(Medicare Claims Processing Manual)

 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.   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 i nitial inpatient telehealth consultations 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)  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 pe rform an assessment of whether the dialysis is working effectively and whether the patient is tolerating the procedure well (physiologically and psychologically).  During this assessment, the physician or practitioner at the distant site must be able to de termine whether alteration in any aspect of the beneficiarys prescription is indicated, due to such changes as the estimate of the patients dry weight.   190.3.5  Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services  (Rev. 3476, Issued: 03- 11-16, Effective: 01 -01-15, Effective: 04 -11-16)  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 telehea lth consultations using the applicable HCPCS G -codes.   Similarly, subsequent nursing facility care services are limited to one telehealth visit every 30 days.  Furthermore, subsequent nursing facility care services reported for a Federally -mandated periodic visit under 42 CFR 483.40(c) may not be furnished thr ough telehealth.  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.   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.