Telehealth Services

Medicare pays a limited number of Part B telehealth services. Medicare telehealth services are Part B services that a practitioner provides to an eligible beneficiary through a telecommunications system. To support rural access to care, Medicare covers telehealth services provided through live, interactive videoconferencing between a beneficiary located at a certified rural originating site and a practitioner located at a distant site.

An eligible originating site must be an authorized medical facility, not a beneficiary’s home or office. CMS publishes an annual Telehealth Services Medicare Learning Network fact sheet that provides telehealth guidance for practitioners at distant sites. Distant-site practitioners of telehealth services must be licensed to provide the services under State law. Practitioners who may furnish and receive payment for covered telehealth services include, for example, physicians, nurse practitioners, and physician assistants.

The Office of the Inspector General (OIG) analyzed telehealth claims in 2014 and 2015 and found that more than half of the professional telehealth claims paid by Medicare did not have matching originating site facility fee claims. A Medicare Payment Advisory Commission study of 2009 claims found that Medicare professional fee claims without associated claims for originating site facility fees were more likely to be associated with unallowable telehealth payments. Medicare Paid a total of $17.6 million in telehealth payments on 2015, compared to $61,302 in 2001.

Service Requirements
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 a 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.

Distant Site Payment Methodology TOB Revenue Code
CAH Method II Separate from cost based (80 percent of MPFS facility amount) 85X, 96x, 97x or 98x

Originating Sites
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 to determine if an address is eligible for Medicare telehealth originating site payment.

Authorized Originating Sites
Non-Eligible Originating Sites
*Submit claim with GY modifier as statutory requirements not met.
Office of a physician/practitioner
Beneficiary’s Home
Hospital
Independent Renal Dialysis Facility
Critical Access Hospital (CAH)
Site within a MSA or not within a HPSA
Rural Health Clinic (RHC)
 
Federally Qualified Health Center (FQHC)
 
Hospital-Based or CAH-Based Dialysis Center
 
Skilled Nursing Facility (SNF)
 
Community Mental Health Center (CMHC)
 

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
2018
$25.76
1.4%
CR10393
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 percent of actual charge or 80 percent of originating site facility fee
  • Geographic practice cost index not applied: Fee statutorily set
  • Beneficiary responsibility: Unmet deductible and coinsurance

Originating Site
Payment Methodology
TOB
Revenue Code
Outpatient Hospital
Outside Outpatient PPS
12x
078x
Independent Hospital
Outside DRG
12x
078x
CAH
Separate from cost-based (80% of originating site facility fee)
12x
078x
RHC/FQHC
Separate from PPS or All Inclusive Rate (AIR)
71x / 77x
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 (not 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:

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now