Telehealth - JE Part A
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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
- Related Latest Updates Articles
- 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
- 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|
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)|
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|
Last Updated Fri, 28 Oct 2022 21:09:03 +0000
The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.