Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that follow-up inpatient telehealth consultations are furnished to beneficiaries in hospitals or 
skilled nursing facility (SNFs) via telehealth to follow up on an initial consultation, or subsequent consultative 
visits requested by the attending physician. The initial inpatient consultation may have been provided in-person 
or via telehealth. Follow-up inpatient telehealth consultations include monitoring progress, recommending 
management modifications, or advising on a new plan of care in response to changes in the patients status or 
no changes on the consulted health issue. Counseling and coordination of care with other providers or agencies 
is included as well, consistent with the nature of the problem(s) and the patients needs.  
 
The physician or practitioner who furnishes the inpatient follow-up consultation via telehealth cannot be the 
physician of record or the attending physician, and the follow-up inpatient consultation would be distinct from 
the follow-up care provided by the physician of record or the attending physician. If a physician consultant has 
initiated treatment at an initial consultation and participates thereafter in the patients ongoing care 
management, such care would not be included in the definition of a follow-up inpatient consultation. Payment 
for follow-up inpatient telehealth consultations includes all consultation related services furnished before, 
during, and after communicating with the patient via telehealth. Pre-service activities would include, but would 
not be limited to, reviewing patient data (for example, diagnostic and imaging studies, interim lab work) and 
communicating with other professionals or family members. Intra-service activities must include at least two of 
the three key elements described below for each procedure code. Post-service activities would include, but 
would not be limited to, completing medical records or other documentation and communicating results of the 
consultation and further care plans to other health care professionals. No additional evaluation and management service could be billed for work related to a follow-up inpatient telehealth consultation. Follow-up inpatient 
telehealth consultations could be provided at various levels of complexity: 
 
 Practitioners taking an expanded focused interval history, conducting an expanded problem focused 
examination, and engaging in medical decision making that is of moderate complexity, would bill an 
intermediate service using HCPCS code G0407(Follow-up inpatient telehealth consultation, intermediate, 
physicians typically spend 25 minutes communicating with the patient via telehealth). 
 
Although follow-up inpatient telehealth consultations are specific to telehealth, these services must be billed 
with point of service (POS) 02 to identify the telehealth technology used to provide the service.  
 
You can find these rules in the Medicare Claims Processing Manual Chapter 12 section 190.3.3  Follow-Up 
Inpatient Telehealth Consultations Defined. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.