Telehealth - JE Part A

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

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.

Facility Fee - Originating Site

Part B reimburses originating sites an originating site facility fee for these services as described by HCPCS Q3014.

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

Resources

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claim Processing Manual, Publication 100, Chapter 12, Section 190
• CMS Preventive Services
• CMS Telehealth