Medicare Compliance & Reimbursement

Hint: Location factors into Medicare’s conditions for payment.

As Medicare and other payers continue to expand their telehealth policies, you may have more opportunities than ever before to bill your services using this unique format.

Unfortunately, even though telehealth does offer a more efficient means of caring for patients, it’s not as easy as Skyping a patient and billing out the visit. In reality, there are myriad regulations you must follow to collect for telehealth services — and not all patients actually qualify for them, said reps from Part B payer NGS Medicare in the Medicare Administrative Contractor’s (MAC) webinar, “Medicare Telehealth Services.”

Read on for tips that NGS staffers shared during the call that can help you maximize your telehealth claims.

Discover What Telehealth Actually Entails

“Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunication system and for eligible telehealth services, the use of a telecommunication system substitutes for an in-person encounter,” said NGS’ Gail O’Leary.

Note, however, that there are differences between telehealth and telemedicine, even though people use those two terms interchangeably to mean the same thing, O’Leary said.

“Telehealth is real-time communication between the physician and the patient using an interactive telecommunication system,” she noted. “The patient must be present and participating during the interaction.” Telemedicine, on the other hand, uses what’s referred to as a “store and forward technology,” which can allow a physician at a distant site to review a patient’s situation — without any live real time interaction with the patient.

Understand the Conditions for Payment

For telehealth to be billed to Medicare, the service must meet certain conditions. For starters, the service must be on the list of covered Medicare telehealth services and meet all these requirements:

A.  Service must be furnished via interactive telecom system.
B.  Service must be furnished by physician or another authorized practitioner.
C.  Service must be furnished to an eligible telehealth individual.
D.  The individual receiving the service must be located in a telehealth originating site.

The originating site is the location of the eligible Medicare beneficiary at the time the service is furnished via that telecom system, O’Leary said. Medicare beneficiaries are eligible for telehealth services only if presented from an originating site located in a health professional shortage area that is either outside of a metropolitan statistical area or within a rural census tract of a metro statistical area as determined by the office of rural health policy. They can also be in a county not included in a metropolitan statistical area.

If this all sounds confusing, CMS has simplified the process of finding out if your patient is eligible for telehealth services. You can visit  data.hrsa.gov and enter the address of where the beneficiary will be located to determine whether the patient will qualify. “Each calendar year, the geographic eligibility is determined, and that decision lasts a full calendar year, so definitely make sure you check in January the originating site because it may have been eligible in the current year but the next year it may not be,” O’Leary said.

Most Telehealth Can’t Be Provided in Patients’ Homes

Although you may be picturing the majority of telehealth services taking place in a patient’s home, the reality is that this is rare. Originating sites covered by Medicare include places such as physicians’ offices, hospitals, rural health clinics, federally qualified health centers, and other locations.

The patient’s home is only an acceptable originating site in very limited circumstances, such as end-stage renal disease (ESRD) patients being evaluated for the ESRD. Otherwise, Medicare’s telehealth services cannot be performed from home.

Equipment tip: All interactive communication systems used during telehealth services must meet state and federal requirements for safety and priorities — so systems like Skype and Zoom are not allowed unless they offer some additional safeguards, O’Leary said. “You’ll want to research HIPAA regulations to find out what’s appropriate,” she said.

Register Physician Location Requirements, Too

Now that you know where the patients can be to qualify for telehealth services, get to know where the practitioners can be at the time of the service. “Subject to state law, allowed Medicare practitioners at the distant site include physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, CRNAs, registered dietitians or nutritional professionals, clinical psychol­ogists, and clinical social workers,” O’Leary said.

The distant site is the location where the practitioner is located when the service is provided using an interactive audio and video telecommunication system. But keep in mind that the distant site location must be in the provider’s enrollment file. “If the physician lists their home as an office location for telehealth services, then the home must be listed on their Medicare enrollment file,” O’Leary said. “So, a hotel room, a personal car, an airport, etc., are not considered valid locations,” she said.

In addition, the provider must be licensed and enrolled in the state where the services are provided. If the patient is in Vermont and the provider in New York, the provider must be licensed and enrolled with the MAC for New York, which is where they are working from, O’Leary added.

Payment tip: The payment amount for the professional services provided via telehealth is equal to the current fee schedule amount for the service, as if they saw the patient in their office. You bill using the appropriate CPT^® or HCPCS code as you normally do. For the place of service, you’ll put “02,” which indicates it was rendered via telehealth.

The site where the patient is located will bill Medicare using HCPCS code Q3014 (Telehealth originating site facility fee) with place of service 11 (Office), which is the only payable place of service for this code. This will allow the location where the patient is to collect for the service.

And if you’re wondering which fee schedule is used if the patient and the provider are in different states, look to the provider, said NGS’ Lori Langevin during the call. “Medicare will utilize the fee schedule where the distant site provider is located and the claim will be sent to the MAC where the distant site provider is located,” she said. So, if the patient is in Florida and the physician is in Arizona, you’ll bill the Arizona MAC.