Telehealth - JE Part B

Telehealth, or sometimes referred to as Telemedicine, is the use of telecommunications technology to provide health care services to persons who are a not in the same location as the provider. It involves a spectrum of technologies. Coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, pharmacologic management, and other services delivered via an interactive audio and video telecommunications system as a substitute for an in-person visit.

View the below related information on this page:

• Temporary Medicare changes through December 31, 2024
• Permanent Medicare changes
• Telehealth vs Telemedicine
• Distant Site
• Originating Site
• Eligible Providers
• Eligible Services
• Acceptable Equipment
• Billing
• Outpatient Therapy and Medical Nutritional Therapy (MNT) Services
• Teaching Physicians
• Consent for Care Management and Virtual Communication Services
• Diabetes Self-Management Training (DSMT)
• Injection training for insulin-dependent beneficiaries
• Coverage Outside the United States
• Federal Demonstration Project
• Resources

Temporary Medicare changes through December 31, 2024

• FQHCs and RHCs can serve as a distant site provider for non-behavioral or mental telehealth services
• Beneficiaries can receive telehealth services in their home
• No geographic restrictions for originating site for non-behavioral or mental telehealth services
• Some non-behavioral or mental telehealth services can be delivered using audio-only communication platforms
• An in-person visit within six months of an initial behavioral or mental telehealth service, and annually thereafter, is not required
• Telehealth services can be provided by all eligible Medicare providers
• Continues to allow qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists
• Delaying the requirement for an in-person visit within six months prior to initiating mental health telehealth services.
• Define direct supervision to permit the presence and "immediate availability" of the supervising practitioner through real-time audio and visual interactive telecommunications
• Allows clinicians to render Telehealth from a hospital when patient is at the home.
  • Note: Must use POS code of hospital.

Permanent Medicare changes

• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as a distant site provider for behavioral/mental telehealth services.
• Medicare patients can receive telehealth services for behavioral/mental health care in their home
• There are no geographic restrictions for originating site for behavioral/mental telehealth services
• Behavioral/mental telehealth services can be delivered using audio-only communication platforms
• Rural Emergency Hospitals (REHs) are eligible originating sites for telehealth

Telehealth vs Telemedicine

Telehealth

Use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.

• Must be face-to face-telecommunication (Skype not acceptable)
• Beneficiary must be in MSA or Rural Areas (Currently waived until 2024)

Examples of Telehealth Using Telecommunications:

Telepathology: Use of telecommunications technology to facilitate the transfer of image-rich pathology data between remote locations for diagnosis, education, and research

Telepsychology: Use of communication technologies in provision of psychological services

Telemedicine

Often used when referring to traditional clinical diagnosis and monitoring that is delivered by technology. Some consider it a subset of telehealth, but the two are used interchangeably.

• Not face-to-face, analyzing readings

Examples of Telemedicine:

Telecardiology: Transmission/interpretation of patient's electrical activity results, such as ECG and other diagnostic studies like Echocardiogram, Cardiac CT scan, Cardiac MRI scan, etc.

Teleradiology: Transmission of radiological patient images, such as x-rays, CTs, and MRIs, from one location to another for sharing studies with other radiologists and physicians.

Distant Site

Location where physician, or non-physician practitioner (NPP) is at time of service.

Provides services using an interactive audio and video telecommunication system that permits real-time communication with beneficiary.

Location must be on provider's enrollment file. Providers may not use a virtual office must have a valid physical address not a P.O Box.

Example: If provider uses his or her home as an office location, home must be listed on enrollment file. A hotel, boat and car are not valid locations. Provider must be licensed and enrolled in state services are provided in.

• Example: If a beneficiary is in California and provider is in Florida, provider must be licensed and enrolled with Medicare Administrative Contractor (MAC) for Florida.

A distant site practitioner (subject to State law) includes:

• Physician
• Nurse practitioner (NP)
• Physician assistant (PA)
• Certified Nurse-midwife (CNM)
• Clinical Nurse Specialist (CNS)
• Certified Registered Nurse Anesthetist (CRNA)
• Clinical Psychologist (CP)
• Clinical Social Worker (CSW)
• Registered Dietitian or Nutrition Professional (MNT)
• Marriage and Family Therapist (MFT) new for 2024
• Mental Health Counselors (MHC) new for 2024

A medical professional is not required to present the beneficiary to the physician or practitioner unless it is medically necessary. The decision of medical necessity is made by the physician or practitioner at the distant site.

Providers who are assisting beneficiaries in their home will be paid at the non-facility rate.

Originating Site

• Location where beneficiary is at time of service (Geographic location is currently waived)

An originating site authorized by law includes:

• Office of physician or practitioner
• Hospital
• Critical Access Hospital (CAH)
• Rural Health Clinic (RHC)
• Federally Qualified Health Center (FQHC)
• Hospital-based or CAH-based Renal Dialysis Center
• Skilled Nursing Facility (SNF)
• Community Mental Health Center (CMHC)
• Beneficiaries Home

A medical professional is not required to present the beneficiary to the physician or practitioner unless it is medically necessary. The decision of medical necessity is made by the physician or practitioner at the distant site.

If the above statutory requirements for the originating site are not met, the claim for both the originating site and distant site must be submitted with modifier GY.

The qualified originating site may be paid an originating site fee, HCPCS Q3014. No originating fee should be billed for beneficiaries located at home.

Eligible Providers

Provider specialties that are eligible include:

• Physicians
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Certified Nurse-Midwives (CNMs)
• Clinical Nurse Specialists (CNSs)
• Certified Registered Nurse Anesthetists (CRNAs)
• Clinical Psychologists (CPs) *
• Clinical Social Worker (CSWs) *
• Registered Dietitians (RDs) or Nutritional Professionals
• Marriage and Family Therapist (MFT) new for 2024
• Mental Health Counselors (MHC) new for 2024

Telemedicine - Provider must be licensed in state in which he/she is reading. Only should get a PTAN in state where reading is done. Billing for reading goes to that contractor. Group must be set up in state where provider is reading.

*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).

Eligible Services

The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician services if the beneficiary is present and participating and furnished by an enrolled physician/practitioner ( within practitioner scope of practice under state law- check with individual state) The list of eligible telehealth services.

Additional information regarding inpatient hospital, emergency department, and follow-up consultations, ESRD-related services, subsequent hospital care, subsequent nursing facility visits, and Diabetes Self-Management Training (DSMT) is available in the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12

Acceptable Equipment

Common Skype is not acceptable for telehealth purposes; however, professional Skype-like products are available. Health Insurance Portability and Accountability Act (HIPAA) guidelines require that any software transmitting protected personal health information meet a 128-bit level of encryption (at a minimum) have auditing, archival, and backup capabilities. State laws must also be followed.

Billing

Modifier 93

Use only for synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system

Opioid Treatment Programs (OTPs) report on claims for counseling and therapy provided using audio-only technology

Only for telehealth services designated as audio only (see telehealth listing)

Modifier GT

Modifier GT is still required on distant site services billed under Critical Access Hospital (CAH) Method II on institutional claims.

Technical Component (TC)

• Billing for equipment, supplies, technicians, and facility, but not the interpretation of service.
  • Example: Beneficiary has an x-ray done. Provider will bill for taking x-ray and the visit, but not bill for the reading of the x-ray.

Professional Component (PC)

• Provider only interprets results and writes a report
  • Example: X-ray is sent to a provider to read and write a report. Provider will bill for reading only
• PC only: Telepathology, Telepsychology, and Telecommunication

Modifier 95

• Use modifier 95 when:
• The clinician is in the hospital and the patient is in their home.
• Outpatient therapy provided via telehealth by physical therapist (PTs),occupational therapist (Ots), or speech language pathologist (SLPs)

Place of Service (POS)

For 2023, continue billing telehealth claims with the POS indicator you'd bill for an in-person visit. You must use Modifier 95 to identify them as telehealth through December 31, 2023.

After December 31, 2023, use POS 02-Telehealth to indicate you provided the billed service as a professional telehealth service when the originating site is other than the patient's home.

Use POS 10 - Telehealth for services when the patient is in their home.

CMS has defined if the patient receives the telehealth service from a location that is not a facility, they would normally receive care, the description provided by CMS in the final rule continues to include temporary lodging such as hotels and homeless shelters or for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth service such as their car or work, then POS 10 would be appropriate.

Outpatient Therapy and Medical Nutritional therapy (MNT) Services

Institutional providers can continue to bill for PT, OT, SLP, DSMT, and MNT services provided remotely in the same way they could during the PHE through the end of CY 2023.

Hospitals and other providers of PT, OT, SLP, DSMT, and MNT services remaining on the Medicare Telehealth Services List can continue to bill for these services when provided remotely in the same way they could during the PHE through the end of CY 2024, except that:

For outpatient hospitals, patients' homes no longer need to be registered as provider-based entities to allow for hospitals to bill for these services.

*Except for Critical Access Hospitals (CAHs) electing Method II, the 95 modifier is required on claims from all providers reassigning their benefits.

Teaching Physicians

Teaching physicians can continue to use audio or video real-time communications technology when the resident provides telehealth in all residency training locations through the end of CY2024. This virtual presence will meet the requirements that the teaching physician be present for the key portion of the service.

Consent for Care Management and Virtual Communication Services

CMS requires patient consent for all services, including non-face-to-face services. Providers may obtain patient consent at the same time you initially provide the services. Direct supervision is not required to get consent.

In general, auxiliary personnel under general supervision of the billing practitioner can obtain patient consent for these services. The person getting consent can be an employee, independent contractor, or leased employee of the billing practitioner.

Diabetes Self-Management Training (DSMT)

Distant site practitioners are allowed to bill for DSMT services. These include RDs, nutrition professionals, physicians, NPs, PAs, and CNSs who personally provide services as part of DSMT entity.

Injection training for insulin-dependent beneficiaries

DSMT insulin injection training (for initial or follow-up training) is allowed to be provided via telehealth when it aligns with clinical standards, guidelines, or best practices.

Coverage Outside the United States

• Medicare services outside the United States, are not covered except in limited situations, Medicare will not pay for health care or supplies provided outside the U.S. This includes telehealth and telemedicine services. If a provider is outside of the U.S, the service would not be covered.
  • Example: If a provider is traveling or on vacation and wants to check in on a patient while in Mexico, we would not cover that service, or the patient is in Mexico and the provider calls them there, it is not a covered service. Both provider and patient must be in the U.S. when the service is performed. For more information CMS IOM, Publication100-2, Medicare Benefit Policy Manual, Chapter15, Section 60. Services not provided within the United States

Federal Demonstration Project

In Alaska and Hawaii only, federal demonstration project allows the following differences:

• Use of asynchronous "store and forward" technology is allowed
• Providers must bill modifier GQ with distant site code. This indicates asynchronous medical file was collected and transmitted to provider at distant site

Resources

• CMS 2024 final rule page 78874 -78876
• CMS IOM, Publication 100-04, Medicare Claim Processing Manual, Chapter 12, Section 190
• CMS Medicare Learning Network (MLN) Telehealth Services
• CMS Change Request (CR) 9034 - MPFS 2015 Policies - Final Rule and Telehealth Originating Site Facility Fee Payment Amount
• 42 CFR Part 410.78
• Telehealth.HHS.gov: Learn how to access or provide telehealth care