Telehealth - JE Part A
Telehealth
Medicare pays a limited number of Part B telehealth services.
Access the below related information from this page.
- Service Requirements
- Substitute In Person Encounter
- Distant Site Practitioners
- Originating Sites
- Facility Fee - Originating Site
- Separately Billable for Part B Reimbursement
- Originating Site Fee Payment and Billing Guidelines
- Resources
- Related Latest Updates Articles
Service Requirements
Services must:
- Be furnished by an enrolled physician/practitioner (within practitioner's scope of practice under state law - check with individual state)
- Be provided to a beneficiary at an approved "originating site" within an eligible location
- Be provided using a real-time telecommunications system
- Meet coding eligibility criteria, conditions of payment and billing methodology
Providers must use telecommunication system which substitutes an in-person encounter and permits real time communication between physician/practitioner and beneficiaries
- System must be interactive
- Patient must be present and participating
Asynchronous "store and forward" technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii.
Substitute In Person Encounter
- Professional consultations (for telehealth services only)
- Office visits
- Office psychiatry services
- Limited number of other physician fee schedule services
- Additions or deletions annually: Physician fee schedule proposed and final rule
Distant Site Practitioners
- Eligible Practitioners
- Physicians
- Nurse Practitioners (NPs)
- Physician Assistants (PAs)
- Nurse Midwifes (CNMs)
- Clinical Nurse Specialists (CNSs)
- Certified Registered Nurse Anesthetists (CRNAs)
- Clinical Psychologists (CPs) who bill independently*
- Clinical Social Workers (CSWs)*
- Registered Dietitians (RDs)
- Nutritional Professionals
*CP and CSWs cannot bill/receive payment for psychiatric diagnostic interview exams with Evaluation and Management (E/M) services or medical services (CPTs 90792, 90833, 90836, 90838)
- Part B services billed on CMS-1500 claim form/electronic equivalent
- Services provided by distant site practitioner
- Part A telehealth distant site services billed on the UB04 or electronic equivalent
- Physician or practitioner services when distant site is in a Critical Access Hospital (CAH) that has elected Method II and physician or practitioner has reassigned his/her benefits to CAH. In all other cases, except for Medical Nutrition Services, distant site telehealth services are billed to Part B
| Distant Site | Payment Methodolgy | Type of Bill | Revenue Code |
|---|---|---|---|
| CAH Method II | Separate from cost based (80% of Medicare Physisican Fee Schedule (MPFS) facility amount) | 85X | 96X, 97X, or 98X |
Originating Sites
The "originating site" is a beneficiary's location at time of service. To ensure eligibility for these services, he/she must present from an originating site located in:
- Rural health professional shortage area (HPSA) - Determined by Health Resources and Services Administration
- County outside Metropolitan Statistical Area (MSA) - Determined by United States Census Bureau
View the HRSA Data Warehouse Medicare Telehealth Payment Eligibility Analyzer webpage to determine if an address is eligible for Medicare telehealth originating site payment.
| Authorized Originating Sites | Non Eligible Originating Sites |
|---|---|
|
Submit claim with GY modifier as statutory requirements not met. |
Facility Fee - Originating Site
Part B reimburses originating sites an originating site facility fee for these services as described by HCPCS Q3014.
| HCPCS | Year | Allowable | Medicare Economic Index (MEI) Increase | Change Request (CR) |
|---|---|---|---|---|
| Q3014 | 2019 | $26.15 | 1.5% | CR11063 |
| Q3014 | 2018 | $25.76 | 1.2% | CR10393 |
Applicable modifiers: GY for denial or G0 (G zero) to identify telehealth services for treatment of acute stroke symptoms.
Separately Billable for Part B Reimbursement
- Physician's or practitioner's office: Lesser of 80% of actual charge or 80% of originating site facility fee
- Geographic practice cost index not applied: Fee statutorily set
- Beneficiary responsibility: Unmet deductible and coinsurance
Originating Site Fee Payment and Billing Guidelines
| Originating Site | Payment Methodology | Type of Bill | Revenue Code |
|---|---|---|---|
| Outpatient hospital | Outside of OPPS | 13X | 078X |
| Inpatient hospital | Outside DRG | 12X | 078X |
| CAH | Separate from cost based (80% of originating site facility fee) | 12X | 078X |
| FQHC or RHC | Separate from Prospective Payment System (PPS) or All Inclusive Rate (AIR) | 77X or 71X | 078X |
| Hospital Based or CAH-Based Renal Dialysis Center | In addition to ESRD PPS or Monthly Capitation payment | 72X | 078X |
| SNF | Outside of SNF PPS (no subject to consolidated billing) | 22X or 23X | 078X |
| CMHC | Not a partial Hospitalization service (or used to determine payment for partial hospitalization) Not bundled in per diem | 76X | 078X |
