Overview of Medicare telehealth services

Please see the Telemedicine article for the rules and guidelines for use during the COVID-19 public health emergency.

---

Medicare covers some services performed via real-time audio and video between a patient in an underserved area and a physician or other practitioner who is not in the same place as the patient. Requirements for Medicare telehealth services (not performed during the public health emergency)include:

• Patient must be in either a rural Health Professional Shortage Area (HPSA) located in a rural census tract or in a county outside a Metropolitan Statistical Area (MSA).
• The patient is in the “originating site” and the facility bills Q3041. There is small payment to the facility for that service.
• The practitioner is somewhere else, provides the service remotely, and bills for the service. This is considered the “distant site.”
• The distant site bills with place of service 02. The originating site is billed by the facility on a UB, and that form does not include a space for POS.
• CPT developed modifier 95 for use with telehealth (-95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system)
• As of October 1, 2018, the GT modifier is only allowed on institutional claims billed by a Critical Access Hospital (CAH) Method II.

What services can be provided? Although CPT^® now has a symbol (star) to indicate services that can be done via telemedicine, for Medicare, use the CMS list.

EXAMPLE: Patient in rural Vermont Emergency Department needs a neuropsychiatric consult. The ED doctor assesses the patient, and bills for her own ED visit. She arranges a consultation with a neuropsychiatrist in Boston. The Vermont hospital bills Q3041 for providing the space and equipment for the telemedicine service. The neuropsychiatrist bills with a HCPCS code G0425, telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth. That physician uses POS 02, and modifier 95.

Starting January 1, 2019, CMS removed the restriction on the originating site for treatment of strokes.  The patient does not need to be in an underserved area in order to receive treatment for a stroke from a distant site physician. CMS developed a specific modifier for this. “Change request (CR) 10883 establishes use of a new Healthcare Common Procedure Coding System (HCPCS) modifier, G0 (G Zero), to be appended on claims for telehealth services that are furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.”

CMS telehealth fact sheet:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf

MLN matters

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10883.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9726.pdf

 

---