(Medicare Claims Processing Manual)

1. Beneficiaries eligible 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 an MSA as defined by 1886(d)(2)(D) (go to the link and select the applicable title) of the Act.   Effective January 1, 2014, rural HPSAs include HPSAs located outside of a county outside of an MSA as well as those located in rural census tracts as determined by the Office of Rural Health Policy.  Also effective January 1, 2014, geographic eligibility for an originating site is established for each calendar year based upon the status of the area as of December 31st of the prior calendar year.   2. 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.   3. Originating site defined   The term originating site means 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 (inpatient or outpatient); A critical access hospital (CAH);  A rural health clinic (RHC);  A federally qualified health center (FQHC); A hospital- based or critical access hospital -based renal dialysis center (including satellites) (effective January 1, 2009);  A skilled nursing facility (SNF) (effective January 1, 2009); and A community mental health center (CMHC) (effective January 1, 2009).  NOTE:   Independent renal dialysis facilities are not eligible originating sites.   For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.   190.3 - List of Medicare Telehealth Services  (Rev. 3476, Issued: 03 -11-16, Effective: 01-01- 15, Effective: 04 -11-16)  The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services.  The various services and corresponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website at www.cms.gov/Medicare/Medicare-General -Information/Telehealth/   NOTE:  Beginning January 1, 2010, CMS eliminated the use of all consultation codes, except for inpatient telehealth consultation G -codes.  CMS no longer recognizes office/outpatient or inpatient consultation CPT codes for payment of office/outpatient or inpatient visits.  Instead, physicians and practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate hospital or nursing facility care code, as appropriate to the particular patient, for all office/outpatient or inpatient visits.   190.3.1 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits (Rev. 10716; Issued: 04-06- 21; Effective: 01 -01-21; Implementation: 07-06-21)  A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patients problem(s).  It can involve an opinion, advice, recommendation, suggestion, direction, or counsel from a physician or qualified nonphysician practitioner (NPP) at the request of another physician or appropriate source.  Section 1834(m) of the Social Security Act includes professional consultations in the definition of telehealth services. Inpatient or emergency department consultations furnished via telehealth can facilitate the provision of certain services and/or medical expertise that might not otherwise be available to a patient located at an originating site.   The use of a telecommunications system may substitute for an in-person encounter for emergency department or initial and follow-up inpatient consultations.  Medicare A/B MACs (B) pay for reasonable and medically necessary inpatient or emergency department telehealth consultation services furnished to beneficiaries in hospitals or SNFs when all of the following criteria for the use of a consultation code are met:   An inpatient or emergency department consultation service is distinguished from other inpatient or emergency department evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.  The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in t he State in which he/she practices;    A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patients medical record and included in the requesting physician or qualified NPPs plan of care in the patients medical record; and    After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.   The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professionals knowledge.   Unlike inpatient or emergency department telehealth consultations, the majority of subsequent inpatient hospital, emergency department and nursing facility care services require in -person visits to facilitate the comprehensive, coordinated, and personal care that medically volatile, acutely ill p atients require on an ongoing basis.  Subsequent hospital care services are limited to one telehealth visit every 3 days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days.  Beginning with dates of service on and after January 1, 2021, the limit for nursing facility care services is one telehealth visit every 14 days.   190.3.2 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)  Emergency department or initial inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practi tioner who furnishes the emergency department or initial inpatient consultation via telehealth cannot be the physician of record or the attending physician, and the emergency department or initial inpatient telehealth consultation would be distinct from the care provided by the physician of record or the attending physician. 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. Emergency department or initial inpatient telehealth consulta tions are subject to the criteria for emergency department or initial inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.  Payment for emergency department or initial 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 labwork) and communicating with other professionals or family members. Intra -service activities must include the three key elements described below for each proced ure 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 E/M servi ce could be billed for work related to an emergency department or initial inpatient telehealth consultation.  Emergency department or initial inpatient telehealth consultations could be provided at various levels of complexity:   Practitioners taking a problem focused history, conducting a problem focused examination, and engaging in medical decision making that is straightforward, would bill HCPCS code G0425 (Telehealth consultation, emergency department or initial inpatient, ty pically 30 minutes communicating with the patient via telehealth).    Practitioners taking a detailed history, conducting a detailed examination, and engaging in medical decision making that is of moderate complexity, would bill HCPCS code G0426 (Telehealth consultation, emergency department or initial inpatient, typically  50 minutes communicating with the patient via telehealth).    Practitioners taking a comprehensive history, conducting a comprehensive examination, and engaging in medical decision making that is of high complexity, would bill HCPCS code G0427 (Telehealth consultation, emergency department or initial inpatient, typ ically 70 minutes or more communicating with the patient via telehealth).   Although emergency department or initial inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.   190.3.3 - Follow- Up Inpatient Telehealth Consultations Defined  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)  Follow -up inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth to follow up on an initial consultation, or subsequent consultative visits requested by the attending physician. The initial inpatient consultat ion 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. Follow -up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.  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, review ing patient data (for example, diagnostic and imaging studies, interim labwork) 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 co de. 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 a problem focused interval history, conducting a problem focused examination, and engaging in medical decision making that is straightforward or of low complexity, would bill a limited service, using HCPCS code G0406 (Follow -up inpat ient telehealth consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth).    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 inp atient telehealth consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth).    Practitioners taking a detailed interval history, conducting a detailed examination, and engaging in medical decision making that is of high complexity, would bill a complex service, using HCPCS code G0408 (Follow -up inpatient telehealth consultation, co mplex, physicians typically spend 35 minutes or more communicating with the patient via telehealth).   Although follow -up inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.   190.3.4  Payment for ESRD-Related Services as a Telehealth Service  (Rev. 3476, Issued: 03- 11-16, Effective: 01 -01-15, Effective: 04 -11-16)