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Telehealth

Medicare pays a limited number of Part B telehealth services.

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 Site

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 This link will take you to an external website. webpage to determine if an address is eligible for Medicare telehealth originating site payment.

Authorized Originating Sites

  • Office of a physicians or practitioners
  • Hospitals
  • Critical Access Hospitals (CAHs)
  • Rural Health Clinics (RHCs)
  • Federally Qualified Health Centers (FQHCs)
  • Hospital-based or CAH-based Dialysis Centers
  • Skilled Nursing Facilities (SNFs)
  • Community Mental Health Centers (CMHCs)

Not Eligible Originating Sites

  • Beneficiary's home
  • Independent Renal Dialysis Facilities
  • Sites within an MSA or not within a HPSA

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 2017 $25.40 1.2% CR9844
Q3014 2016 $25.10 1.1% CR9476

Do not append any modifier to HCPCS Q3014. Exception: Modifier GY is appropriate for denial.

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 12X 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

 

Resources

 

Last Updated Aug 10, 2017