Telemedicine Reimbursement Guidelines
Medicare
Although there are still many restrictions on how a service is provided, Medicare has expanded the list of reimbursable telemedicine services. Medicare will reimburse for telehealth services offered by a healthcare provider at a distant site to a Medicare beneficiary (the patient) at an “originating site.” In order to qualify, the originating site must be in an HPSA (Health Professional Shortage Area).The types of originating sites are listed below.
Additionally, in order to be eligible for Medicare reimbursement, a patient must reside in an HSPA. The patient must also be receiving virtual care at one of the clinical settings mentioned above. Once again, that site must also be located within a HPSA.
Medicare will pay the originating site a facility fee in addition to the reimbursement for the telemedicine service. As an example, if you’re a primary care physician with a patient in your office and you do a telemedicine visit to consult a provider in another location, you could bill for two separate things – the telemedicine service and a facility fee for using your practice to “host” the patient visit.
According to CMS, the following providers are eligible to be reimbursed for telemedicine:
- Physicians
- Nurse Practitioners
- Physician Assistants
- Nurse Midwives
- Clinical Nurse Specialists
- Clinical Psychologists
- Clinical Social Workers
- Registered Dietitians or Nutrition Professionals
It is important to note that only certain CPT and HCPCS codes are eligible for telemedicine reimbursement. Periodically checking the CMS website is essential to stay up to date on the specific list of CPT and HCPCS codes that are covered under telemedicine services.
Lastly when billing for telemedicine visits, it is essential to include the GT modifier with the relevant CPT code. This will indicate that the service was provided virtually. When all conditions are met, Medicare covers 80% of the physician fee (the other 20% is paid by the patient) and as stated above Medicare will also pay a facility fee to the originating site.In order to check rates based on your location, you should use the Medicare physician fee schedule lookup tool.
Medicaid
Medicaid will also cover telemedicine services but that is dependent on the specific legislation passed in each state. Medicaid programs are state-run and therefore follow state-specific telemedicine regulations. In 46 states, Medicaid offers various levels of physician reimbursement for telemedicine services delivered over live video (according to the evisit.com “Ultimate Telemedicine Guide”). Currently 26 state Medicaid programs pay an additional facility or transmission fee to cover the cost of hosting a telemedicine visit, or transmitting patient medical data in a secure way. Once again these specific restrictions and regulations vary widely by state. In order to find out more about what your state Medicaid program will cover, it is best to visit the Center for Connected Health Policy’s most recent report .
Private Payers
With demand high and evidence of cost-savings, private payers are increasingly paying for telemedicine services. For instance, United Healthcare recently announced it would expand coverage for 24/7 on-demand virtual visits to people enrolled in employer health plans.
Similar to Medicaid, the mechanics of reimbursement and services covered can vary widely by state. While services are trending toward broader coverage of telemedicine services for plan enrollees, private payers are still deciding on exactly what they will or won’t be covered. Currently, 29 states and Washington, D.C. have passed telemedicine laws. These laws mandate that private payers in those states pay for telemedicine services at the same rate as in-person visits.
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