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Will Medicare pay for Telehealth services?


Medicare will pay for Telephonic services under following criteria

1. If the beneficiaries are presented from an originating site located either in a rural HPSA (health professional shortage areas) or in a county outside of an MSA (metropolitan statistical area).

2. Entities participating in a Federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location. Such entities are not required to be in a rural HPSA or non-MSA.

An originating site is the location of an eligible Medicare beneficiary at the time the service being furnished via telecommunications system occurs. Originating sites authorized by law are listed below.

The office of a physician or practitioner;

A hospital;

A critical access hospital (CAH);

A rural health clinic (RHC);

A federally qualified health center (FQHC);

A hospital-based or critical access hospital-based renal dialysis center (including satellites)(Effective January 1, 2009.);

A skilled nursing facility (SNF) (Effective January 1, 2009.);

A community mental health center (CMHC) (Effective January 1, 2009.).

NOTE: Independent renal dialysis facilities are not eligible originating sites.

List of Medicare Telehealth Services

The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services. These services are listed below.

Consultations (Effective October 1, 2001- December 31, 2009)

Initial inpatient telehealth consultations (Effective January 1, 2010)

Follow-up inpatient telehealth consultations (Effective January 1, 2009)

Office or other outpatient visits

Subsequent hospital care services (with the limitation of one telehealth visit every 3 days) (Effective January 1, 2011)

Subsequent nursing facility care services (with the limitation of one telehealth visit every 30 days) (Effective January 1, 2011)

Individual psychotherapy

Pharmacologic management

Psychiatric diagnostic interview examination (Effective March 1, 2003)

End stage renal disease related services (Effective January 1, 2005)

Individual and group medical nutrition therapy (Individual effective January 1, 2006; group effective January 1, 2011)

Neurobehavioral status exam (Effective January 1, 2008)

Individual and group health and behavior assessment and intervention (Individual effective January 1, 2010; group effective January 1, 2011)

Individual and group kidney disease education (KDE) services (Effective January 1, 2011)

Individual and group diabetes self-management training (DSMT) services (with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training) (Effective January 1, 2011)

CPT codes to report Telehealth services

99441 - Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

99442 - Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

99443 - Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

Please note:

Do not report 99441-99443 when using 99339-99340, 99374-99380 for the same call(s)

Do not report 99441-99443 for anticoagulation management when reporting 99363-99364

Telehealth Bundle edits

Medicare does not pay separately for physician or nonphysician telephone conversations with patients (or their families), but that these conversations may be taken into account when the physician is determining which level of evaluation and management (E/M) code to assign on the next claim for a face-to-face E/M visit. Codes meeting this criteria are bundled under the Medicare Physician Fee Schedule (MPFS). Since the status indicator assigned to Telehealth service CPT codes are ‘N’ (Non-covered service) the physician or nonphysician practitioner may bill the beneficiary directly for these services as defined in the CPT, at his/her established rate.

Advance Beneficiary Notice

An ABN is not required when such claims are billed to patients but providers may issue the voluntary “Notice of Exclusion from Medicare Benefits" (NEMBs). NEMBs alert Medicare beneficiaries in advance that Medicare does not cover certain item(s) and service(s) because the item or service do not meet the definition of a benefit, or because the item or service is specifically excluded by law. Hence by this way the beneficiaries were kept informed as he / she is responsible for the payment.

Provider alert

The Telehealth services are billable to the beneficiaries only if the services are not related to an Evaluation and Management visit and must meet every part of the CPT definition and must be documented in the patients Medical records.

Patient alert

The beneficiary is responsible for any unmet deductible amount or coinsurance.

References:

https://www.cms.gov/manuals/Downloads/bp102c15.pdf


https://www.cms.gov/transmittals/downloads/R1423CP.pdf

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