(Medicare Claims Processing Manual)

 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)  The ESRD -related services included in the monthly capitation payment (MCP) with 2 or 3 visits per month and ESRD -related services with 4 or more visits per month may be paid as Medicare telehealth services.  However, at least 1 visit must be furnished face- to-face hands on to examine the vascular access site by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.  An interactive audio and video telecommunications system may be used for providing additional visits required under the 2 -to-3 visit MCP and the 4- or-more visit MCP.  The medical record must indicate that at least one of the visits was furnished face -to-face hands on by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.  The MCP physician, for example, the physician or practitioner who is responsible for the complete monthly assessment of the patient and establishes the patients plan of care, may use other physicians and practitioners to furnish ESRD -related visits throug h an interactive audio and video telecommunications system.  The non- MCP physician or practitioner must have a relationship with the billing physician or practitioner such as a partner, employees of the same group practice or an employee of the MCP physici an, for example, the non MCP physician or practitioner is either a W -2 employee or 1099 independent contractor.  However, the physician or practitioner who is responsible for the complete monthly assessment and establishes the ESRD beneficiarys plan of care should bill for the MCP in any given month.  Clinical Criteria   The visit, including a clinical examination of the vascular access site, must be conducted face-to-face hands on by a physician, clinical nurse specialist, nurse practitioner or physicians assistant.  For additional visits, the physician or practitioner  at the distant site is required, at a minimum, to use an interactive audio and video telecommunications system that allows the physician or practitioner to provide medical management services for a maintenance dialysis beneficiary.  For example, an ESRD -related visit conducted via telecommunications system must permit the physician or practitioner at the distant site to perform an assessment of whether the dialysis is working effectively and whether the patient is tolerating the procedure well (physiologic ally and psychologically).  During this assessment, the physician or practitioner at the distant site must be able to determine whether alteration in any aspect of the beneficiarys prescription is indicated, due to such changes as the estimate of the pati ents dry weight.  190.3.5  Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services  (Rev. 10716; Issued: 04- 06-21; Effective: 01 -01-21; Implementation: 07 -06-21)  Subsequent hospital care services are limited to one telehealth visit every 3 days.  The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow -up inpatient telehealth consultations using the applicable HCPCS G -codes.   Similarly, 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.  Furt hermore, subsequent nursing facility care services reported for a Federally- mandated periodic visit under 42 CFR 483.40(c) may not be furnished through telehealth.  The frequency limit of the benefit is not intended to apply to consulting physicians or pra ctitioners, who should continue to report initial or follow -up inpatient telehealth consultations using the applicable HCPCS G -codes.   Inpatient telehealth consultations are furnished to beneficiaries in hospitals or skilled nursing facilities via telehealth at the request of the physician of record, the attending physician, or another appropriate source.  The physician or practitioner wh o furnishes the initial inpatient consultation via telehealth cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telehealth consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner.  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.  Initial and foll ow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3 of this chapter.   190.3.6  Payment for Diabetes Self -Management Training (DSMT) as a Telehealth Service  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)  Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefits initial training must be furnished in -person to allow for effective injection training.  Because injection training is not always clinically indicated, we are revis ing this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow -up training to be furnished via telehealth in those cases when injecti on training is not applicable.  The in-person injection training , when provided,  may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the GT or GQ modifier with HCPCS code G0108 (Diabetes outpatient self- management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests  that the beneficiary has received or will rec eive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar years 2 hours of follow -up training .   As specified in 42 CFR 410.141(e) and stated in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 300.2, individual and group  DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applic able.  190.3.7  Payment for Telehealth for Individuals with Acute Stroke  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)  Section 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Act by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke (acute stroke telehealth services), as determined by th e Secretary.  Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke telehealth services can be furnished.  Section 1834(m)(6)(B) of the Act specifies that a cute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determined appropriate by the Secretary, in addition to the current eligible telehealth origina ting sites.  Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the usual telehealth restrictions under section 1834(m)(4)(C) of the Act.  These are identifie d in Section 190.1 of this chapter.   Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informat  HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for  purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:    Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals,   CAH method II (revenue codes 096X, 097X, or 098X); or    Telehealth originating site facility fee, billed with HCPCS code Q3014.    190.4 - Conditions of Payment  (Rev. 1, 10- 01-03)  1. Technology  For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real -time communication between the distant site physician or practitioner and the Medicare beneficiary.  As a condition of payment, the patient must be present and participating in the telehealth visit.   2. Exception to the interactive telecommunications requirement   In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, Medicare payment is permitted for telemedicine when asynchronous store and forward technology in single or multimedia formats is used as a substitute for an interactive telecommunications system.   The originating site and distant site practitioner must be included within the definition of the demonstration program.   3. Store and forward defined   For purposes of this instruction, store and forward means the asynchronous transmission of medical information to be reviewed at a later time by physician or practitioner at the distant site.  A patients medical information may include, but not limited to, video clips, still images, x -rays, MRIs, EKGs and EEGs, laboratory results, audio clips, and text.  The physician or practitioner at the distant site reviews the case without the patient being present.  Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real -time.   NOTE:  Asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail).  Photographs must be specific to the patients condition and adequate for rendering or confirming a diagnosis and or treatment plan.  Dermatological photographs, e.g., a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this instruction.   4. Telepresenters   A medical professional is not required to present the beneficiary to physician or practitioner at the distant site unless medically necessary.  The decision of medical necessity will be made by the physician or practitioner located at the distant site.   190.5 - Originating Site Facility Fee Payment Methodology  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)   1. 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.  For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.    2. Facility fee for originating site    The originating site facility fee is a separately billable Part B payment.  The contractor pays it outside of other payment methodologies.  This fee is subject to post payment verification.    For telehealth services furnished from October 1, 2001, through December 31, 2002, the originating site facility fee was the lesser of $20 or the actual charge.  For services furnished on or after January 1 of each subsequent year, the originating site fac ility fee is updated by the Medicare Economic Index.  The updated fee is included in the Medicare Physician Fee Schedule (MPFS) Final Rule, which is published by November 1 prior to the start of the calendar year for which it is effective.  The updated fee for each calendar year is also issued annually in a Recurring Update Notification instruction for January of each year.   3. Payment amount: