7 Essential Rules for Medicare Telehealth Services
Provide healthcare at remote locations and, with careful reporting, get paid.
By G.J. Verhovshek, MA, CPC
Telehealth services allow patients to receive healthcare from providers at remote locations. The Centers for Medicare & Medicaid Services (CMS) provides payment for telehealth services, but only under carefully defined conditions. Here are the seven essential rules for reporting telehealth services provided to Medicare patients.
Rule 1: Target Underserved Areas
Per Medicare rules, “beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural Health Professional Shortage Area (HPSA) or in a county outside of a Metropolitan Statistical Area” (see Medicare Learning Network, “Rural Health Fact Sheet Series: Telehealth Services”). An originating site is defined as, “the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.”
In other words, telehealth services aren’t available to patients in just any location. The patient receiving the service must be in an underserved area.
A list of HPSAs by state and county can be found on the U.S. Department of Health & Human Services (HHS) Health Resources and Services Administration (HRSA) website; and the U.S. Census Bureau maintains a list of metropolitan statistical areas on its website.
Exception: Entities that participated in a federal telemedicine demonstration project prior to Jan. 1, 2001 qualify as originating sites, regardless of geographic location.
Rule 2: The Patient Must Be in a Medical Facility or Office
An originating site (where the patient is), in addition to being within an HPSA or in a county outside of a metropolitan statistical area, must be a type authorized by law. Originating sites include:
- Physician or practitioner office
- Critical access hospitals (CAH)
- Rural health clinics (RHC)
- Federally qualified health centers (FQHC)
- Skilled nursing facilities (SNF)
- Community mental health centers (CMHC)
- Hospital-based or CAH-based renal dialysis centers (including satellites) (Independent renal dialysis facilities are not eligible originating sites.)
The originating site must be a medical facility (not, for instance, the patient’s home). There are no specific rules regarding the location from which the telehealth services are delivered (i.e., the “distant” site or where the provider is).
Rule 3: Providers Must Be Approved
Practitioners who may provide and bill for Medicare telehealth services include:
- Nurse practitioners (NP)
- Physician assistants (PA)
- Nurse midwives
- Clinical nurse specialists (CNS)
- Registered dietitians or nutrition professionals (RD)
- Clinical psychologists (CP) and clinical social workers (CSW)
Per CMS rules, CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management (E/M) services under Medicare, and may not bill or receive payment for codes:
90792 Psychiatric diagnostic evaluation with medical service
+90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
+90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
+90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
Payment for telehealth services is the same as for services furnished without the use of a telecommunications system, but billed services must be within a practitioner’s scope of practice under applicable state law.
Rule 4: Services Must Be Interactive
Medicare pays only for interactive video consultation services, which mimic face-to-face interactions between patients and providers. CMS stipulates that a video telecommunications system must permit “real-time communication between … the physician or practitioner at the distant site, and the beneficiary, at the originating site.”
In other words, telehealth has to be delivered in such a way that the patient and provider are in constant, two-way communication during the service.
What CMS defines as “asynchronous ‘store and forward’ technology” (e.g., video clips, still images, X-rays, magnetic resonance images, electrocardiograms, and electroencephalogram, laboratory results, audio clips, and text) is covered only in federal telemedicine demonstration programs in Alaska or Hawaii. In all other cases, as a condition of payment, the patient must be present and participating in the telehealth visit.
Rule 5: Report Covered Services Using Approved Codes
Medicare pays for a wide range of telehealth services, including consultations, office visits, subsequent hospital care, and behavioral assessments. All services must be delivered in accordance with specific, applicable coding and documentation guidelines.
Rule 6: Append Modifier GT
When reporting an approved telehealth service, you must append modifier GT Via interactive audio and video telecommunication systems to the appropriate service code(s). For example, to report a level III established patient office visit provided by telehealth, report 99213-GT. The modifier tells your Medicare contractor the beneficiary was present at an eligible originating site when the telehealth service was furnished.
Special circumstance: When appending modifier GT with a covered ESRD-related service telehealth code, you are further certifying that one visit per month was furnished “hands on” to examine the vascular access site.
In those rare cases (limited to Alaska and Hawaii) when you may bill Medicare for non-face-to-face telehealth services, you should report the appropriate code for the professional service with modifier GQ Via asynchronous telecommunications system.
Rule 7: Originating Sites Get to Bill, Too
The practitioner providing the telehealth service bills for his or her professional service following rules 1-6 above. The facility serving as the originating site may also report Q3014 Telehealth originating site facility fee to receive a separate Part B payment. See the Medicare Benefit Policy Manual, chapter 15, section 270.5 for complete details.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.