Telehealth, or sometimes referred to as Telemedicine, is the use of telecommunications technology to provide health care services to persons who are at some distance from 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. Providers are located at the distant site and beneficiaries are located at the originating site.

View the below related information on this page.

• Telehealth vs Telemedicine
• Enrollment
• Distant Site
• Originating Site
• Eligible Providers
• Eligible Services
• Acceptable Equipment
• Billing
• Federal Demonstration Project
• Resources

Telehealth vs Telemedicine

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
  • Example: If provider uses his/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)

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.

Originating Site

• Location where beneficiary is at time of service
• Beneficiaries are eligible for telehealth services only if he/she is treated at an originating site located either in a rural health professional shortage areas (HPSA) or in a county outside of a Metropolitan Statistical Area (MSA)
  • Health Resources and Services Administration (HRSA) provides a tool to determine originating site's eligibility
• Fees billed by Part A providers

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)

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 beneficiary's home is not a covered originating site.

The originating site may be paid an originating site fee, HCPCS Q3014.

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

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. The list of eligible telehealth services can be found https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

Additional information regarding inpatient hospital, emergency department and follow-up consultations, ESRD-related services, subsequent hospital care and subsequent nursing facility visits and Diabetes Self-Management Training (DSMT) is available in the CMS Internet Only Manual (IOM), Publication 100-04, 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, need auditing, archival and backup capabilities. State laws must also be followed.

Billing

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
• Geographic location can be anywhere; rural HPSA or non-MSA does not apply

Resources

• 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