Lesson 1 of 6
Traditional Medicare
The Centers for Medicare and Medicaid Services (CMS) published current payment policies, payment rates, and other service provisions in the CY 2022 Medicare Physician Fee Schedule (PFS). Summary of key provisions effective on or after January 1, 2022:
● Revises telehealth services under the Consolidated Appropriations Act, 2021; allows audio-only communications technology to furnish mental health services in certain circumstances.
● Finalizes recent changes to Evaluation and Management (E/M) visit codes, such as policies for split or shared E/M visits, critical care services, and services furnished by teaching physicians.
● Modifies payment for therapy services furnished in whole or in part by a physical therapist assistant or occupational therapy assistant.
● Updates payment regulation for medical nutrition therapy services.
● Finalizes considerations for vaccine administration services.
In general, an FQHC/RHC is allowed to be an originating site for Medicare when the clinic is in an eligible geographic location and the patient is receiving services from a distant site provider while physically present within the four walls of the FQHC or RHC.
As of 2022, FQHCs and RHCs are permitted to bill for Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same time period.
CMS established five basic criteria for telehealth reimbursement. Let’s review these along with the corresponding changes during the public health emergency:
#1: Eligible Originating Site
The location of the patient during a telehealth visit is also known as the “originating site”.
In order to meet this criteria for reimbursement, the patient must have been seen at an originating site as defined by CMS. Eligible originating sites include:
● Hospitals (inpatient or outpatient)
● Critical Access Hospitals
● Rural Health Clinics
● Federally Qualified Health Centers
● Skilled Nursing Facilities
● Community Mental Health Centers
● Mobile Stroke Units
● Rural Emergency Hospitals
● Hospital-based or critical access hospital-based renal dialysis centers (including satellites)
● Home of a patient for mental health services
Geographical requirements do not apply if certain conditions are met, including an initial in-person visit with the telehealth provider six months prior to provision of telehealth mental health services
● Home of a patient for:
◊ Monthly end stage renal disease (ESRD)-related clinical assessments
◊ Treatment of a substance use disorder
RESTRICTION TEMPORARILY WAIVED DURING COVID-19:
Patient does not need to be seen at an eligible originating site. Patients may be located in their place of residence or at an eligible originating site for the remainder of the public health emergency as deemed by the Secretary of the HHS.
Tip: HRSA developed the Medicare Telehealth Payment Eligibility Analyzer, a tool to help providers determine geographic eligibility for Medicare originating site telehealth services.
NOTE: Medicare does not apply originating site geographic conditions to hospital-based and critical access hospital-based renal dialysis centers, renal dialysis facilities, and beneficiary homes when practitioners furnish monthly home dialysis end-stage renal disease (ESRD)-related medical evaluations. Independent renal dialysis facilities are not eligible originating sites.
NOTE: As of January 1, 2019, the Bipartisan Budget Act of 2018 removed the originating site geographic conditions and added eligible originating sites to diagnose, evaluate, or treat symptoms of an acute stroke.
NOTE: The Consolidated Appropriations Act of 2021 included an update to the eligible originating site list to include rural emergency hospitals. The Act also requires an in-clinic visit six months prior in order for a patient to receive telehealth mental health services in the home.
#2: Originating Site Location
The Originating site must be located in one of the following geographical areas
- Outside of a Metropolitan Statistical Area (MSA)
- Inside of a Rural Health Professional Shortage Area (HPSA) inside of a rural census tract.
To determine if a location is eligible, visit the HRSA eligibility analyzer FOUND HERE
RESTRICTIONS TEMPORARILY WAIVED DURING COVID-19:
For the remainder of the public health emergency patients may be located in an urban or rural area.
#3: Eligible Distant Site Provider
The location of the provider during a telehealth visit is also known as the “distant site”.
In order to meet this criteria for reimbursement, the encounter must have been performed by an eligible practitioner at the distant site. Eligible distance site practitioners are as follows:
● Physicians
● Nurse Practitioners (NPs)
● Physician Assistants (PAs)
● Nurse-midwives
● Clinical Nurse Specialists (CNSs)
● Certified Registered Nurse Anesthetists (CRNAs)
● Clinical Psychologists (CPs)*
● Clinical Social Workers (CSWs)*
● Registered Dieticians or Nutritional Professionals
● X-waivered providers supporting SUD/MAT/Opioid Treatment Programs (OTP)
*Note: CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838
What is an Originating Site?
With the passage of the CARES Act, for the duration of the PHE, FQHCs/RHCs can act as a distant site.
CMS also added PT, OT and SLPs as eligible distant site providers.
#4: Real-Time Communication
The patient must be present and the encounter must involve interactive audio and video telecommunications that provides real-time communication between the practitioner and the Medicare beneficiary.
Select services can be audio only for the duration of the PHE
#5: Eligible Telehealth Service
The type of service provided must fall within the Medicare eligible services table.
You can find eligible services and corresponding CPT and HCPCS codes in the Telehealth Services Fact Sheet
CMS has added 80 additional codes to the existing list of eligible telehealth services
Billing & Reimbursement
Originating Site Fee
The originating site is eligible to receive a facility fee for providing services via telehealth. As of January 2022, the payment amount is 80% of the lesser of the actual charge, or $27.59. The site receives a flat reimbursement rate, outside of any other reimbursement arrangements such as inpatient prospective payment systems (IPPS)/diagnosis-related groups (MS-DRGs) under or Rural Health Center (RHC) per-visit payments.
Billing Instructions for Various Originating Site Facilities
- Community Mental Health Centers (CMHCs)
The originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services. - Critical Access Hospitals (CAHs)
Traditional Medicare payment amount is 80 percent of the originating site facility fee. - FQHCs and RHCs
The originating site facility fee for Medicare telehealth services is not an FQHC or RHC service. When an FQHC or RHC serves as the originating site, the originating site facility fee must be paid separately from the center or clinic all-inclusive rate (AIR).
Medicare Telehealth Billing Reference
- In addition to FQHCs, RHCs, and CAHs, Chapter 12 of the Medicare Claims Processing Manual, Section 190 describes Medicare payment for telehealth services delivered in a variety of originating and distant sites
Distant Site Clinical Services Fees
NOTE: A distant site designates the location of the practitioner at the time the telehealth service is furnished. The cost of a visit may not be billed or included on the cost report.
- Distant Site Clinical Services Fees provide reimbursement to the health professional delivering the clinical service at the same rate as the current fee schedule amount for the service provided without telemedicine.
- Distant site claims for reimbursement should be submitted with the appropriate CPT code or HCPCS code for the professional services provided. Distant site practitioners billing telehealth services under the CAH Optional Payment Method (Method II) will submit institutional claims using the GT modifier.
- Distant sites use Place of Service (POS) 02 (Telehealth) for all encounters.
- Although FQHCs and RHCs are included on the eligible list of facility types that may serve as distant site providers, FQHCs and RHCs are not paid the typical prospective payment system (PPS) or all-inclusive rate (AIR). While these entities may provide services via telehealth under Medicare, they will not be paid a set rate calculated by CMS for each eligible service delivered via telehealth, all of which are billed using HCPCS code G2023. The amount is based on a formula created by CMS.
Telehealth Place of Service (POS) Codes
CMS publishes a list of Place of Service (POS) codes to use on the CMS-1500 Health Insurance Claim Form to indicate where the provider and patient are located during a health encounter. The treatment location affects reimbursement, CPT code categories, and modifiers to use with CPT codes.
Synchronous Services POS Codes.
The Q3014 is to be used when services are provided within an outpatient medical facility. It is not reimbursable for encounters outside of a clinical setting.
- The POS 02 code is required to bill for Medicare synchronous telehealth services on billing form CMS 100.
- In 2022, CMS introduced the code POS 10 for telehealth patients receive when located in their homes.
POS 02: Telehealth Provided Other than in a Patient’s Home. This code designates that the place of service where the patient receives health services and health-related services provided via telecommunication technology is not the patient’s home. Policy went into effect 1/1/17. An updated description went into effect 1/1/2022, and is applicable for Medicare as of 4/1/22.
POS 10: Telehealth Provided in a Patient’s Home. This code designates the patient’s home as the place of service where health services and health-related services are provided or received through telecommunication technology as opposed to locations other than the patient’s home such as a hospital, clinic, or other care facility. Effective 1/1/2022, and applicable for Medicare 4/1/2022.
- HCPCS Originating Site Facility Fee Code: Q3014
- Type of Service: 9-Other Items and Services
- Place of Service: 02-Telehealth
- Bill the Medicare Administrative Contractor (MAC) for the separately billable originating site facility under Medicare Part B
For a full List of Medicare Telehealth Services, view the CTRC California Telehealth Reimbursement Guide.