As healthcare regulations change every year, government regulations regarding reimbursements from Medicare, impact the way the telehealth healthcare providers are reimbursed.

There are certain restrictions that the Centers for Medicare and Medicaid Services (CMS) have placed so that only specific services performed are reimbursed during live video calls. Services such as store-and-forward (video calls that were saved and used later) services are not allowed, except for approved CMS demonstration programs in Alaska and Hawaii. Medicare also reimburses for certain services that are not considered “telehealth services”, but are in regards to communicating to patients remotely.

Medicare Telehealth Parity Act of 2017 (MTP Act of 2017)

Not only does Medicare reimburse for telehealth procedures, but private payers and insurance companies must reimburse for telemedicine the same way that care is given in-person. At this point in time, it is not required by the federal government to legally reimburse for these services. As of 2019, there are 39 states and the District of Columbia that mandate private payer reimbursement of telehealth, however, this number is rising as specific states are becoming compliant with telehealth services.

Although these jurisdictions are covered for reimbursement, some states like New York do not mandate that private insurers need to fully reimburse treatment for telehealth services provided. Instead, the pay is reduced by 50%. Furthermore, many states may make their telehealth parity laws based on the terms and conditions of their contract which gives them the right to deny claims for reimbursement.

Geographic Location

The originating site is the location of services rendered to the patient. Medicare geographically limits these services to areas where there are shortages in healthcare professionals, typically in rural areas.

As defined by the Health Resources and Services Administration (HSRA), the originating site must be in a Health Professional Shortage Area (HPSA) or in a county outside of a Metropolitan Statistics Area (MSA) which is defined by the United States Census Bureau. According to the MTP Act of 2017, and MSA has a population of at least 50,000 individuals, but fewer than 100,000 individuals.

Many underserved areas are incapable of receiving telehealth services due to network availability and lack of resources. The areas that are eligible to receive telehealth services are unable because the population base is too small to maintain a telehealth network.

The Office of Rural Health Policy (OHRP) determines rural census tracts and CMS redefines rural HSPAs located in these areas. The OHRP enables eligible facilities located within the rural census tracts to operate within an MSA to be eligible telehealth originating sites. Furthermore, the HSRA regulates a Medicare telehealth payment eligibility search tool. This search tool determines the location of any eligible originating site.

CPT and HCPCS Codes

The Department of Health and Human Services (HHS) determines which services are eligible for reimbursement by using identifiers such as Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes.

CMS determines which services recommended by HHS to be approved for the next calendar year. New CPT codes submitted for reimbursement must meet requirements in one of two categories below:

Category One: These are existing telehealth services that are already approved; however, in order to approve the new CPT codes, similarities with existing services and interactions provided to the patient are examined. Furthermore, the similarities with existing technology are considered for approval.

Category Two: Telehealth services that are not currently approved by Medicare, must show that an assessment is accurately described for the CPT codes submitted to CMS. Services provided via telehealth and the technology used must demonstrate a clinical benefit to the patient to be considered for approval.

Eligible Providers

Medicare currently sets restrictions on which healthcare professionals can provide telehealth services. The providers that Medicare allows include:

  • Physicians
  • Nurse Practitioners
  • Physician Assistants
  • Nurse Midwives
  • Clinical Nurse Specialists
  • Certified Registered Nurse Anesthetists
  • Clinical Psychologists (CP) and Clinical Social Workers (CSWs)
    • These healthcare providers bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for CPT codes 90792, 90833, 90836, and 90838.
  • Registered Dietician or Nutrition Professionals

Eligible Facilities

Telehealth-delivered services that are eligible for Medicare reimbursements occur in the following facilities:

  • Healthcare provider offices
  • Hospitals
  • Critical Access Hospitals
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Skilled Nursing Facilities
  • Community Mental Health Center
  • Hospital-based or Critical Access Hospital-based Renal Dialysis Centers

Evaluation and Management Coding

Virtual check-in services have been implemented to assess whether an established patient needs an office visit or other necessary services that could take place via live video or telephone call. Remote evaluation of ePHI representing CPT code 99091 was separated into two codes, allowing providers to be reimbursed for time spent on data collection and analysis that was produced from remote services. Since these codes are not defined as telehealth, remote communication technology services are not subject to restrictions that telehealth services face.

Regarding chronic care management and remote monitoring, CMS adopted new chronic care management (CCM) codes, which allow for non-face-to-face encounters. In turn, reimbursement for complex CCM as well as two add-on codes were implemented. Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) can bill for CCM. Furthermore, three additional remote physiological codes were created and additional guidance on the proper use of these codes is expected in 2019. RHCs and FQHCs receive payment for remote evaluation of pre-recorded patient information that has been transmitted via pre-recorded services requiring at least 5 minutes of communication-based remote evaluation services. When services are rendered within 7 days by the same provider, the service would not be billed separately. Similarly, if services are rendered within 24 hours by the same provider, the services would be bundled for reimbursement.

interprofessional collaborative consultation is essential to promoting a safe and well respective environment while minimizing medical errors in the telehealth network. These services are limited to practitioners that can bill Medicare for Evaluation and Management (E/M) via communications technology. Encounters can take place over the telephone or during live internet consultation. When collaborating, the provider performing the consultation and the provider perform treatments can be reimbursed simultaneously. Input between each health profession on how to work together is essential in order to successfully treat the underlying problem, contributing to the quality of care and patient satisfaction.

Bipartisan Budget Act of 2018 & 2018 SUPPORT for Patients and Communities Act

As part of the Bipartisan Budget Act of 2018, CMS finalized its requirements to reflect changes in telehealth reimbursements for the fiscal calendar year of 2019. Exceptions to the originating site and geographic location have been made for patients with end-stage renal disease (ESRD) services, acute stroke treatment (AST), treatment of substance abuse disorder (SUD), and mental health-related conditions stemming from these conditions.

For services pertaining to ESRD and AST, there are no geographic limitations. Renal dialysis facilities and related-care that is provided in- home, are eligible for originating sites. Furthermore, mobile stroke units in conjunction with qualified originating sites are eligible for telehealth reimbursements. Home visits require an in-person visit once a month for the first three months of service and once every three months afterward.

The 2018 SUPPORT for Patients and Communities Act was created in conjunction with CMS’s current reimbursement policy. For telehealth services done on or after July 1st, 2019, the geographic limitations will be removed from telehealth originating sites for treating existing Medicare patients with SUDs or co-occurring mental health disorders. However, regular telehealth service code limitations will remain. Providers must assess patients in order to give an accurate diagnosis of SUDs and clearly communicate that it will be clinically beneficial to the patient to use telehealth services as their treatment option.

With dates of service after January 1, 2019, Medicare Administrative Coordinators (MAC) will accept HCPCS modifier G0 to be used to identify Telehealth services for diagnosing, evaluating, and treating symptoms of an acute stroke. Examples of services and codes are listed:

  • Telehealth distant site codes billed with Place of Service (POS) code 02
  • Critical Access Hospitals, CAH method II (revenue codes 096X, 097X, or 098X
  • Telehealth originating site facility fee billed with HCPCS code Q3014.

In addition to these changes, CMS will reimburse for G0513 and G0514, prolonged preventive services when provided via telehealth.

HCPCS Code Q3014 details the Medicare telehealth originating site facility fee. The MAC needs to be billed separately for Part B services.

Medicare Advantage and ACOs

Medicare Advantage Plans may offer telehealth services as an additional benefit; however, patients that choose to receive these benefits may potentially pay higher premiums or additional co-pays. Starting in 2020, Medicare Advantage Plans will be able to offer additional telehealth services without current restrictions. Furthermore, all Medicare two-sided ACOs will be able to be reimbursed for telehealth services delivered to patient homes through the Shared Savings Program.

Medicaid Regulations

  • Currently, 49 states and the District of Columbia (DC), Puerto Rico, and the Virginia Islands have defined telehealth, telemedicine, or both.
  • Only 11 states reimburse for store-and-forwards services
  • All 50 states and DC reimburse for live video sessions.
  • Twenty-one states reimburse for remote patient monitoring (RPM)
  • Only 14 states reimburse to the home (DE, CO, MD, MI, MN, MT, NH, NV, NY, SC, TX, VT, WA, and WY)
  • Massachusetts’s Medicaid programs recently began to reimburse mental and behavioral health services delivered via telehealth. It is the only state that requires private insurers to reimburse for services provided via telehealth.
  • Thirty-eight states and DC have included informed consent as part of regulations, policy, and law.
  • Some states require that an in-person visit must occur before the patient can be prescribed medication online. As of 2018, Kansas has approved telehealth and prescription laws as the same as in-person visits. Furthermore, West Virginia allows medication-assisted therapy (MAT) through telehealth.
  • Currently, nine state boards issue licenses relating to telehealth services that allow an out of state provider to deliver care.

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