Medicare Telehealth Coding, Billing, and Payment
As with typical Medicare Part B services, providers submit medical codes that represent their telehealth services on paper or electronic claim forms to request reimbursement.
For physicians and other practitioners, CPT® and HCPCS codes identify the services and ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) codes show the reason for the service, such as the patient’s diagnosis. Telehealth claims also may use medical code modifiers and place of service (POS) codes to provide more detail about the encounter.
Figure 1 shows some of the fields on the CMS-1500 claim form used by physicians and other practitioners (most use an electronic equivalent). For instance, the CPT® or HCPCS Level II code and relevant modifiers belong in field 24.D with the POS in field 24.B. Field 21 is for ICD-10-CM codes. Field 24.E (Diagnosis Pointer) shows which diagnosis from field 21 supports the CPT® or HCPCS Level II code in each row.
Figure 1. Sample From CMS-1500 Claim Form
Coding differs for telehealth distant sites and originating sites. The information below applies to Medicare’s standard telehealth reporting rules. For information about telehealth and telemedicine coding during the COVID-19 PHE, see AAPC Knowledge Center’s COVID-19 page or search Medicare’s website.
Telehealth Distant Site Billing and Payment
The distant site, where the furnishing provider is, submits claims to its Medicare Administrative Contractor (MAC), meaning the contractor that processes claims for the performing physician or practitioner’s service area. The MAC pays the correct amount based on the Medicare Physician Fee Schedule (MPFS) at the facility rate, rather than the non-facility (office) rate. The service has to be in the provider’s scope of practice per state law. The beneficiary is responsible for paying coinsurance and unmet deductible amounts, according to Medicare Claims Processing Manual, Chapter 12, Section 190.6.
The furnishing provider should use the applicable CPT® or HCPCS Level II code from Medicare’s list of telehealth codes. The appropriate POS for the distant site provider to report in CMS-1500 field 24.B (or the electronic equivalent) is 02 Telehealth. The physician or practitioner who uses POS 02 certifies that the patient receiving the service was at an eligible originating site. For ESRD-related services, use of POS 02 certifies that one visit per month met the face-to-face examination requirement, states Medicare Claims Processing Manual, Chapter 12, Section 190.6.1.
CAH: The rules differ slightly for Critical Access Hospitals (CAHs), which are participating Medicare hospitals that meet specific requirements, such as being in a rural area and having no more than 25 inpatient beds.
Distant site practitioners billing telehealth under CAH Optional Payment Method II use modifier GT Via interactive audio and video telecommunication systems on their institutional claims. In short, Payment Method II involves the CAH billing facility and professional outpatient services to the MAC when its physicians or practitioners reassign billing rights to the CAH.
“The payment is 80 percent of the Medicare PFS facility amount for the distant site service,” Medicare’s Telehealth Services booklet states.
Telehealth Originating Site Billing and Payment
The originating site, where the patient is, reports Q3014 Telehealth originating site facility fee to its MAC.
Medicare Claims Processing Manual, Chapter 12, Section 190.5, details the payment methodology for the originating site fee. According to the manual, the Medicare contractor pays the originating site facility fee as a separately billable Part B payment outside of other payment methodologies. For instance, a hospital outpatient department that is an originating site gets the Part B fee. It does not get payment based on Medicare’s Outpatient Prospective Payment System (OPPS).
The originating site receives the lesser of 80% of the actual charge or 80% of the originating site facility fee. CAHs are the exception, getting 80% of the originating site facility fee. The patient is responsible for coinsurance and any unmet deductible amount.
The manual provides additional details on things like bill types, making this an important resource for individuals responsible for claims. For example, the manual states that the type of service (TOS) for the telehealth originating site facility fee is “9,” which means “other medical items and services.” For A/B MAC (B) processed claims, POS 11 Office is the correct option for Q3014. POS codes are used on professional claims to indicate the entity where a service was rendered.
For dates of service Jan. 1, 2019, and later, providers must use modifier G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke to identify telehealth services for acute stroke symptoms in Medicare patients. The modifier is the letter G and the number 0. Distant sites using POS code 02 or CAHs should use the modifier. Telehealth originating sites that report Q3014 also should use modifier G0 to identify stroke care, according to Medicare Claims Processing Manual, Chapter 12, Section 190.3.7.
The MLN telehealth booklet instructs providers that when they use asynchronous telecommunications systems, they must append modifier GQ Via asynchronous telecommunications system to the CPT® or HCPCS Level II code. Because Medicare typically requires real-time communication, use of this modifier certifies “the asynchronous medical file was collected and transmitted to you at the distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii,” the booklet states.