Telemedicine Billing and Reimbursement

The opportunities for providers who want to provide telemedicine continue to expand in all sectors of the healthcare market. Even the VA, long a symbol of a fossilized, bureaucratic healthcare entity, has begun to embrace this technology. Though most are familiar with what telemedicine is, many still have questions surrounding the billing and reimbursement of these services.

First, know what type of telemedicine you are billing. Interactive (synchronous) telemedicine is when the provider and patient are connected in real time via telecommunications equipment (e.g., telephone, video conferencing). Store-and-forward (asynchronous) telemedicine refers to the sharing of patient information across locations and physicians. This type of telemedicine is only reimbursable in very limited situations. Remote patient monitoring is another form of telemedicine, where though the use of medical devices, data about conditions such as blood sugar, blood pressure, and more are collected and sent to physicians or caregivers who are not physically with the patient.

The most important thing to note about billing telemedicine is that things are constantly changing. It is your responsibility to stay aware of any changes in policies. Keep the American Telemedicine Association (ATA) website bookmarked in your browser and sign-up for the Find-A-Code newsletter to stay on top of industry changes.

Clinical Guidelines

You should treat telemedicine encounters as you would any in-person encounter. Proper documentation habits, ethical guidelines, HIPAA standards, etc. should all be followed. Some healthcare providers have stated that is it more difficult to assess some patient information due to the inability to either feel or see things which are more easily identified in a face-to-face encounter. Documentation will need to compensate for these situations. Attend telehealth-focused training where possible to learn compensatory measures for these shortcomings.

Billing Medicare

As of January 1, 2018, Medicare claims will no longer use the GT modifier to signify an interactive telemedicine service. Instead, telemedicine services will be indicated using the Place of Service (POS) code 02. The GQ modifier, for asynchronous telemedicine (only reimbursable in Alaska and Hawaii), should continue to be used when appropriate.

You need to know what originating and distant sites are. Originating sites are where the Medicare beneficiary receives services. The distant site is where the provider offering the service is located. Medicare will only reimburse for telemedicine services when the originating site is in a county outside a Metropolitan Statistical Area (MSA) or a Health Professional Shortage Area (HPSA). Go here to see if the site is in an HPSA.

Authorized originating sites include:

• The offices of physicians or practitioners

• Hospitals

• Critical Access Hospitals (CAHs)

  • Note that for distant site services billed under Critical Access Hospital (CAH) method II on institutional claims, the GT modifier will still be required. 

• Rural Health Clinics

• Federally Qualified Health Centers

• Hospital-based of CAH-based Renal Dialysis Centers (including satellites)

• Skilled Nursing Facilities (SNFs)

• Community Mental Health Centers (CMHCs)

Note: Independent Renal Dialysis Facilities are not eligible originating sites.

Medicare reimburses for telehealth services at the same rate as the equivalent in-person service. They also reimburse the originating site for a “facility fee,” which covers the cost of hosting the telemedicine visit. Use HCPCS code Q3014 “Telehealth originating site facility fee” for this purpose.

Appendix D in a Reimbursement Guide contains the list of CMS-approved telehealth codes. You can also see the list here.

Billing Medicaid

Because Medicaid is state-specific, use the tool located at the here to find out how to bill and what you can bill. Most states reimburse for synchronous telemedicine and a number also reimburse for store-and-forward telemedicine and remote patient monitoring.

Billing Commercial Payers

As of January 1, 2017, commercial payer claims typically require the use of modifier 95 for telehealth services. The insurance giants Aetna, BCBS, Cigna, Humana, and United Healthcare all cover telemedicine to some degree. For any questions on billing telemedicine services to private payers, or to see exactly what services are reimbursed under different plans from these entities, contact the provider relations department or check the payer's website for policies or coverage information.

A growing number of states require private payers to reimburse telemedicine at the same rate as the equivalent in-person service. Contact the payer to find out reimbursement rates.

Appendix D in a Reimbursement Guide contains the list of AMA-selected telehealth codes. You can also see the list in Appendix P in a CPT codebook.

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