Telemedicine Guide: Medicare Coverage and The Medical Billing Process

By: Gilbert Johnston

 

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:

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● 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:

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● 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.

 
 

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