Coverage Information for Telehealth Services

By Judith L. Kares, JD

Medicare continually seeks to expand access to certain basic health care services, particularly for beneficiaries located in remote areas of the country. Under the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Congress significantly expanded coverage for telehealth services under original Medicare to include consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. The use of a telecommunications system substitutes for an in-person encounter. Although Medicare generally requires the telecommunications system to be interactive, BIPA does allow the use of asynchronous “store and forward” technology to deliver these services when the originating site is an otherwise qualified federal telemedicine demonstration program in Alaska or Hawaii.

In a recently released Medicare Learning Network fact sheet (Telehealth Services Fact Sheet—Revised), CMS provided an overview of telehealth services available to Medicare beneficiaries during CY 2016. CMS began by defining key terms—“originating sites”, “distant site practitioners”, and “telehealth services”—including a comprehensive list of covered services identified by HCPCS code. This information is followed by a comprehensive discussion of billing and payment rules for professional telehealth services, as well as originating site facility fees. The final portion of the fact sheet provides a list of additional resources, including a list of helpful websites and Regional Office Rural Health Coordinators. 

The following is a brief summary of Medicare coverage and payment rules for telehealth services furnished during CY 2016. For more information, hospitals and practitioners are encouraged to review the fact sheet and related resources, including the Medicare Benefit Policy Manual, Chapter 15, section 270 and the Medicare Claims Policy Manual, Chapter 12, section 190.

Key terms

Originating site. For Medicare purposes, an originating site is the location of an eligible Medicare beneficiary at the time the telehealth service occurs.

Telehealth services. There is an extensive list of CY 2016 covered telehealth services, identified by specific HCPCS codes, set out in the fact sheet. As noted above, the threshold coverage requirement is the use of an interactive audio and video telecommunications system that permits real-time communication between the practitioner, at the distant site, and the beneficiary, at the originating site. The only exception is for federal telemedicine demonstration programs in Alaska or Hawaii. For these programs, an asynchronous “store and forward” technology is permitted.

In addition, for ESRD-related services, a physician, NP, PA, or CNS must furnish at least one “hands-on” visit (not telehealth) each month to examine the vascular access site.

Click here to read the complete editor's note about coverage for telehealth services.