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Telemedicine Guide: Medicare Coverage and The Medical Billing Process

By: Gilbert Johnston

June 27, 2019

Telehealth doctor providing services
 

Every year, telemedicine grows in popularity. More than half of U.S. hospitals already have some sort of telemedicine program, and countless more hospitals are currently developing programs. By 2022, analysts believe that the telemedicine industry will be worth as much as $70 billion.

To accommodate this growing healthcare trend, commercial health insurers are increasingly adopting new telemedicine coverage plans, as well as expanding existing plans. For physicians looking to grow their practices, now is the time to jump into Telehealth, as coverage has expanded to the point where it makes fiscal sense. In fact, most mid-range insurance plans now cover telemedicine to some extent.

However, before jumping into this new form of care, it’s important to understand how the reimbursement process works. As with most new forms of medical treatment, The Centers for Medicare and Medicaid Services (CMS) has set the initial coverage standards through Medicare. The commercial carriers have followed suit, with similar coverage rules.

Below, we go through Medicare’s Telemedicine rules and processes, including what makes a patient eligible, what makes a provider eligible, and what forms of treatment are covered. We also explain how to bill for Telehealth services and provide the full list of accepted CPT codes.

 

1) Covered Patients and Facilities

For telemedicine, the CMS reserves coverage to patients for which telemedicine may be the most convenient form of care. Put more simply, patients can utilize telemedicine when they don’t have easy access to a specific form of care.

The CMS refers to an area lacking convenient coverage as a Health Professional Shortage Area (or HPSA). An agency called the Health Resources and Services Administration (HRSA) is tasked with determining these areas. Official HPSA status is granted annually. Locations are evaluated (and reevaluated) at the end of each calendar year.

HPSAs are broken up by specialty. Separate shortage areas exist for Primary Care, Dental Health, and Mental Health. So if a patient receives telemedicine treatment for a specific specialty, at a location within a correlating HPSA, he/she may be covered by Medicare.

Note: If a location is not in an HPSA, but the location’s county is outside a Metropolitan Statistical Area (MSA), as determined by the Census Bureau, the patient may still be covered for telemedicine services.

Approved HPSA locations (or facilities) can include:


● Physician and practitioner offices
● Hospitals
● Critical Access Hospitals (CAHs)
● Rural Health Clinics
● Federally Qualified Health Centers
● Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
● Skilled Nursing Facilities (SNFs)
● Community Mental Health Centers (CMHCs)
● Renal Dialysis Facilities
● Homes of beneficiaries with End-Stage Renal Disease (ESRD) getting home dialysis
● Mobile Stroke Units

 

2) Approved Providers

Simply being located in an HPSA does not mean a patient is covered to receive any and all types of medical treatment via telecommunications. Coverage is limited to specific diagnoses and forms of treatment.

Furthermore, not all medical providers are permitted to provide care. Coverage is limited to:


● Physicians
● Nurse practitioners (NPs)
● Physician assistants (PAs)
● Nurse-midwives
● Clinical nurse specialists (CNSs)
● Certified registered nurse anesthetists
● Clinical psychologists (CPs) and clinical social workers (CSWs)
CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.
● Registered dietitians or nutrition professional

 

3) Procedural Guidelines

There are also specific guidelines that define telemedicine.

Patents and their providers must communicate via an interactive audio and video telecommunications system, that permits real-time communication.

Non-real-time communication (i.e. transmitting medical information to a physician or practitioner who reviews it later) is permitted only in Alaska or Hawaii via Federal telemedicine demonstration programs.

 

4) Covered Treatment (CPT Codes)

Medicare covers around 50 Telehealth procedures, which totals to around 70 CPT codes. To bill the codes, providers simply add modifiers to the normal, respective CPT codes. For most procedures, the modifier is GT. For non-real-time communication (in Hawaii or Alaska) the modifier is GQ.

Scroll down to view the full list of covered Telemedicine CPT Codes.
Or check out our Telehealth facility lookup tool, if you’re curious about where Telehealth services are covered.

 
 

Wondering whether a facility is approved for Telehealth services?

Check out our Telemedicine Facility (HPSA) Lookup Tool:

HPSA Lookup Tool

Full List of Medicare-Approved CPT Codes for Telemedicine

G0425–G0427

Telehealth consultations, emergency department or initial inpatient

G0406–G0408

Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs

99201–99215

Office or other outpatient visits

99231–99233

Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days

99307–99310

Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days

G0420–G0421

Individual and group kidney disease education services

G0108–G0109

Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction furnished in the initial year training period to ensure effective injection training

96150–96154

Individual and group health and behavior assessment and intervention

90832–90838

Individual psychotherapy

G0459

Telehealth Pharmacologic Management

90791–90792

Psychiatric diagnostic interview examination

90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961

End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment

90963

End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90964

End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 2–11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90965

End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 12–19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90966

End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older

90967

End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age

90968

End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 2–11 years of age

90969

End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 12–19 years of age

90970

End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 20 years of age and older

G0270, 97802–97804

Individual and group medical nutrition therapy

96116

Neurobehavioral status examination

G0436, G0437, 99406, 99407

Smoking cessation services

G0396, G0397

Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services

G0442

Annual alcohol misuse screening, 15 minutes

G0443

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

G0444

Annual depression screening, 15 minutes

G0445

High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes

G0446

Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

G0447

Face-to-face behavioral counseling for obesity, 15 minutes

99495

Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)

99496

Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

99497

Advance Care Planning, 30 minutes

99498

Advance Care Planning, additional 30 minutes

90845

Psychoanalysis

90846

Family psychotherapy (without the patient present)

90847

Family psychotherapy (conjoint psychotherapy) (with patient present)

99354

Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour

99355

Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes

99356

Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service)

99357

Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service)

G0438

Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit

G0439

Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit

G0508

Telehealth Consultation, Critical Care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth

G0509

Telehealth Consultation, Critical Care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

G0296

Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making

90785

Interactive Complexity Psychiatry Services and Procedures

96160, 96161

Health Risk Assessment

G0506

Comprehensive assessment of and care planning for patients requiring chronic care management

90839, 90840

Psychotherapy for crisis

G0513, G0514

Prolonged preventive services

About the Author: Gilbert Johnston

Gilbert has nearly 15 years of experience in the medical billing industry. He's a Certified Healthcare Business Management Executive (CHBME), as recognized by the Healthcare Business Management Association (HBMA), the leading organization for Revenue Cycle Management professionals. He also has extensive knowledge in matters of compliance, including HIPAA and HITECH, having served as the Compliance Manager at Valletta for years.

Full Bio


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