CMS releases hospital telemedicine billing decision tree

CMS’ latest round of updates to its novel coronavirus (COVID-19) FAQs on Medicare fee-for-service billing provides additional information on hospital billing for remote services, including a decision tree guiding hospitals through their options for billing for telemedicine.

According to the updated information in Section LL: Hospital Billing for Remote Services, a hospital may bill for telemedicine services during the COVID-19 public health emergency when a beneficiary’s home is serving as a provider-based department (PBD) of the hospital. The decision provides various scenarios and options that can inform hospital billing in each scenario.

For example, a patient’s home is serving as a hospital PBD and the patient is a registered outpatient at that location. A practitioner at another location—the distant site—is billing for services on the telehealth list using modifier -95 on a 1500 claim form. Hospital staff are supporting the professional telehealth services. In this case, the hospital may bill an originating site facility fee using HCPCS code Q3014 (telehealth originating site facility fee) on the UB-04 claim form.

Hospitals must follow billing instructions for using modifier -PO or -PN as applicable.

Other new and updated FAQs in Section LL include:

• Hospital billing for telehealth services provided by certain practitioners. Generally, hospitals may bill a telemedicine facility when it is serving as the originating site, that is, the location of the patient. For example, if a patient’s home is serving as a hospital PBD and the patient is a registered outpatient, that location would be considered the originating site and the location of the practitioner would be considered the distant site. However, the practitioner’s services are considered professional services and are billed using a professional claim, even if the practitioner is employed by the hospital. A hospital or other institutional provider cannot submit a professional claim.
• Hospital billing for HCPCS codes G0463 (hospital outpatient clinic visit) and Q3014. In any circumstance, hospitals must bill using the HCPCS code that describes the service.
  • If a patient is a registered outpatient at a remote PBD (for example, the patient’s home) and the patient receives telemedicine services from a distant site practitioner and hospital staff provide administrative and clinical support, the hospital may bill Q3014. It would not be appropriate for the hospital to bill G0463 in this situation.
  • If a physician is practicing from a hospital and provides an evaluation and management outpatient service to a patient that is a registered outpatient at a remote PBD (for example, the patient’s home), the physician and the patient are both considered to be in the hospital. In this situation, normal hospital outpatient billing rules would apply to the services furnished. CMS considered that in this situation there is no distant site practitioner, and no telemedicine services are furnished.

Organizations should carefully review their coding and billing processes to ensure they comply with CMS’ rules. Organizations may reach out to their MACs with specific questions or attend CMS’ bimonthly COVID-19 office hours calls. COVID-19 office hour calls are held every other Tuesday at 5–6 p.m. eastern time.

Organizations should also review the FAQ document for additional updates. CMS is continuing to update this document, and organizations should review it regularly for changes.