a five mile radius from the distant site, providers at the distant or originating site are not eligible for payments related to telemedicine under this rule.

(D) Claim payment.

(1) The distant site provider may submit a professional claim for the health care service delivered through the use of telemedicine. No institutional (facility) claim may be submitted by the distant site provider for the health care service delivered through the use of telemedicine. All appropriate codes and modifiers must be reported.

(2) An originating site provider that is neither an inpatient hospital nor a nursing facility may submit a claim for a telemedicine originating fee. If such an originating site provider renders a separately identifiable evaluation and management service to the patient on the same date as the health care service delivered through the use of telemedicine, the provider may submit either a claim for the evaluation and management service or the telemedicine originating fee with the appropriate modifier. No originating site provider may receive both a telemedicine originating fee and payment for an evaluation and management service provided to a patient on the same day.

(3) The payment amount for a health care service delivered through the use of telemedicine, a telemedicine originating fee, or an evaluation and management service is the lesser of the submitted charge or the maximum amount shown in Appendix DD to rule 5160-1-60 of the Administrative Code for the date of service.

Effective: 1/2/2015
Five Year Review (FYR) Dates: 01/02/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.95
Rule Amplifies: 5164.02, 5164.95