Telehealth Reimbursement & Medicare

It’s not easy to make sense of telemedicine reimbursement through Medicare. Comiere team has done the work for you, however so you don’t have to sift through the layers of rules to understand medicare reimbursement for telemedicine. This is what you need to know about Medicare reimbursement and telemedicine:

Your Patient Must Be at an Eligible Originating Site

So what is an eligible originating site? According to Medicare, the Originating Site is where the Medicare beneficiary (that would be the patient) is located when they receive the telehealth service, whereas the Distant Site is where the healthcare provider is located at that time.

The Originating Site must be in:

  • A county outside of a Metropolitan Statistical Area (MSA). The Census Bureau decides on MSAs.
  • A rural Health Professional Shortage Area (HPSA) located in a rural census tract. The Health Resources and Services Administration (HRSA) decides on HPSAs. Check HRSA’s Medicare Telehealth Payment Eligibility Analyzer to see if your originating site is eligible for Medicare telehealth payment.

These are the legally authorized Originating Sites:

  • The offices of physicians or practitioners
  • Hospitals
  • Critical Access Hospitals (CAH)
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Hospital-based or CAH-based Renal Dialysis Centers (Independent Renal Dialysis Facilities are not eligible)
  • Skilled Nursing Facilities
  • Community Mental Health Centers

Are You an Eligible Distant Site?

To be reimbursed for eligible telehealth services (subject to state law), you must fall into one of the following categories:

    • Physician
    • Nurse practitioners
    • Physician assistants
    • Nurse-midwives
    • Clinical nurse specialists
    • Certified registered nurse anesthetists
    • Clinical psychologists (CPs) and clinical social workers (CSWs)
      Note: Medicare does not reimburse CPs and CSWs for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. Neither does it reimburse these practitioners for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.
    • Registered dietitians or nutrition professionals

Eligible Telehealth Services

Eligible telehealth services must use an interactive audio and video telecommunications system that facilitates live communication between the patient and the provider.

Asynchronous so-called store-and-forward telemedicine is covered only in Alaska or Hawaii.

Not all CPT and HCPCS Codes Are Eligible for Telemedicine Reimbursement

Find out which CPT/HCPS Codes are eligible. Centers for Medicare & Medicaid Services (CMS) updates this list annually. The application of the codes is strict, so ensure your telemedicine service is accurately described.

Billing & Payment for Telehealth Services

You will also need the telehealth modifier GT, “via interactive audio and video telecommunications systems” (e.g. 99201 GT). For store-and-forward telemedicine demonstration programs in Alaska or Hawaii, use the modifier GQ (e.g. 99201 GQ).

For services delivered after January 1, 2017, submit claims for telehealth services using Place of Service (POS) 02: Telehealth: The location where the telehealth services are delivered.

The Originating Site Can Also Charge A Facility Fee

Originating sites are eligible for an originating site facility fee for telehealth services. See HCPCS code Q3014.

Medicare Reimbursement Rates for Telemedicine and Comparable In-Person Visits Are the Same

Your billable rate for both in-person and telemedicine consultations should match the standard Medicare physician fee schedule ($72.81). Check the Medicare reimbursement rates here.

Greater Flexibility with Medicare Advantage Plans

This guide to Medicare reimbursement for telemedicine applies to traditional Medicare. Medicare Advantage plans provided through commercial payers may not have the same restrictions on what qualifies as an eligible originating site. Contact the payer to find out what they will cover and what their policy on telemedicine is.