Lesson 1 of 6
Lesson 1 of 6
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:
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.
The Originating site must be located in one of the following geographical areas
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.
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:
● Nurse Practitioners (NPs)
● Physician Assistants (PAs)
● 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.
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
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
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
Medicare Telehealth Billing Reference
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.
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.
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.
For a full List of Medicare Telehealth Services, view the CTRC California Telehealth Reimbursement Guide.