By: Susan St. John
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With the rise in services provided to patients via telehealth entities, it is important that both practitioners and patients understand what criteria must be met in order to provide and bill telehealth on behalf of Medicare patients. Here are a few of the basics.
First, “telehealth service” for Medicare purposes means “professional consultations, office visits, and office psychiatry services, and any additional service specified by the Secretary. To be eligible for payment, telehealth services must be rendered to an eligible individual, that is, an individual enrolled in Medicare, who receives telehealth services at an originating site from a physician or practitioner at a distant site via telehealth communications system. An eligible individual does not need to be presented by a physician or practitioner at the originating site to a physician or practitioner at a distant site, unless it is medically necessary. Determination of whether a presenting physician or practitioner is necessary at the originating site is made by the physician or practitioner at the distant site.
An “originating site” is the site at which the eligible individual is located at the time telehealth services are furnished via a telecommunications system. Included in Medicare’s definition of “originating site” is location and description of originating sites – and IT IS NOT A PATIENT’S HOME! So here we go.
An originating site must be located: 1) in an area that is described as a rural health professional shortage area, 2) in a county that is not included in a Metropolitan Statistical Area, or 3) from an entity that participates in a Federal telemedicine demonstration project that has been approved by the Secretary of HHS as of December 31, 2000, regardless of location. Further, the law is very specific as to what can be an originating site, and these include only the following:
- The office of a physician or practitioner;
- A critical access hospital (“CAH”);
- A rural health clinic;
- A Federally qualified health center;
- A hospital;
- A hospital-based or critical access hospital-based renal dialysis center;
- A Skilled Nursing Facility; or
- A community mental health center.
The matrix below provides a visual aide for defining an originating site.
|Rural health Professional Shortage Area||NON-MSA County||An Entity Participating in a Federal Telemedicine Demonstration Project|
|Physician or Practitioner Office|
|Critical Access Hospital|
|Rural Health Clinic|
|Federally Qualified Health Center|
|Hospital-Based or CAH-based Renal Dialysis Center|
|Skilled Nursing Facility|
|Community Mental Health Center|
You can check the Medicare Telehealth Payment Eligibility Analyzer at https://datawarehouse.hrsa.gov/tools/analyzers/geo/Telehealth.aspx to determine if the patient is at an originating site eligible for Medicare telehealth services and payment.
A distant site means the site at which a physician or practitioner is located at the time a telehealth service is provided. For telehealth purposes, Medicare defines physicians as allopathic doctors, osteopathic doctors, dentists, podiatrists, optometrists and chiropractors. Practitioners, for Medicare telehealth purposes means: a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, a certified nurse mid-wife, clinical social worker, clinical psychologist, and a registered dietician or nutrition professional.
The physician or practitioner at the distant site must be licensed under the state law where the distant site is located, and be authorized pursuant to such state’s law to provide telehealth services. Keep in mind that not all states allow the physicians and practitioners listed above to rendered telehealth services.
So what is a telecommunications system for telehealth service purposes? In the eyes of Medicare, a telecommunications system is an interactive telecommunications system with multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time, interactive communication between patient and distant site physician or practitioner. Telephones, fax machines and email do not meet the definition of interactive communication systems. Of course, there is an exception to this definition, but only if the originating site is in a Federal telemedicine demonstration program in Alaska or Hawaii – this limited exception allows for store and forward communications (recorded then sent to distant site).
For telehealth services provided to a Medicare beneficiary, Medicare will pay the distant site provider or practitioner the same amount as if the services had not been rendered as telehealth services, i.e., no need for a telecommunication system. Because a telepresenter, that is a physician or practitioner at the originating site, is not required, Medicare will only pay the originating site a facility fee for the telehealth service.
Medicare Telehealth Conclusion
For physicians and practitioners wanting to provide telehealth services to Medicare beneficiaries, prudent consideration of the minimum requirements discussed above must be undertaken. Carefully evaluate whether you have a telecommunication system that includes audio and video capabilities and two-way, real time communication. A telephone alone is not enough. Additionally, the Medicare patient receiving the telehealth service must be at an originating site as defined by Medicare, and that definition does not include the patient’s home. Further, physicians and practitioners should make sure that the state in which they are licensed allows them to provide Medicare telehealth services.