Medicare Looking to Expand Telehealth Services – Learn the Reimbursement Rules

by | Published on Jul 4, 2017 | Medical Outsourcing

Telehealth Services
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The recent introduction of rare bipartisan legislation to expand Medicare’s telehealth services is being hailed as a development that could potentially reduce costs and improve patient health. With an estimated 17.6 million beneficiaries in 2016, physicians and medical billing service providers need to understand Medicare’s reimbursement guidelines for telehealth services.

  • Services covered: The telehealth services that CMS pays are represented by about 85 CPT and HCPCS Level II codes, These include but are not limited to:
    • Psychiatric diagnostic procedures (90791-90792)
    • Individual and group health and behavior assessment and intervention (96150-96154)
    • Select psychotherapy services (90832-90838)
    • End-stage renal disease services (90951-90952, 90954-90956)
    • Outpatient evaluation & management (E/M) services (99201-99215)
    • Advanced care planning (99497-99498)
    • Annual depression screening (G0444)
    • Telehealth Pharmacologic Management (G0459)
    • Annual Wellness Visit (G0438, G0439)
  • Patient setting: The Centers for Medicare & Medicaid Services reimburses only telemedicine services performed on a Medicare beneficiary in an approved site termed the “originating site”. According to a recent article published by Physicians Practice, two conditions need to be fulfilled:
    • CMS requires that, “beneficiaries are eligible for telehealth services, only if they are presented from an originating site located in a rural Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area.”
    • The originating site should be one approved by law such as: a physician’s office, hospital, Critical Access Hospital (CAH), Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), Skilled Nursing Facilities (SNF), Community Mental Health Centers (CMHC) or Hospital-based or CAH-based Renal Dialysis Centers (including satellites), excluding Independent Renal Dialysis Facilities.
  • Provider type: Practitioners who are Medicare-approved to bill telehealth services include: Physicians, Nurse Practitioners (NP), Physician Assistants (PA), Nurse midwives, Clinical Nurse Specialists (CNS), registered dietitians or nutrition professionals, clinical psychologists (CP) and clinical social workers (CSW).
  • Session must be interactive: CMS pays only for telehealth sessions that are interactive. The service has to be provided using an interactive audio and video telecommunications system that permits real-time communication between the provider at the distant site, and the beneficiary or patient at the originating site.
  • Use the appropriate Modifier to report service: In addition to the appropriate CPT or HCPCS code for the professional service, claims for telehealth services should be reported with modifier GT. Appending telehealth modifier GT confirms that the beneficiary was present at an eligible originating site. Telehealth modifier GQ should be used if the provider performed telehealth services “via an asynchronous telecommunications system”
  • Report Place of Service (POS) 02: Starting January 1, 2017, CMS introduced a new Place of Service (POS) 02 for telehealth services: the location where health services and health related services are provided or received, through telehealth telecommunication technology. Medicare will pay for these services using the Medicare Physician Fee Schedule (MPFS). This Telehealth POS code is not applicable to originating site facilities billing a facility fee. However, claims for Telehealth services with POS code 02, but without the GT or GQ modifier, will be denied.

Supporters of the new legislation say that it will benefit the frail, the homebound and the elderly – those who need Medicare services frequently and face the most challenges when it comes to accessing these services. Forbes reports that employers and private insurers are welcoming the trend as a way to make healthcare more convenient and help patients avoid costly and unnecessary trips to the emergency room or a physician’s office.

However, reports say that lack of understanding about the reimbursement rules for telemedicine visits is preventing many providers and delivery systems from making informed decisions about implementing this technology. In these circumstances, outsourced medical billing and coding services could be the best option for providers to successfully report telehealth services to Medicare and prevent denials. Companies providing these services have expert teams that keep track of the latest developments in the medical billing and coding scene and are well-equipped to help their clients ensure error-free claims for maximum reimbursement.


Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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