Medicare Coverage of Telehealth Services
The Centers for Medicare and Medicaid Services (CMS) defines telehealth services to include those services that require a face-to-face meeting with the patient. Reimbursement for these services was initiated through Congressional legislation. Such reimbursement is limited to the type of services provided, geographic location, type of institution delivering the services and type of health provider.
Medicare telehealth services are divided into three areas:
- Remote patient face-to-face services seen via live video conferencing
- Non face-to-face services that can be conducted either through live video conferencing or via store and forward telecommunication services
- Home telehealth services
- Remote Patient Face-To-Face, Interactive Services
Eligible Medical Services
Services that are eligible for reimbursement include consultation, office visits, individual psychotherapy and pharmacologic management delivered via a telecommunications system. The use of a telecommunications system may substitute for a face-to-face, "hands on" encounter for consultation, office visits, individual psychotherapy and pharmacologic management.
- The service must be on the list of Medicare telehealth services and meet all of the following additional requirements:
- The service must be furnished via an interactive telecommunications system;
- The service must be furnished by a physician or authorized practitioner;
- The service must be furnished to an eligible telehealth individual; and
- The individual receiving the service must be located in a telehealth originating site.
Only the following health professionals may claim reimbursement for remote telehealth services:
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Clinical nurse specialists (CNS)
- Certified registered nurse anesthetists (CRNAs)
- Clinical psychologists (CPs) and Clinical Social Workers (CSWs)
- Note: CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for CPT codes 90805, 90807 and 90809.
- Registered dietitians or nutrition professionals
Only the following facilities are eligible to be an originating site under the rules of the program:
- The offices of physicians or practitioners
- Critical Access Hospitals (CAHs)
- Rural Health Clinics (RHCs)
- Federally Qualified Health Centers (FQHCs)
- Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
- Skilled Nursing Facilities (SNFs)
- Community Mental Health Centers (CMHCs)
Note: Independent Renal Dialysis Facilities are not eligible originating sites.
Remote Non Face-to-Face Services
Services provided using telecommunications technology but not requiring the patient to be present during their implementation are covered the same as services delivered when on-site at the medical facility.
“A service may be considered to be a physician’s service where the physician either examines the patient in person or is able to visualize some aspect of the patient’s condition without the interposition of a third person’s judgment. Direct visualization would be possible by means of x-rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc.
For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service.
These remote services are not considered “telehealth” or “telemedicine”. Rather, they are considered the same as services delivered on-site, are to be coded, and will be paid in the same way. There are no geographic or facility limitations on these services.
The largest single specialty providing remote services is radiology.
Section 1895(e) of the Act states that telehealth services are outside the scope of the Medicare home health benefit and Home Health/Prospective Payment System (HH/PPS). This provision does not provide coverage or payment for Medicare home health services provided via a telecommunications system. The law does not permit the substitution or use of a telecommunications system to provide any covered home health services paid under the home health PPS, or any covered home health service paid outside of the home health PPS. As stated in 42 CFR 409.48(c), a visit is an episode of personal contact with the beneficiary by staff of the Home Health Agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service.
However, this provision clarifies that there is nothing to preclude a home health agency from adopting telemedicine or other technologies that they believe promote efficiencies, but that those technologies will not be specifically recognized or reimbursed by Medicare under the home health benefit. This provision does not waive the current statutory requirement for a physician certification of a home health plan of care under current §§1814(a)(2)(C) or 1835(a)(2)(A) of the Act.
Claim Submission Information
Reimbursement to the health professional delivering the medical service is the same as the current fee schedule amount for the service provided. In addition, the non-metropolitan facility with the patient is eligible to receive a facility fee.
Claims for reimbursement should be submitted with the appropriate CPT code for the professional service provided and the appropriate telehealth modifier.