Telehealth is being utilized more every day, all across the United States. As this service expands, it’s essential to have knowledge surrounding the topic. When it’s time for you to submit Medicare telehealth claims in your office, you want to be ready.
This guide provides a high-level overview of billing Medicare for telehealth visits. Let’s dive in.
Medicare Telehealth Vocab to Know
To begin, let’s go over a few common terms you’ll come across regarding Medicare telehealth.
A beneficiary is an individual entitled to benefits under Medicare Part A and enrolled under Medicare Part B or enrolled in both Medicare Part A and B who reside in the United States. Medicare beneficiaries pay deductibles and 20% coinsurance for most services and equipment.
An originating site is a location where a Medicare beneficiary receives services through a telecommunications system. They must go to a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) in a rural census tract.
An originating site’s geographic eligibility is based on the area’s status. Eligibility is determined on December 31 of the prior calendar year (CY), and the site is eligible for a full calendar year.
Authorized originating sites include:
- Physician and practitioner offices
- Hospitals
- Critical Access Hospitals (CAHs)
- Rural Health Clinics
- Federally Qualified Health Centers
- Hospital-based or CAH-based Renal Dialysis Centers (satellite locations included)
- Skilled Nursing Facilities (SNFs)
- Community Mental Health Centers (CMHCs)
- Renal Dialysis Facilities
- Homes of beneficiaries with End-Stage Renal Disease (ESRD) who are receiving home dialysis
- Mobile Stroke Units
A distant site is where the provider is located when the professional service is provided via a telecommunications system.
A Medicare Administrative Contractor (MAC) is a “private health care insurer that can process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.”
Providers Who Can Offer Medicare Telehealth Services
Distant site practitioners who can provide professional services and get paid for covered telehealth services include:
- Physicians
- Nurse practitioners (NP)
- Physician assistants (PA)
- Nurse-midwives
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists
- Registered dietitians or nutrition professional
- Clinical psychologists (CPs) and clinical social workers (CSWs)
Updates during COVID-19 Pandemic
The Section 1135 waiver has been expanded to allow several providers to offer specific telehealth services.
These services include evaluation and management visits (regular office visits, mental health counseling, and preventive health screenings). In addition, Medicare beneficiaries can receive these telehealth services in any health care facility, including doctor offices, hospitals, nursing homes, or rural health clinics and at their home. It allows Medicare beneficiaries, who are at a higher risk for COVID-19 to visit their doctor from where they are, so they don’t have to go out to get the services they need.
Medical Conditions Treated via Telehealth Services
Medicare reimburses providers for a limited number of medical conditions using telehealth services.
Medicare has started covering more telehealth services due to changes to chronic care policies over the last few years. Many of these changes do not fall under the official Medicare telehealth definition. However, CMS is reimbursing for these remote services. Because the changes don’t fall within Medicare’s telehealth definition, the geographic and originating site limits don’t apply.
Beginning in 2013, providers can bill for telehealth related transitional care management using transitional care management codes instead of telehealth codes.
Starting in 2015, providers can bill for telehealth related chronic care management using chronic care management codes, rather than telehealth codes.
In 2019, CMS “unbundled” a payment code to reimburse for the time spent collecting and interpreting health data that was remotely generated by a patient, digitally stored, and transmitted to the provider, meaning Medicare now reimburses for “asynchronous services” unrelated to the Medicare telehealth definition.
Updates During COVID-19 Pandemic:
Medicare has expanded the list of services that can be delivered via telehealth during the worldwide pandemic.
Examples include:
99201 – Office/outpatient visit – New Patient
99218 – Initial observation care
97161 – PT evaluation – low complexity – 20 mins
97166 – OT evaluation – moderate complexity – 45 mins
97802 – Medical nutrition therapy; initial assessment and intervention, face to face, 15 mins
To see all the temporary additions during the COVID-19 Pandemic, refer to the List of Telehealth Services on the Centers for Medicare and Medicaid Services site.
Telehealth Services Covered Under Medicare
There are three main types of telehealth services covered under Medicare, including:
- Medicare Telehealth Visits
- Virtual Check-Ins
- E-visits
Medicare Telehealth Visits
Include services like office visits, psychotherapy, consultations, and other specific health services provided by an eligible practitioner who isn’t at the beneficiaries’ location using a 2-way interactive telecommunication system.
Under certain conditions, these services are available in rural areas, but the beneficiary must be located at one of the following:
- A doctor’s office
- A hospital
- A critical access hospital (CAH)
- A rural health clinic
- A federally qualified health center
- A hospital-based dialysis facility
- A skilled nursing facility
- A community mental health center
Updates to Medicare telehealth Visits During COVID-19 Pandemic:
Starting on service date March 6, 2020, Medicare will pay for Medicare telehealth services provided to patients in broader circumstances. The visits will be treated as regular in-person visits and paid at the same rate as in-person visits. During the Pandemic, Medicare will make payment for telehealth services delivered in any healthcare facility and at the patient’s home. See this announcement for the entire update to Medicare Telehealth Visits.
Virtual Check-Ins
The check-ins let beneficiaries speak to their provider or other specific practitioners, such as NPs or PAs, using a device like a phone, tablet, laptop or computer with integrated audio/visual and captured video images, so they don’t have to travel to their providers’ office.
Providers can respond to beneficiaries by using:
- Phone
- Audio/visual
- Secure text messages
- A patient portal
The following practitioners may offer these services:
- Doctors
- Nurse practitioners
- Physician assistants
- Licensed clinical social workers, in specific circumstances
- Clinical psychologists, in specific circumstances
- Physical therapists
- Occupational therapists
- Speech-language pathologists
Updates to Virtual Check-Ins during COVID-19 Pandemic:
Virtual check-ins can only be reported when the provider has an established relationship with the patient. There are no geographical restrictions during this time. Services must be agreed to by the patient, but providers can explain the benefits to beneficiaries prior to patient agreement.
Use HCPCS codes G2012 and G2010 to report these services during the pandemic.
Virtual check-ins can be conducted with more types of communication methods, unlike Medicare telehealth visits, that must have audio and visual capabilities for real-time communication.
For the entire update to virtual check-ins during the COVID-19 pandemic, see this announcement.
E-visits
E-Visits allow beneficiaries to talk to their providers using an online patient portal, so they don’t have to go to the doctor’s office.
Providers who may offer these telehealth services are:
- Doctors
- Nurse practitioners
- Physician assistants
- Licensed clinical social workers, in specific circumstances
- Clinical psychologists, in specific circumstances
- Physical therapists
- Occupational therapists
- Speech-language pathologists
Updates to E-Visits during the COVID-19 Pandemic
E-visits can only be reported when the provider has an established relationship with the patient. There are no geographical restrictions during this time. Patients can communicate with their providers via patient portals. Services need to be initiated by the patient, but the providers can educate them about the services before the services take place.
These services can be billed with CPT codes 99421 – 99423 and HCPCS codes G2061 – G2063 as applicable.
For the entire update to Medicare E-visits, see this announcement.
Overview of Billing Medicare for Telehealth Visits
To bill Medicare for telehealth claims, submit a CMS-1500 claim form using the correct CPT or HCPCS codes.
If telehealth services were performed using an “asynchronous telecommunications system,” append the telehealth GQ modifier to the CPT or HCPCS code, like 99201 GQ.
For other telehealth services, use the Place of Service (POS) 02 – Telehealth to indicate the service was a professional telehealth service from a distant site.
Bill covered Medicare telehealth services to your Medicare Administrative Contractor (MAC). They will pay for your telehealth services with the amount found on the Medicare Physician Fee Schedule (PFS).
For more detailed information, refer to the Medicare Learning Network, Telehealth Services Booklet.
Overview of Medicare Telehealth Reimbursement
Medicare reimbursement for telehealth can be complicated. There are several rules, so let’s do a high-level overview of Medicare reimbursement. Here are the key points to know:
- Live video telehealth visits are covered. Store-and-forward visits are only covered in two states currently – Alaska and Hawaii. The Distant site has few restrictions. However, the patient must be at an eligible Originating site that satisfies the following requirements:
- Be within a Health Professional Shortage Area (HPSA)
- Fall into one of the following categories:
- Physicians or practitioner offices
- Hospitals
- Critical Access Hospitals (CAH)
- Rural Health Clinics
- Federally Qualified Health Centers
- Hospital-based or CAH-based Renal Dialysis Centers
- Skilled Nursing Facilities (SNF)
- Community Mental Health Centers (CMHC)
- Specific CPT and HCPCS codes are eligible for reimbursement. CMS updates this list annually. CMS has expanded the list of covered services during the COVID-19 pandemic.
- You must include modifiers on your bills. Once you have the correct CPT or HCPCS code, use the “GT” modifier to show the service was done via telehealth. If you are located in Alaska or Hawaii, use the “GQ” modifier.
- Certain providers are eligible for reimbursement via telehealth. They include physicians, NPs, PAs, Nurse Midwives, Clinical nurse specialists, Clinical Psychologists, Clinical Social Workers, Registered dietetics or nutrition professionals. CMS has expanded the list of eligible providers during the COVID-19 pandemic.
- The originating site can charge a facility fee described by HCPCS code Q3014. You can separately bill your MAC for the Part B originating site facility fee.
- Medicare reimbursement for telehealth services should be similar to an in-person visit. For example, using CPT code 99213, whether services are provided in-person or via telehealth, should be reimbursed the same amount based on the Medicare Physician Fee Schedule.
Several rules surround reimbursement for Medicare telehealth. Refer to the Medicare.gov site for detailed explanations and the latest guidance.
Final Thoughts
Medicare billing for telehealth has many parts to understand. There are several resources to find information such as the Centers for Medicare and Medicaid Services, the Center for Connected Health Policy, and Medicare.gov to name a few.
Be sure to refer to the Medicare Telemedicine Health Care Provider Fact Sheet during the ongoing COVID-19 pandemic for updates relating to Medicare telehealth.
Sources:
https://www.medicare.gov/coverage/telehealth
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
https://www.medicare.gov/coverage/doctor-other-health-care-provider-services
