Telehealth services

The Centers for Medicare & Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient. Reimbursement for these services was initiated through congressional legislation. Such reimbursement is limited to the type of services provided, geographic location, type of institution delivering the services and type of health provider.

Medicare telehealth services are divided into three areas:

Eligible medical services

Services that are eligible for reimbursement include consultation, office visits, individual psychotherapy and pharmacologic management delivered via a telecommunications system. The use of a telecommunications system may substitute for a face-to-face, "hands on" encounter for consultation, office visits, individual psychotherapy and pharmacologic management.

A List of Medicare Telehealth Services by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are available on the CMS website.

The service must be on the list of Medicare telehealth services and meet all of the following additional requirements:

A list of telehealth modifiers can be found on the modifiers page of our website.

Eligible providers

Only the following health professionals may claim reimbursement for remote telehealth services:

Eligible facilities

Only the following facilities are eligible to be an originating site under the rules of the program:

Note: Independent renal dialysis facilities are not eligible originating sites.

Remote non face-to-face services

Services provided using telecommunications technology but not requiring the patient to be present during their implementation are covered the same as services delivered when on-site at the medical facility.

“A service may be considered to be a physician’s service where the physician either examines the patient in person or is able to visualize some aspect of the patient’s condition without the interposition of a third person’s judgment. Direct visualization would be possible by means of x-rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc.

For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service.

These remote services are not considered “telehealth” or “telemedicine”. Rather, they are considered the same as services delivered on-site, are to be coded, and will be paid in the same way. There are no geographic or facility limitations on these services.

The largest single specialty providing remote services is radiology.

Home telehealth

Section 1895(e) of the Act states that telehealth services are outside the scope of the Medicare home health benefit and home health prospective payment system (PPS). This provision does not provide coverage or payment for Medicare home health services provided via a telecommunications system. The law does not permit the substitution or use of a telecommunications system to provide any covered home health services paid under the home health PPS, or any covered home health service paid outside of the home health PPS. As stated in 42 CFR 409.48(c), a visit is an episode of personal contact with the beneficiary by staff of the home health agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service.

However, this provision clarifies that there is nothing to preclude a home health agency from adopting telemedicine or other technologies that they believe promote efficiencies, but that those technologies will not be specifically recognized or reimbursed by Medicare under the home health benefit. This provision does not waive the current statutory requirement for a physician certification of a home health plan of care under current §§1814(a)(2)(C) or 1835(a)(2)(A) of the Act.

Claim submission information

Reimbursement to the health professional delivering the medical service is the same as the current fee schedule amount for the service provided. In addition, the non-metropolitan facility with the patient is eligible to receive a facility fee.

Claims for reimbursement should be submitted with the appropriate CPT code for the professional service provided and the appropriate telehealth modifier.

To receive the originating facility site fee, the provider submits claims with HCPCS code “Q3014, telehealth originating site facility fee.” The type of service for the telehealth originating site facility fee is “9, other items and services.”

The “office” place of service (code 11) is the only payable setting for Q3014. There is no participation payment differential for Q3014. Deductible and coinsurance rules apply. By submitting Q3014, the originating site authenticates you are located in either a rural health professional shortage area (HPSA) or non- metropolitan statistical area (MSA) county.

Institutional providers submit claims for the originating site facility fee on type of bill (TOB) 12X, 13X, 22X, 23X, 71X, 72X, 73X, 76X, and 85X. Unless otherwise applicable, report the originating site facility fee with revenue code 078X and Q3014.

For additional information on claim submission, please refer to our claim form tutorials.

Modifiers

Telehealth modifiers must be submitted with distant site telehealth services. Generally, interactive audio and video communications must be used to permit real-time communication between distant site physician/practitioner and patient. Patient must be present and participating in telehealth visit.

Hospitals and CAHs

Hospitals and CAHs bill their Part A Medicare administrative contractor (MAC) for the originating site facility fee. Telehealth bills originating in inpatient hospitals must be on a 12X TOB using the date of discharge as the line item date of service.

Hospital-based or CAH-based renal dialysis centers (including satellites) bill their local Part A MACs for the originating site facility fee on a 72X TOB under revenue code 078X.

The renal dialysis center serving as an originating site must include HCPCS code Q3014, telehealth originating site facility fee, on a separate revenue line from any other services provided to the beneficiary.

RHCs and FQHCs

Independent and provider-based RHCs and FQHCs bill their Part A MAC using the RHC or FQHC bill type and provider number.

Report revenue code 078X when billing for the originating site facility fee. For all other non-RHC/FQHC services, provider based RHCs and FQHCs must bill using the base provider’s bill type and billing number.

If an RHC/FQHC visit occurs on the same day as a telehealth service, the RHC/FQHC serving as an originating site must bill for HCPCS code Q3014 telehealth originating site facility fee on a separate revenue line from the RHC/FQHC visit using revenue code 078X.

Independent RHCs and FQHCs must bill their Part B MAC for all other non-RHC/FQHC services.

ESRD

The ESRD-related services included in the MCP with 2 or 3 visits per month and ESRD-related services with 4 or more visits per month may be paid as Medicare telehealth services. However, at least 1 visit must be furnished face-to-face “hands on” to examine the vascular access site by a physician, clinical nurse specialist, nurse practitioner, or physician assistant. An interactive audio and video telecommunications system may be used for providing additional visits required under the 2-to-3 visit MCP and the 4-or-more visit MCP. The medical record must indicate that at least one of the visits was furnished face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.

The MCP physician, for example, the physician or practitioner who is responsible for the complete monthly assessment of the patient and establishes the patient’s plan of care, may use other physicians and practitioners to furnish ESRD-related visits through an interactive audio and video telecommunications system. The non-MCP physician or practitioner must have a relationship with the billing physician or practitioner such as a partner, employees of the same group practice or an employee of the MCP physician, for example, the non MCP physician or practitioner is either a W-2 employee or 1099 independent contractor. However, the physician or practitioner who is responsible for the complete monthly assessment and establishes the ESRD beneficiary’s plan of care should bill for the MCP in any given month.

The visit, including a clinical examination of the vascular access site, must be conducted face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner or physician’s assistant. For additional visits, the physician or practitioner at the distant site is required, at a minimum, to use an interactive audio and video telecommunications system that allows the physician or practitioner to provide medical management services for a maintenance dialysis beneficiary. For example, an ESRD-related visit conducted via telecommunications system must permit the physician or practitioner at the distant site to perform an assessment of whether the dialysis is working effectively and whether the patient is tolerating the procedure well (physiologically and psychologically). During this assessment, the physician or practitioner at the distant site must be able to determine whether alteration in any aspect of the beneficiary’s prescription is indicated due to such changes as the estimate of the patient’s dry weight.

SNFs

SNFs bill their Part A MAC for the originating site facility fee on TOB 22X or 23X. For SNF inpatients in a covered Part A stay, the originating site facility fee must be submitted on a 22X TOB. All SNFs must use revenue code 078X when billing for the originating site facility fee.

The SNF serving as an originating site must bill for HCPCS code Q3014, telehealth originating site facility fee, on a separate revenue line from any other services provided to the beneficiary.

Subsequent hospital and nursing

Subsequent hospital care services are limited to one telehealth visit every 3 days. The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

Similarly, subsequent nursing facility care services are limited to one telehealth visit every 30 days. Furthermore, subsequent nursing facility care services reported for a federally mandated periodic visit under 42 CFR 483.40(c) may not be furnished through telehealth. The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

Inpatient telehealth consultations are furnished to beneficiaries in hospitals or skilled nursing facilities via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practitioner who furnishes the initial inpatient consultation via telehealth cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telehealth consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patient’s needs. Initial and follow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services.

CMHCs

CMHCs bill their Part A MAC for the originating site facility fee on a 76X TOB. All CMHCs must use revenue code 078X when billing for the originating site facility fee.

The CMHC serving as an originating site must bill for HCPCS code Q3014, telehealth originating site facility fee, on a separate revenue line from any other services provided to the beneficiary.

Diabetes self-management training

Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefit’s initial training must be furnished in-person to allow for effective injection training. Because injection training is not always clinically indicated, we are revising this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow-up training to be furnished via telehealth in those cases when injection training is not applicable.

The in-person injection training, when provided, may be furnished through either individual or group DSMT services. By reporting POS 02 or the –GT or –GQ modifier with HCPCS code G0108 (diabetes outpatient self-management training services, individual, per 30 minutes) or G0109 (diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar year’s 2 hours of follow-up training.

As specified in 42 CFR 410.141(e) and stated in CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 300.2, individual and group DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.6, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM, clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.

Individuals with acute stroke

Section 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Act by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary. Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished. Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth originating sites.

Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the usual telehealth restrictions under section 1834(m)(4)(C) of the Act. These are identified in Section 190.1 of this chapter.

Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informational HCPCS modifier G0 (G zero), to be used to identify telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

Modifier G0 is valid for all:

Originating site defined

Originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal Telemedicine Demonstration Program conducted in Alaska or Hawaii.

Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural health professional shortage area located either:

Originating site facility fee

The originating site facility fee is a separately billable Part B payment. The payment amount to the originating site is 80 percent of the actual charge or the originating site facility fee, except CAHs. The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance.

The originating site-facility-fee payment methodology, for each type of facility, is clarified below.

When the originating site is a hospital outpatient department, payment for the originating site facility fee must be made as described above and not under the outpatient prospective payment system (OPPS). Payment is not based on the OPPS payment methodology.

For hospital inpatients, payment for the originating site facility fee must be made outside the diagnosis related group (DRG) payment, since this is a Part B benefit, similar to other services paid separately from the DRG payment (e.g., hemophilia blood clotting factor).

When the originating site is a critical access hospital, make payment separately from the cost-based reimbursement methodology. For CAHs, the payment amount is 80 percent of the originating site facility fee.

When FQHCs and RHCs serve as the originating site, the originating site facility fee must be paid separately from the center or clinic all-inclusive rate.

When the originating site is a physician’s or practitioner’s office, the payment amount, in accordance with the law, is 80 percent of the actual charge or the originating site facility fee, regardless of geographic location. The Part B MAC shall not apply the geographic practice cost index to the originating site facility fee. This fee is statutorily set and is not subject to the geographic payment adjustments authorized under the Medicare physician fee schedule (MPFS).

When a hospital-based or critical access hospital-based renal dialysis center (or their satellites) serves as the originating site, the originating site facility fee is covered in addition to any composite rate or MCP amount.

When the originating site is a SNF, the originating site facility fee is outside the SNF prospective payment system bundle and, as such, is not subject to SNF consolidated billing. The originating site facility fee is a separately billable Part B payment.

When the originating site is a CMHC, the originating site facility fee is not a partial hospitalization service. The originating site facility fee does not count towards the number of services used to determine payment for partial hospitalization services. The originating site facility fee is not bundled in the per diem payment for partial hospitalization. The originating site facility fee is a separately billable Part B payment.

Distant site practitioners

Effective January 1, 2018, the requirement to use modifier GT on professional claims for telehealth services has been eliminated.

Use of the telehealth place of service code 02 certifies that the service meets the telehealth requirements (via interactive audio and video telecommunications systems).

Claims for telehealth services are submitted to the contractors that process claims for the performing physician/practitioner’s service area. Physicians/practitioners submit the appropriate HCPCS procedure code for covered professional telehealth services along with the “GT” modifier (“via interactive audio and video telecommunications system”). By coding and billing the “GT” modifier with a covered telehealth procedure code, the distant site physician/practitioner certifies that the beneficiary was present at an eligible originating site when the telehealth service was furnished. By coding and billing the “GT” modifier with a covered ESRD-related service telehealth code, the distant site physician/practitioner certifies that 1 visit per month was furnished face-to-face “hands on” to examine the vascular access site.

In situations where a CAH has elected payment method II for CAH outpatients, and the practitioner has reassigned his/her benefits to the CAH, A MACs should make payment for telehealth services provided by the physician or practitioner at 80 percent of the MPFS amount for the distant site service. Telehealth services provided by the physician or practitioner at the distant site are billed to the B MAC.

Physicians and practitioners at the distant site bill their local B MAC for covered telehealth services, for example, “99213 GT.” Physicians and practitioners’ offices serving as a telehealth originating site bill their local B MAC for the originating site facility fee.

For additional information on telehealth services, please refer to the CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Sections 190-190.7.

References