This article contains policy and billing instructions implementing §223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) – Revision of Medicare Reimbursement for Telehealth Services. BIPA amended §1834 of the Social Security Act (the Act) to provide for an expansion of Medicare payment for telehealth services.
Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural Health Professional Shortage Area (HPSA) as defined by §332(a)(1) (A) of the Public Health Services Act or in a county outside of a Metropolitan Statistical Area (MSA) as defined by §1886(d)(2)(D) of the Act.
Exception to Rural HPSA and Non-MSA Geographic Requirements
Entities participating in a federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Such entities are not required to be in a rural HPSA or non-MSA.
Originating Site Defined
An originating site is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. Originating sites authorized by law are listed below.
- The office of a physician or practitioner.
- A hospital.
- A critical access hospital.
- A rural health clinic.
- A federally qualified health center
The originating site must be located in a rural HPSA or non-Metropolitan
Statistical Area County
Entities that participate in a Federal Telemedicine demonstration project approved by (or receiving funding from) the Secretary of HHS as of December 31, 2000 qualifies regardless of geographic location.
Coverage of Telehealth
The use of a telecommunications system may substitute for a face-to-face, “hands on” encounter for consultation, office visits, individual psychotherapy and pharmacologic management. These services and corresponding Current Procedure Terminology (CPT) codes are listed below.
- Consultations (Current Procedural Terminology [CPT] codes 99241 – 99275);
- Office or other outpatient visits (CPT codes 99201 – 99215);
- Individual psychotherapy (CPT codes 90804 – 90809);
- Pharmacologic management (CPT code 90862);
- Psychiatric diagnostic interview examination (CPT code 90801) (effective March 1, 2003); and
- ESRD-related services included in the monthly capitation payment (Healthcare Common Procedure Coding System [HCPCS] codes G0308, G0309, G0311, G0312, G0314, G0315, G0317, and G0318) (effective January 1, 2005).
Note: With regard to ESRD-related services, at least one face-to-face, ”hands on“ visit (not telehealth) must be furnished each month to examine the vascular access site by a physician, PA, NP, or CNS.
Conditions of Payment
For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real-time communication between the distant site physician or practitioner and the Medicare beneficiary. As a condition of payment, the patient must be present and participating in the telehealth visit.
Exception to the Interactive Telecommunications Requirement
In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, Medicare payment is permitted for telemedicine when asynchronous ‘store and forward technology’, in single or multimedia formats, is used as a substitute for an interactive telecommunications system. The originating site and distant site practitioner must be included within the definition of the demonstration program.
For purposes of this instruction, ”store“ and ”forward“ means the asynchronous transmission of medical information to be reviewed at a later time by a physician or practitioner at the distant site. A patient’s medical information may include, but is not limited to, video clips, still images, x-rays, MRIs, EKGs and EEGs, laboratory results, audio clips, and text. The physician or practitioner at the distant site reviews the case without the patient being present. Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real-time.
Note: Asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail). Photographs must be specific to the patients’ condition and adequate for rendering or confirming a diagnosis and/or treatment plan. Dermatological photographs, e.g., a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this instruction.
Payment Methodology for Physician/Practitioner at the Distant Site
The term “distant site” means the site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system.
The payment amount for the professional service provided via a telecommunications system by the physician or practitioner at the distant site is equal to the current fee schedule amount for the service provided. Payment for an office visit, consultation, individual psychotherapy or pharmacologic management via a telecommunications system should be made at the same amount as when these services are furnished without the use of a telecommunications system. For Medicare payment to occur, the service must be within a practitioner’s scope of practice under State law. The beneficiary is responsible for any unmet deductible amount and applicable coinsurance.
Medicare practitioners who may receive payment at the distant site (i.e., at a site other than where the beneficiary is). As a condition of Medicare Part B payment for telehealth services, the physician or practitioner at the distant site must be licensed to provide the service under State law. When the physician or practitioner at the distant site is licensed under State law to provide a covered telehealth service (i.e., professional consultation, office and other outpatient visits, individual psychotherapy, and pharmacologic management) then he or she may bill for and receive payment for this service when delivered via a telecommunications system.
Practitioners at the distant site who may furnish and receive payment for telehealth services are listed below (subject to State law):
- Nurse practitioner.
- Physician assistant.
- Nurse midwife.
- Clinical nurse specialist.
- Clinical psychologist.*
- Clinical social worker.*
*Clinical psychologists and clinical social workers cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for the following CPT codes: 90805, 90807, and 90809
Originating Site Facility Fee Payment Methodology
As a condition of payment, an interactive audio and video telecommunications system must be used that permits real-time communication between the physician or practitioner at the distant site and the beneficiary at the originating site. Asynchronous ”store and forward“ technology is permitted only in Federal telehealth demonstration programs conducted in Alaska or Hawaii.
Payment is made for the telehealth service furnished by the physician or practitioner at the distant site and a telehealth facility fee is made to the originating site. Claims for telehealth services should be submitted using the appropriate CPT or HCPCS code for the professional service and the telehealth modifier ”GT“ ”via interactive audio and video telecommunications system“ (e.g., 99243 GT). In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, submit the appropriate CPT code and telehealth modifier ”GQ“ ”via asynchronous telecommunications system“ (e.g., 99243 GQ).
Claims for the facility fee should be submitted using HCPCS code Q3014: ”Telehealth originating site facility fee.“
Submission of Telehealth Claims
Professional Service – Carriers
Claims for professional consultations, office visits, individual psychotherapy, and pharmacologic management provided via a telecommunications systems for dates of service October 1, 2001, and later must be submitted to the carrier that processes claims for the practitioners service area. Submit such claims with the appropriate CPT code for the professional service provided and the telehealth modifier “GT” – “via interactive audio and video telecommunications system.” By using the “GT” modifier to bill for the telehealth service, the distant site practitioner verifies that the beneficiary was located at an eligible originating site at the time of the telehealth service.
In the case of a Federal telemedicine demonstration program conducted in Alaska or Hawaii, store and forward technologies may be used as a substitute for an interactive telecommunications system. When store and forward technologies are used, submit the appropriate CPT code and telehealth modifier “GQ”, “via asynchronous telecommunications system.” (See “Store and forward defined” and “Medical practitioners who may receive payment at the distant site” sections).
By using the “GQ” modifier, the distant site practitioner verifies that the asynchronous medical file was collected and transmitted to the physician or practitioner at the distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii. (See “Eligibility Criteria” and “Conditions of Payment” sections.)
Originating Site Facility Fee – Carriers and Intermediaries
To receive the facility payment, submit claims with HCPCS code “Q3014, telehealth originating site facility fee”; short description “telehealth facility fee.” The type of service for the telehealth originating site facility fee is “9, other items and services.”
By submitting Q3014 HCPCS code, the originating site authenticates they are located in either a rural HPSA or non-MSA county. Physicians’ and practitioners’ offices must bill the appropriate Medicare carrier for the originating site facility fee.
The facility fee will be updated yearly based upon the Medicare Economic Index.
Carrier Editing of Telehealth Claims
Edits will be installed effective for dates of service October 1, 2001, and later to ensure that only providers approved to bill for these telehealth services are paid.
When the “GT” modifier or the “GQ” modifier is billed for dates of service October 1, 2001, and later with CPT codes 99241 – 99275, 99201 – 99215, 90804 – 90809, or 90862 the claim will be processed only when the physician or practitioner is licensed to provide the service under State law. Medicare Part B will review the state licensure provisions and disallow any claims from practitioners who are not authorized as a covered telehealth service under state law. For example, if a nurse practitioner were not licensed to provide individual psychotherapy under state law, he or she would not be permitted to receive payment for individual psychotherapy under Medicare.
If professional claims are submitted with the “GQ” modifier representing “via asynchronous telecommunications system”, by physicians or practitioners who are not affiliated with a Federal telemedicine demonstration conducted in Alaska or Hawaii, they will be denied. The physician or practitioner at the distant site may be required to document his or her participation in a Federal telemedicine demonstration program conducted in Alaska or Hawaii prior to payment being made for telehealth services provided via asynchronous, store and forward technologies.
For services for which claims are denied because the provider may not bill for the service, the Medicare Summary Notice (MSN) message 21.18 will be used : “This item or service is not covered when performed or ordered by this practitioner.”
If professional service codes are submitted with one of the telehealth modifiers and the service is not considered a consultation, office or other outpatient visit, individual psychotherapy or pharmacologic management, MSN message 9.4 will be used: “This item or service was denied because information required to make payment was incorrect. The remittance advice message depends on what is incorrect, e.g., B18 if procedure code or modifier is incorrect, 125 if submission billing error, 4-12 for difference inconsistencies.”
This revision does not affect Medicare enrollment. The physician or practitioner at the distant site and the originating site facility are not subject to separate enrollment procedures for telehealth.
To find additional information about telehealth services, visit www.cms.hhs.gov/Telehealth on the CMS website.