Navigating telehealth billing requirements

Editor's note: This article was originally published in June 2018 and is presented for archival purposes. For an updated telehealth billing article specific to the COVID-19 emergency from this author, click here.

Medicare Part B covers a limited range of telehealth services, and the Centers for Medicare & Medicaid Services (CMS) provides guidelines for reporting these services using specific terminology. 

Understanding these terms is critical for both providers and originating sites to ensure eligibility, service delivery and proper reimbursement. 

According to CMS, telehealth services must be provided via an interactive audio and video telecommunications system that allows for real-time communication between the provider and the beneficiary. The exceptions are Alaska and Hawaii, where asynchronous technology — defined as the transmission of medical information to the distant site and reviewed later by the physician or practitioner — is permitted in federal telemedicine demonstration programs.

The originating site is the location of the beneficiary at the time the service is furnished. Telehealth is only a covered benefit if the originating site is:

• A county outside of a Metropolitan Statistical Area (MSA) 
• A rural Health Professional Shortage Area (HPSA) located in a rural census tract

In addition, sites that participate in a federal telemedicine demonstration program qualify as originating sites in most cases. Per CMS, authorized originating sites include:

• Physicians or practitioner offices
• Hospitals
• Critical access hospitals (CAHs)
• Rural health clinics
• Federally qualified health centers (FQHCs)
• Hospital-based or CAH-based renal dialysis centers (including satellites) 
• Skilled nursing facilities 
• Community mental health centers 

Each calendar year, geographic eligibility for originating sites is established. The Health Resources and Services Administration (HRSA) provides an online Medicare Telehealth Payment Eligibility Analyzer to determine if a site qualifies for Medicare telehealth payment. 

The distant site is where the provider delivering the service is located. Providers at the distant site who are eligible to receive payment for telehealth services include:

• Physicians
• Nurse practitioners
• Physician assistants
• Nurse-midwives
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Clinical psychologists and clinical social workers (may not bill for psychiatric diagnostic interviews or E/M services)
• Registered dietitians or nutrition professionals

Billing guidelines

If the telehealth service delivered does not meet the requirements outlined above, the service cannot be billed. If the beneficiary receives a telehealth service at an originating site that is not qualified for Medicare telehealth payment, then the visit is essentially unbillable (For example: An office visit with a specialist at an originating site that is not eligible per Medicare guidelines). 

Not all services on the Medicare Physician Fee Schedule (PFS) are eligible for payment when performed via telehealth. For CY 2018, there are 96 services designated by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes that are eligible for telehealth payment. Medicare telehealth services include but are not limited to office or other outpatient evaluation and management visits, subsequent hospital and nursing facility care visits, psychotherapy, health and behavior assessments and interventions and end-stage renal disease services. 

Eligible services are indicated by a star symbol in the CPT manual and are also listed in Appendix P of the manual. Furthermore, a list of Medicare telehealth services can be found on the Medicare PFS website. Additions and deletions to Medicare telehealth services are made annually on Jan. 1, via the PFS.

Professional fee claims

Claims for covered telehealth services provided at the distant site should be submitted using the applicable CPT or HCPCS code. Using the telehealth Place of Service (POS) code 02 indicates that the services were provided via telehealth and meet the telehealth requirements. Medicare payment is based on the PFS for telehealth services.

Since using POS code 02 certifies that the services provided meet telehealth requirements, modifier 95 (synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system) is not applicable for Medicare telemedicine services. However, it may be required by other payers. 

For eligible providers who have reassigned billing rights to a CAH that elected the Optional Payment Method, the CAH may bill for telehealth services on an institutional claim using the GT modifier (via interactive audio and video telecommunications systems). The payment amount is 80% of the Medicare PFS for telehealth services.

Federal telemedicine demonstration programs in Alaska and Hawaii are directed to submit claims using the appropriate CPT or HCPCS code with modifier GQ (via an asynchronous telecommunications system) appended. 

Medicare Administrative Contractors (MACs) have been directed by CMS to apply frequency edit logic to telehealth codes billed with POS code 02 for claims with dates of service Jan. 1, 2018, and after. The “one every 30 days” frequency edit logic applies when subsequent nursing facility care codes are billed with POS code 02 and the “one every three days” frequency edit logic applies when subsequent hospital care codes are billed with POS code 02.

Originating site claims

The originating site is eligible for payment of an originating site facility fee for telehealth services, which is separately billable to Medicare Part B. Code Q3014 (telehealth originating site facility fee) is used to report this service.

By law, the payment amount to the originating site is the lesser of 80% of the actual charge or 80% of the originating site facility fee. Deductible and coinsurance rules apply. Payment amount methodologies for each originating site facility type is explained thoroughly in the CMS Medicare Claims Processing Manual.

Case example

A Medicare patient presents to a rural health clinic complaining of a headache, nausea and vomiting. A clinical staff employee at the originating site escorts the patient to a room where the patient can interact with the provider using audiovisual equipment. The provider performs the necessary history, and a clinical staff employee obtains the clinical information, such as vital signs, requested by the provider.

If the clinic has the appropriate equipment and personnel, diagnostic tests ordered by the provider are performed onsite. The provider renders the patient assessment and plan to be discussed with the patient. During this new patient encounter, the provider performs and documents a detailed history, an expanded problem-focused exam and moderate medical decision-making. Also included in the documentation is information stating that the service was provided through telehealth, the location of the patient and the provider, and the names of any other staff involved in the service.

For the distant site in this example, CPT code 99202 is billed with POS code 02 for the professional provider’s service. The originating site should report HCPCS code Q3014 for the services provided.

Documentation requirements

Documentation requirements for a telehealth service are the same as for a face-to-face encounter. The information of the visit, the history, review of systems, consultative notes or any information used to make a medical decision about the patient should be documented. Best practice suggests that documentation should also include a statement that the service was provided through telehealth, both the location of the patient and the provider and the names and roles of any other persons participating in the telehealth service.

It is advisable to follow local Medicare Administrative Contractor (MAC) guidance for final instructions on billing and documentation requirements for telehealth services. Additionally, private payers may follow the guidelines set forth by Medicare or may have their own.

As telehealth becomes more efficient and improves patient outcomes, more services are likely to be approved for reimbursement. As more payers cover telehealth services, payment policies and criteria will change, so keep a watchful eye on the situation.

Telehealth resources for providers

• Telehealth services fact sheet
• Medicare telehealth payment eligibility analyzer
• MGMA Stat poll: Providers slowly adopted telehealth services in 2017