The information below was current at the time this article was published. This article is not intended as legal advice. If you are considering billing for telehealth services, it is recommended that you seek guidance from a qualified health care attorney that specializes in telehealth so that they can advise you on matters related to your specific practice’s situation, state medical license requirements, Federal and State DEA requirements, and malpractice insurance considerations. After you have spoken with your attorney, contact Comprehensive Medical Solutions for your telehealth billing needs.
In 1905, Hugo Gernsback emigrated from Germany to the US at the age of 20. He was a pioneer in the radio and publishing industry and invented the first home radio set. In the Feb 1925 issue of his Science and Invention magazine, he wrote an article where he predicted in the year 1975, a device would be used where doctors would not only view their patients remotely through a display screen but they could also touch the patient with robot arms. He called this device the Teledactyl, from the Greek Tele meaning far and Dactyl meaning finger. He envisioned that he could see the patient through this device and the fingers of his robot could feel and touch the patient. Gernsback’s vision is not too far off from what the telemedicine carts look like today. But odds are he did not envision how confusing and complex the Centers for Medicare and Medicaid Services (CMS) would make billing and getting reimbursed for telemedicine services! Can we unofficially call Gernsback the “Father of Telemedicine?”
Health care providers use telehealth to improve patients’ access to and quality of care. Under Medicare, these patients are likely to live in rural areas, be over the age of 65, or be disabled. Telemedicine is cost effective for the hosting facility where the patient is located – it allows the facility to have a qualified provider evaluate the patient but the facility does not have to carry those additionally skilled providers on their payroll.
The Medicare, Medicaid and SCHIP Benefits Improvement & Protection Act of 2000 (BIPA) Section 223 Subsection 1834 was amended to provide for an expansion of Medicare payment for telehealth services. Telehealth doesn’t go back as far as 1925 as Gernsback fantasized, but Medicare did begin paying for telehealth services in late 2001. Coverage and payment for Medicare telehealth services became effective October 1, 2001 and includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. While Medicare has reimbursed telehealth services for several years, the Office of the Inspector General (OIG) is making it a priority to audit telehealth billings in 2018. The OIG is targeting providers who bill for telehealth services but there is not also a corresponding Originating Facility Fee charge from the Originating Site.
ORIGINATING SITE
The patient receiving the service via telecommunication must be located at an eligible/approved address, called the Originating Site. The Health Resources and Services Administration (HRSA) determines Health Professional Shortage Areas (HPSA) and the US Census Bureau determines Metropolitan Statistical Areas (MSA).1 Rural HPSA and counties not classified as an MSA are eligible geographic areas where telehealth services may be reimbursed. There is an exception: Entities that receive funding or participate in the Federal Telemedicine Demonstration Project administered by the Health and Human Services Department (HHS) automatically qualify as an Originating Site regardless of the geographic location. These programs are generally conducted in Alaska and Hawaii. You can use the HRSA tool to check to see if the service address of the Originating site is an approved HPSA location.2
A Telepresenter is an individual located at the Originating Site facility who may assist the Distant Site provider. Telepresenter services may not be billed and are not separately reimbursed.
ADDITIONAL CONDITIONS MUST BE MET WHEN PROVIDING TELEHEALTH SERVICES
Several additional conditions must be met in order for Medicare to reimburse telehealth services under the Part B Physician Fee Schedule. The service provided must be on the list of covered Medicare telehealth services and meet all of the following additional requirements:
- must be furnished via an interactive telecommunications system
- must be furnished by a physician or authorized practitioner (listed below)
- must be furnished to an eligible patient
- the individual receiving the service must be located in an approved telehealth Originating Site
There are several Place of Service codes that are allowed to be used for telehealth billing:
- 11 – Office
- 21/22/23 – Hospital IP/OP/ER
- 72 – Rural Health
- 50 – FQHC
- 65 – Renal dialysis
- 31/32 – SNF
- 53 – Mental health centers
The geographic eligibility of an originating site is established based on the status of the area as of December 31st of the prior calendar year. That eligibility is updated every January 1st and then continues for that full calendar year. Independent Renal Dialysis Facilities are not considered eligible originating sites nor is a patient’s home.
EQUIPMENT REQUIREMENTS
As a condition of payment, the provider must use an interactive audio and video telecommunications system. Telehealth services must be delivered via an interactive telecommunication system that permits real-time communication, between the physician at the Distant Site and the beneficiary at the Originating Site. According to 42 CFR 410.78 Telehealth Services (a)(3): “Interactive Telecommunications Systems means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and the Distant Site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.”
Asynchronous “store and forward” technology may be permitted in Alaska and Hawaii where Federal telemedicine demonstration programs are conducted.
A cell phone is not an approved telecommunication device.
ELIGIBLE DISTANT SITE PRACTITIONERS
The practitioners listed below are the types of providers who are eligible to bill for telehealth services. These practitioners are called “Distant Site” providers. Distant Site practitioners are required to be licensed by the state where they are providing the service, and may also be required to be licensed by the State where the Originating Site is located. It is important to note that the practitioner must provide the scope of service to the patient for which they are licensed. Practitioners should also evaluate, and meet, malpractice insurance requirements for each State in which they are licensed, as related to providing “telehealth” services. If the practitioner intends to prescribe drugs, the practitioner must meet any Federal and possibly State drug licensing requirements in the State in which they are providing the service, and possibly the Originating Site as well.
- Physician (MD/DO)
- Nurse Practitioner (NP)
- Physician Assistant (PA)
- Nurse-midwife
- Clinical Nurse Specialist (CNS)
- Certified Registered Nurse Anesthetist (CRNA)
- Clinical Psychologist (CP)
- Clinical Social Worker (CSW)
- Registered Dietician or Nutrition Professional
TELEHEALTH CPT CODES
In their Telehealth Fact Sheet, CMS Lists almost 100 CPT codes that are allowed to be used for telehealth services.3 Below are new codes added for 2018:
- G0296 Visit to determine LDCT eligibility
- 90785 Interactive Complexity
- 96160 and 96161 Health Risk Assessment
- G0506 Care Planning for Chronic Care Mgmt
- 90839 and 90840 Psychotherapy for Crisis
CMS is currently finalizing separate payment for 99091 (Certain remote patient monitoring), which is proposed to be payable in both facility and non-facility settings.
CMS accepts input from practitioners regarding additional services they would like to see added. Go to CMS’s website to submit your request.4
The provider would use the appropriate CPT code, whether it is a traditional Evaluation & Management (E&M) code or a CPT designated for telehealth when billing for telehealth services. The provider would not bill for both a regular E&M CPT and a telehealth CPT. As always, services provided must be medically necessary.
INITIAL, FOLLOW-UP, AND EMERGENCY ROOM CONSULTS
A local physician of record (POR) may need to seek advice, opinion, or recommendation that is beyond their expertise and knowledge in a particular area when treating a patient. Using telehealth to contact another qualified provider may substitute for the in-person encounter when the needed qualified practitioner is not available to the patient locally. The telehealth encounter must be distinct from the care provided by the POR or the Attending physician. The type of care that the telehealth practitioner provides should be consistent with the patient’s needs.
Telehealth consultation services provided to patients in Hospitals or Skilled Nursing Facilities (SNF) may be paid by Medicare Part B when certain conditions are met:
- the telehealth consult is a separate service distinguished from other services because the service is requested by the POR/Attending to address a specific problem. As mentioned previously, the service that the telehealth practitioner provides must be within their scope of practice and licensure requirements for the Distant Site State, and possibly the Originating Site State;
- the request and the need for the telehealth consultation must be documented by the telehealth provider in the patient’s medical record and recorded in the requesting physician’s Plan of Care;
- the telehealth practitioner must document a written report of their findings and recommendations and provide this to the requesting physician.5
SUBSEQUENT HOSPITAL CARE SERVICES
There are limitations to the number of telehealth visits beneficiaries may receive.
- Subsequent hospital care services are limited to 1 telehealth visit every 3 days
- Subsequent nursing facility care services are limited to 1 telehealth visit every 30 days
The same inpatient/emergency department rules apply: the visit is provided at the request of the POR/Attending physician and the practitioner providing the telehealth consult cannot be the POR/Attending.
PART B BILLING AND PAYMENT
The Distant Site provider is permitted to bill for his/her visit services for treating the patient and the Originating Site may bill for an “Originating Site Facility Fee” for hosting the patient. The Distant Site provider will bill his/her claims to the Medicare Administrative Contractor (MAC) where they physically conducted the telehealth service (the Distant Site). The Distant Site service address MUST be inside the United States and is the Service Address enrolled with the MAC. The Distant Site’s address will be reported in Block 32/electronic equivalent of the HCFA 1500 claim. The Distant Site is not required to be an eligible HPSA address, however, the Originating Site must be an approved eligible HPSA address.
Provider Services (Distant Site)
>Use appropriate CPT/HCPCS code to bill for the service rendered
>POS 02 – Telehealth
Originating Site Facility Fee
>Use CPT Q3014
>2018 Allowable = $25.76
>Billed to Part B MAC
Starting January 1, 2018, CMS eliminated the use of the GT modifier6 to indicate the service was provided via telehealth. The use of the Place of Service Code 02 serves this purpose.
Billing for the Facility Fee using CPT Q3014 may require that the Originating facility enroll in their corresponding Medicare Part B MAC.
The Medicare beneficiary is responsible for any deductible and co-pays related to telehealth services rendered.
DISTANT SITE TELEHEALTH PROVIDER DOCUMENTATION REQUIREMENTS
The patient’s medical record documentation requirements are the same as any other face-to-face encounter, but the telehealth practitioner must also add the following:
-Verbiage that the service was provided via telecommunication
- Patient Location
- Provider Location
- All of the names of the individuals participating in the telemedicine service and their role in the encounter.
“INCIDENT TO” 7 8 9 10 11 12 13
It is very important to mention Incident To rules. “Incident To” basically means that, for example, a Nurse Practitioner actually rendered the service, but the claim is billed out under the responsible physician’s name, and the claim is paid at the physician’s rate. Some may see telehealth as an opportunity to utilize Nurse Practitioners or Physician Assistants (PA) to conduct telehealth visits as a way to enhance the medical practice’s business plan/service offering. Please be advised that at this time, Incident To rules apply and would need to be followed when providing telehealth services:
- Incident To is only permitted to be billed in the Office setting, Place of Service code 11
- An MD/DO must conduct the initial visit
- The supervising physician must be physically present in the office suite where the NP/PA is providing the telehealth service – the supervising physician being “a phone call away” in another building/city/state is not permitted
- The Medicare beneficiary cannot be in a Medicare covered Part A stay (SNF)
- The service must be provided to Established patients; new problems do not apply
Please see the References and Resources below to learn about the details regarding Incident To billing.
OTHER ISSUES TO CONSIDER
Non-Medicare insurances may have different billing requirements, such as they may require the use of the GT or 95 modifier to indicate the service was telehealth in nature. Contact each commercial insurance company to determine their rules to follow when billing for telehealth services. Billing with Place of Service Code 02 may create denials from Medicare. It is important to understand any denial received because denials affect cash flow.
Some commercial insurances may not recognize/pay for telehealth CPT codes. Regardless, providers must maintain accurate and complete documentation to support the service provided.
Credentialing may be an issue. The Distant Site provider will probably already be enrolled in his/her local MAC, however certain Medicaids and some commercial insurance companies may require that the Distant Site provider be enrolled in their plan in the same state where the Originating Site/patient is located. Credentialing takes time not only to complete the many different enrollment applications, but time for the insurance company to process the enrollment request, sometimes up to 120 days or longer. During this time the provider will either be paid at the lower out of network rate or not at all. Make sure you have your credentialing enrollments in line. You may want to assess a line of credit or other temporary funding to fund cash flow when beginning to bill for telemedicine services.
A Distant Site provider using their cell phone in their car to conduct the telehealth visit is not permitted because 1) a cell phone is not an approved communication device and 2) the provider must be at the Distant Site address reported in Block 32/electronical equivalent on the HCFA1500 form when providing the telehealth service.
Many of the instructions relayed in this article seem counter-intuitive and defy common sense. We wholeheartedly agree. However, these are the current rules that CMS and the OIG impose upon us, therefore we are obligated to bill claims correctly and according to the current regulations. While billing for telehealth may be a little more complex and complicated, it is not impossible. We at CompMed know and understand this type of billing. Please call us if we can assist you with organizing and billing for your telehealth services. Contact Angela Patterson at (423)903-6796 angela.patterson@compmedsolutions.com
REFERENCES
- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/
- https://datawarehouse.hrsa.gov/tools/analyzers/geo/Telehealth.aspx
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
- https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html
- https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 190.3.2 and 190.3.3 - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10393.pdf
- https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00004947&_adf.ctrl-state=wtsimpm10_4&_afrLoop=76552792129552#!
- https://www.novitas-solutions.com/webcenter/portal/MedicareJH/IncidentTool?_afrLoop=78862728617149#!%40%40%3F_afrLoop%3D78862728617149%26_adf.ctrl-state%3Dwtsimpm10_46
- https://www.cgsmedicare.com/partb/pubs/news/2013/0813/cope22806.html
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0441.pdf
- https://palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20B~Browse%20by%20Specialty~Non-physician%20Practitioners~8EEL5M1652?open&navmenu=Browse%5Eby%5ESpecialty%7C%7C%7C%7C
- https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00004947&_adf.ctrl-state=iwaj2u8k7_4&_afrLoop=316101275188915#!
- https://codingleader.com/blogs/compliancepop/boost-your-npp-reimbursement-with-incident-to
OTHER RESOURCES
Medicare Benefit Policy Manual Publication 100-02 Chapter 15
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-P.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8545.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf