Medicare reimbursement for telemedicine

The Medicare Chronic Care Management Program

National telehealth policy sets many restrictions on patient location, services provided over telemedicine and facilities at which patients receive these services. Those are discussed below. However, the Medicare Chronic Care Management Program is a national policy that set no such restrictions on practicing telemedicine. The program was adopted in order to help practitioners better provide monthly care to patients with two or more chronic conditions through telehealth services. Patients can be located anywhere, even in the middle of a metropolitan city, and they may receive services from any facility, including their home or office. Visit our informational page to learn more about the Medicare CCM Program and telemedicine.

Distant site practitioners

Medicare limits the type of healthcare professionals who are eligible to provide telemedicine services to Medicare patients. Any provider not on the list below may not legally provide telehealth services.

• Physician
• Nurse practitioner
• Physician assistant
• Nurse midwives
• Clinical nurse specialists
• Clinical psychologists and social workers
• Registered dietitians or nutrition professionals

Telemedicine modality reimbursement limitations

There are four forms of telemedicine applications, commonly referred to as telehealth modalities. With the exception of the Medicare CCM Program which has it’s own modality restrictions, Medicare restricts reimbursement based on the type of technology used by the physician to deliver care.

Videoconferencing

Live, two-way video interactions between patient and provider, also referred to as “real-time” video, is the gold standard of care. With the exception of a few pilot programs in Alaska and Hawaii, Medicare will only reimburse for telehealth services delivered over videoconferencing.

Store-and-forward

With the exception of the Medicare CCM Program, Medicare does not reimburse for services delivered through store-and-forward methods, e.g. email or fax.

Remote patient monitoring

Currently, Medicare does not having any specific legislation regarding reimbursement for RPM. It is likely that this will change in the near future — using monitoring devices in combination with videoconferencing or telephone calls is an ideal way to do remote physical examinations of patients on a regular basis.

mHealth

Medicare does not reimburse for the use of mobile communication devices to deliver care to patients.

Geographic limitations

With the exception of the Medicare Chronic Care Management Program, Medicare places certain restrictions on where patients can be located when receiving telehealth services. Because Medicare sees telehealth as a tool that should specifically target people in remote, rural areas, it has limited the geographic location of patients receiving remote care. Patients must be either:

• Located in what is referred to as a Health Professional Shortage Area (HPSA) outside of a Metropolitan Statistical Area (MSA) or;
• In a rural census tract or in a county that is outside of a MSA.

To check if an originating site is eligible to receive telemedicine services, an originating site search tool has been created by the Center for Connected Health Policy.

Originating site requirements

Medicare not only limits the site location where patients may receive telehealth services, it also limits the type of facility where patients may receive these services. For example, even if a patient is in an HPSA, they may not receive care from their home or office, as those are not eligible facilities. The eligible facilities where a patient may receive telemedicine-delivered services are:

• Provider offices
• Hospitals
• Critical access hospitals
• Rural health clinics
• Federally qualified health centers
• Skilled nursing facilities
• Community mental health centers
• Hospital-based or critical access hospital-based renal dialysis centers

Again, this is only a facility-requirement for the patient’s location. The physician may be located in a facility outside of this list. Furthermore, patients being seen through the Medicare CCM Program may be located anywhere.

Additional reimbursement requirements

Currently, the Centers for Medicare & Medicaid Services decide to approve a submitted Current Procedural Terminology (CPT) code based on the type of service that was provided over telehealth. They have certain services for which they do reimburse (see category 1 below) and certain services for which they do not reimburse (see category 2 below).

Category 1

The services provided are similar to existing services, such as professional consultations, office visits, and office psychiatry services, that are approved for telemedicine delivery. When Medicare is deciding whether to approve new codes, they largely consider similarities between the requested service and existing telehealth services.

Category 2

If services are not similar to Medicare-approved telehealth services, reimbursement is not granted. When reviewing requirements, Medicare assesses whether the service delivered by telemedicine is accurately described by the corresponding CPT code, even when delivered via remotely, and whether the use of telemedicine technology to deliver the service demonstrates clinical benefit to the patient.

Here is a list of Medicare-approved telehealth services, last updated February 2018.

Billing for telemedicine

In order to appropriately bill for synchronous telehealth services, practitioners should submit the appropriate Healthcare Common Procedure Coding System (HCPCS) or CPT code along with the telemedicine Place of Service code 02. The Place of Service 02 indicates the location in which the services took place.

If located in Hawaii or Alaska, practitioners should use the appropriate CPT or HCPCS code for the professional service in addition to the GQ modifier. The GQ indicates that the service was provided “via an asynchronous telecommunications system.”