Telemedicine reimbursement through Medicare can be tricky. That’s why we dived into the reimbursement rules and put together this handy summary for you on Medicare telemedicine reimbursement rules.

The good news is – Medicare covers a wide range of telemedicine services! CMS adds additional CPT codes for telemedicine reimbursement every year. This past year, CMS added 7 new telehealth codes to expand coverage.

Here’s a quick overview of the top things you should know about Medicare’s telemedicine reimbursement rules.

Live video is covered. Store-and-forward telemedicine is only reimbursable in two states.

For the most part, Medicare only covers telemedicine services that model in-person visits. That means telemedicine that allows the provider and patient to see and chat with each other in real-time via live video. Medicare only covers store-and-forward telemedicine services in Alaska and Hawaii.
The patient must be at an eligible Originating Site.

Medicare defines the originating site as the location of the Medicare beneficiary (patient) at the time of service. The Distant site refers to the location of the healthcare provider at the time of medical service. While there are few restrictions on the distant site, the originating site has to satisfy two requirements:

1. It has to be within a Health Professional Shortage Area (HPSA).  To see if a site falls into a HPSA, visit site.

2. It has to fall into one of these categories:

§  Physicians or practitioner offices

§  Hospitals

§  Critical Access Hospitals (CAH)

§  Rural Health Clinics

§  Federally Qualified Health Centers

§  Hospital-based or CAH-based Renal Dialysis Centers

§  Skilled Nursing Facilities (SNF)

§  Community Mental Health Centers (CMHC)

So to be covered under Medicare, your patient will need to be at a facility that falls into one the categories above, and is within a Health Professional Shortage Area.

Only certain CPT and HCPCS codes are eligible for telemedicine reimbursement

Check this list for the eligible CPT/HCPCS codes. CMS updates this list on a yearly basis. The code will need to accurately describe the medical service provided via telemedicine. When billing, you’ll need to use the GT modifier

In addition to the right CPT or HCPCS code, you’ll need to use the “GT” modifier when billing to show that the service was delivered via telemedicine. If you’re a provider located in Hawaii or Alaska using a store-and-forward telemedicine solution, use the GQ modifier instead. Only certain providers can get reimbursed for telemedicine. Here’s the list of eligible providers:

Physicians
Nurse Practitioners
Physician Assistants
Nurse Midwives
Clinical nurse specialists
Clinical Psychologists
Clinical Social Workers
Registered dietitians or nutrition professionals

The originating Site can also charge a facility fee

Since the originating site is essentially hosting the telemedicine visit, Medicare allows the originating site to bill a separate facility fee. For more details on the facility fee, look up HCPCS code Q3014.

Medicare reimbursement for telemedicine at the same rate as a comparable in-person visit

Whether you’re billing a 99213 that was done in-person or via telemedicine, your billable rate should match the standard Medicare physician fee schedule ($72.81). Want to check the Medicare physician rates? Lookup Medicare reimbursement rates for any code here.

Medicare Advantage plans have much more flexibility than traditional Medicare!

All the guidelines and restrictions we’ve listed above are for billing telemedicine through traditional Medicare. Medicare Advantage plans under a commercial payer have complete flexibility to cover telemedicine however they want! This means, Advantage plans may cover telemedicine for your patient and not have any of those restrictions on what qualifies as an eligible originating site. Call the payer and ask what they’ll cover and what their telemedicine guidelines are.

The future of Medicare & Telemedicine

What’s likely to change in the coming years? It’s hard to say, but Medicare’s coverage of telemedicine seems to expand every year.

On July 7th, 2015, House representatives introduced the Medicare Telehealth Parity Act of 2015. If passed, the bill will expand what telemedicine services Medicare will cover and get rid of many limitations (like the requirements for what qualifies as an “originating site“). Legislation like this one could have a huge impact on coverage for remote patient monitoring and other telemedicine services delivered to the patient in their own home.