Learn the Criteria Necessary for Medicare’s Telemedicine Services—Part II

Posted on 8 Jun, 2018 |comments_icon 0|By Elizabeth

Telemedicine now allows providers to virtually interact with patients in a way that improves the quality and delivery of care, especially for those patients who are unable to come to the office. The convenience and instant feedback patients receive are among the driving factors behind this rapidly growing branch of medicine. It’s a win-win situation for both medical practices and their patients, but you must know the criteria to ensure Medicare reimbursement.

Location, Location, Location

Medicare will reimburse Part B providers for telehealth services only if the patient presents from a qualifying — and rural — location.

Here’s a list of qualifying originating sites with their POS codes:

  1. Offices of physicians/practitioners (POS 11)
  2. Hospitals (POS 21, 22, 23)
  3. Critical access hospitals (POS 21, 22, 23)
  4. Rural health clinics (POS 72)
  5. Federally qualified health centers (POS 50)
  6. Hospital-based or CAH-based renal dialysis centers (including satellites) (POS 65)
  7. Skilled nursing facilities (POS 31, 32)
  8. Community mental health centers (POS 53)

The service must be on the list of Medicare telehealth services and meet all of the following:

  • The visit must be furnished via an interactive telecommunications system.
  • The visit must be furnished by a physician or authorized practitioner.
  • The visit must be furnished to an eligible telehealth individual.
  • The individual receiving the service must be located in a telehealth originating site.

The Health Resources and Services Administration (HRSA) determines whether the originating site qualifies as rural and reevaluates these sites every year, so be sure to verify your address. Many sites that qualified in December 2017 lost their qualifying rural status on Jan. 1, 2018.

“The patient has to present from a rural location; the doctor can be anywhere. There is no requirement for the doctors’ location,” O’Leary said.

For example: Medicare Part B will reimburse a physician located in Boston if she has a telemedicine appointment with a Part B recipient who uses a video system to call in from a qualifying, rural site of origin, like a rural skilled nursing facility, as long as the other conditions are met and the documentation has the necessary information.

Remember: The patient’s home is not an approved originating site. Even if the patient is homebound, a telemedicine encounter qualifies for Part B reimbursement only if the patient presents at an originating site in a rural location.

Caution: A patient’s condition has no bearing on telemedicine coverage requirements.

Use the Right Equipment

Though the technology in your office (or even your pocket) make connecting over a video call possible, you need to use equipment that is advanced enough that there won’t be any lag time.

You must use interactive audio and video telecommunications system that permits real-time communication between the doctor and the beneficiary. Asynchronous ‘store and forward’ technology is not permitted except in federal telemedicine demonstration programs in Alaska and Hawaii.

Submit This Documentation

The claim for reimbursement should be the same as with any patient encounter, except you need to add the following information:

  • A statement that the service was provided using telemedicine;
  • The location of the patient;
  • The location of the provider; and
  • The names of all persons participating in the telemedicine service and their role in the encounter.

Get to Know the Telehealth Services Medicare Covers

Medicare pays for the following services for an approved provider to a patient located at an approved originating site. Note that telehealth services can be included as a HCPCS or CPT® code, and the code descriptor may not specific “telehealth” or “telemedicine.”

Facility-Based Care:

  • Telehealth consultations, emergency department or initial inpatient (G0425–G0427)
  • Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs (G0406–G0408)
  • Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days (99231–99233)
  • Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days (99307–99310)
  • ESRD-related services (90951-90952, 90954-90955, 90957-90958, 90960-90961, and 90963-90970)
  • Transitional care management (99495-99496)
  • Advance care planning (99497-99498)
  • Prolonged services for inpatient or observation (99356-99357)

General Outpatient Care:

  • Office or outpatient visits (99201-99205, 99211-99215)
  • Annual wellness care (G0438-G0439)
  • Prolonged services for office or other outpatient (99354-99355)
  • Critical care telehealth consultations (G0508-G0509)

Health and Condition Management:

  • Kidney disease education services (G0420-G0421)
  • Diabetes self-management training (G0108-G0109)
  • Health and behavior assessments and interventions (96150-96154)
  • Medical nutrition therapy (G0270 and 97802-97804)
  • Pharmacologic management (G0459)
  • Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making (effective for services furnished on and after January 1, 2018) (G0296)
  • Comprehensive assessment of and care planning for patients requiring chronic care management (effective for services furnished on and after January 1, 2018) (G0506)

Behavioral Health:

  • Individual or family psychotherapy (90832-90834, 90836-90838, and 90846-90847)
  • Psychiatric diagnostic interview (90791-90792)
  • Psychoanalysis (90845)
  • Neurobehavioral status examination (96116)
  • Smoking cessation (99406-99407)
  • Alcohol and substance abuse assessments and interventions (G0396-G0397)
  • Alcohol screening or counseling (G0442-G0443)
  • Annual depression screening (G0444)
  • Behavioral counseling to prevent sexually transmitted diseases (G0445)
  • Behavioral therapy for cardiovascular disease (G0446)
  • Behavioral counseling for obesity (G0447)
  • Interactive Complexity Psychiatry Services and Procedures (effective for services furnished on and after January 1, 2018) (90785)
  • Health Risk Assessment (effective for services furnished on and after January 1, 2018) (96160 and 96161)
  • Psychotherapy for crisis (effective for services furnished on and after January 1, 2018) (90839 and 90840)

Originating Site Reimbursement

Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014 (Telehealth originating site facility fee). You should bill the MAC for the originating site facility fee, which is a separately billable Part B payment.

Remember: The originating site refers to the location of the patient at the time of telehealth services. Medicare reimburses telehealth services only if the patient is present at the site that is either a rural health professional shortage area or any place outside a metropolitan area.

Key: Originating sites are specified as the office of a provider; a hospital; a critical access hospital, or CAH; a rural health clinic, or RHC; a federally qualified health center, or FQHC; a hospital based or CAH based renal dialysis center; a skilled nursing facility, or SNF; or a community mental health center, or CMHC.

Important: As of 2018, the originating site payment has increased from $25.40 to $25.76.

Note: When a CMHC serves as an originating site, the originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services.

Strategy: When billing the facility fee for the originating site, you will not have to report the particular CPT® code that the distant site will be reporting for the service they provide through telehealth. Instead, you will only bill one code claiming the facility fee for the originating site for any service that you provide through telehealth. There is only one code for the originating site and it is Q3014 (Telehealth originating site facility fee).

Important: Deductible and coinsurance rules apply to Q3014.

Example: Your psychiatrist performs an initial psychiatric evaluation of a patient who is suffering from symptoms of depressed mood. The patient is receiving the services from the outpatient department of a hospital that is within a rural HPSA. Both your provider and the patient communicate with each other using interactive video and audio telecommunication systems. You report 90792 (Psychiatric diagnostic evaluation with medical services) for the evaluation your provider performs. To let the payer know that the service is a telehealth service, report 90792 with the modifier 95 appended. The outpatient department of the hospital will bill the facility fee for their part of the service using Q3014.

Learn More

Conquer the requirements for Medicare reimbursement of your telehealth services—and get up to speed on telemedicine technology, guidelines, and coding. Pick up your copy of TCI’s best-selling Telemedicine & Telehealth Handbook for Medical Practices 2018.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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