Medicare is the federal health insurance program for people 65 or older, people with certain disabilities under 65, and people with end stage renal disease. Medicare will reimburse for a limited set of telehealth delivered services if certain parameters are met. The program is administered by the Center for Medicare and Medicaid Services (CMS).
Medicare telehealth policies during COVID-19
Following is a description of Medicare telehealth permanent policy — but please note that currently telehealth reimbursement within Medicare is more expansive as a result of the public health emergency. These exceptions are temporary and being tracked by CCHP here.
Medicare reimburses only for specific services when they are delivered via live video. Store-and-forward delivered services are prohibited, except for CMS telehealth demonstration programs in Alaska and Hawaii.
(Medicare does reimburse for certain other kinds of services that are furnished remotely using communications technology but are not considered Medicare “telehealth services.” To learn more about those, jump here.)
The specific telehealth-delivered services eligible for reimbursement under Medicare are identified by Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes. Each year, the US Department of Health and Human Services considers submissions for new telehealth-delivered services to be approved. Submissions are allowed from providers, advocacy organizations, and other interested parties.
CMS will decide to approve a submitted CPT code for reimbursement based on whether the service meets the requirements in one of two categories:
- Category 1: Services are similar to existing services, such as professional consultations, office visits, and office psychiatry services, which already are approved for telehealth delivery.In deciding whether to approve the new codes, similarities between the requested and existing telehealth services are examined, including interactions among the beneficiary and the practitioner at the distant site and, if necessary, the telepresenter, and similarities in the technologies used to deliver the proposed service.
- Category 2: Services not similar to Medicare-approved telehealth services.Reviews of these requests include an assessment of whether the service is accurately described by the corresponding CPT code when delivered via telehealth, and whether the use of technology to deliver the service produces a demonstrated clinical benefit to the patient.
- Category 3 — new in 2020: Services that are likely to provide clinical benefit via telehealth, yet lack sufficient clinical evidence to evaluate making them permanent under Category 1 or Category 2.These are to remain in effect until the end of the calendar year in which the COVID-19 public health crisis ends (not when the PHE ends).
CMS maintains a list of current CPT codes eligible for Medicare reimbursement for calendar year (CY) 2020, and codes that are specific to the public health emergency are available here. For more information on changes made for CY 2021, see CMS’ calendar year final physician fee schedule or CCHP’s factsheet on the CY 2021 proposed physician fee schedule. Newly approved services typically become eligible for reimbursement on January 1 of the following year.
Medicare limits the types of health care professionals who can provide telehealth-delivered services. The small group of eligible professionals are:
- Nurse practitioners
- Physician assistants
- Nurse midwives;
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Clinical psychologists and clinical social workers (these professionals cannot bill for psychotherapy services that include medical evaluation and management services)
- Registered dietitians or nutrition professionals.
The patient’s location at the time services are received via telehealth is known as the “originating site.” Medicare treats telehealth almost exclusively as a tool for rural areas, and has narrowly restricted the geographic areas that are eligible to use telehealth. The originating site must be in a Health Professional Shortage Area (HPSA) as defined by Health Resources and Services Administration (HRSA), or in a county that is outside of any Metropolitan Statistical Area (MSA) as defined by the US Census Bureau. Some argue against this restriction because many underserved areas are still barred from receiving telehealth-delivered services, and those that are eligible may not have an adequate population base to maintain a telehealth network.
In 2019, there were some exceptions made from both the geographic and originating site requirements for the end stage renal disease (ESRD) services, treatment of acute stroke and treatment of substance use disorder and co-occurring mental health conditions. Additionally, the Consolidated Appropriations of 2021, which passed in December 2020, also provided an exception for mental health patients. Those exceptions are outlined in a subsequent section.
Effective as of January 2014, CMS redefined rural HPSAs as areas located in rural census tracts as determined by the office of Rural Health Policy (ORHP). This allows eligible facilities located in rural census tracts that are within an MSA to be eligible telehealth originating sites. HRSA also maintains a Medicare telehealth payment eligibility search tool, where eligibility of an originating site may be checked.
In addition to the rural restriction, Medicare limits the originating sites (where the patient is located) eligible for telehealth-delivered services to the following facilities:
- Provider offices
- Critical access hospitals
- Rural health clinics
- Federally qualified health centers
- Skilled nursing facilities
- Community mental health centers
- Hospital-based or critical access hospital-based renal dialysis centers
- Rural emergency hospitals (new designation for 2023)
Note that there are certain exceptions to the facility requirement in the case of end stage renal disease (ESRD) services, treatment of mental health disorder, acute stroke and treatment of substance use disorder and co-occurring mental health conditions. These exceptions are outlined in the section below.
Exceptions from geographic and facility restrictions
Effective as of January 2019, CMS finalized their regulations to reflect required changes in telehealth reimbursements made by the Bipartisan Budget Act of 2018. These changes specifically relate to end stage renal disease (ESRD) services and the treatment of acute stroke.
- End Stage Renal Disease: For ESRD services, renal dialysis facilities and the home now qualify as eligible originating sites. If the site is the home, an in-person visit is required once a month for the first three months and once every three months thereafter. Additionally, the geographic limitation would not apply to these new sites or hospital-based or CAH-based renal dialysis centers for the treatment of ESRD. There would be no facility fee if the home were the originating site.
- Acute Stroke Treatment: For the treatment of acute stroke, a mobile stroke unit along with any currently eligible originating site is eligible for telehealth reimbursement. The Secretary has the ability to designate additional sites, but has not done so at this time. Additionally, the geographic limitation would not apply for the treatment of acute stroke in any of the eligible originating sites (including mobile stroke units). However, originating sites that would not otherwise qualify for telehealth reimbursement (under Medicare’s geographic and originating site requirements) would not be eligible for the facility fee.
- Treating Individuals with Substance Use Disorders (SUDs) or co-occurring mental health disorders: The 2018 SUPPORT for Patient and Communities Act required CMS to adjust their reimbursement policy of telehealth for treating individuals with SUDs or a co-occurring mental health disorder. Specifically, it removed the originating site geographic requirements for telehealth services on or after July 1, 2019 for any existing Medicare telehealth originating site (except for a renal dialysis facility). Additionally, the home was made an eligible originating site for purposes of treating these individuals, however the home would not qualify for the facility fee.
The normal telehealth service code limitations still apply for services rendered under this exception. Practitioners would also be responsible for assessing whether individuals have a SUD diagnosis and whether it would be clinically appropriate to furnish the telehealth services for the treatment.
- Diagnosis, Evaluation or Treatment of Mental Health Disorder once COVID-19 emergency ends: Due to the passage of the Consolidated Appropriations Act of 2021 , eligible telehealth individuals under Medicare will be able to utilize telehealth for purposes of diagnosis, treatment or evaluation of mental health disorders without the geographic restrictions. This new rule will become permanent after the PHE. This new law also permits beneficiaries to receive telehealth services from their home for purposes of mental health diagnosis, treatment or evaluation (in addition to substance use disorder treatment, which was previously allowed).
There are important stipulations regarding the scope of eligible tele-mental health services. Specifically, eligible patients must have an existing in-person relationship with a provider, as defined by 1 in-person visit with the provider within a 6-month period prior to the telehealth encounter and subsequent periods as determined by the Secretary. However, as written, the bill’s language appears to require the in-person visit regardless of where the patient is located (e.g., home, clinic, doctor’s office) if that location is newly-eligible under the provision (e.g., a doctor’s office in an urban area). This in-person requirement would not apply to any location that is eligible under the previous rules (e.g., eligible originating sites in rural areas).
Payment for communication technology-based services (CTBS)
Beginning in January, 2019, CMS will reimburse for certain kinds of services furnished remotely using communications technology that are not considered “Medicare telehealth services.” Medicare has labeled these services communication technology-based services, or CTBS. Because they are not defined specifically as telehealth, the limitations and restrictions outlined previously applicable to telehealth would not apply. These services include the following categories:
- Brief communication technology-based service (or “virtual check-ins”): A brief, non-face-to-face check-in with an established patient via communication technology to assess whether or not an office visit or other service is necessary. This service is only available to practitioners who furnish E/M services, and could take place via live video or telephone call.
- Remote evaluation of pre-recorded patient information: Remote professional evaluation of patient-transmitted information conducted via pre-recorded video or image technology to determine whether or not an office visit or other service is necessary. This would only be available for established patients.
- Interprofessional internet consultation: Interprofessional internet consultations between professionals performed via communications technology. This service is limited to practitioners that can independently bill Medicare for E/M visits. This could take the form of either a telephone call or a live or asynchronous internet consultation. Both the consulting and treating provider could be reimbursed for this service.
- Online Digital/Medical Evaluations (E-Visit): Allows a patient to communicate with a provider through an online patient portal.
In the 2021 Physician Fee Schedule, CMS clarified that clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can furnish brief online assessment and management services, virtual check-ins and remote evaluation.
There are other restrictions for when and how these services can be provided. For instance, when the brief communication technology-based service or remote evaluation of pre-recorded patient information originates from a related E/M service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered bundled into the previous E/M service and would not be separately billable.
Likewise, if the service leads to an E/M in-person service with the same provider within 24 hours or the next available appointment it would also be bundled into the pre-visit time. CMS is requiring verbal consent be obtained from the patient for all three of these services, in order to ensure they are aware of any costs they may incur from these services.
How does the remote communication technology services apply to FQHCs and RHCs?
CMS will allow RHCs and FQHCs to receive payment for brief communication technology based services or remote evaluation of pre-recorded patient information services when at least 5 minutes of communications-based technology or remote evaluation services are furnished by an RHC or FQHC practitioner to a patient that has been seen in the RHC or FQHC within the previous year. They also have waived the RHC and FQHC face-to-face requirements for these services. RHCs and FQHCs, however, are not eligible to receive reimbursement for interprofessional internet consultations. For further details, see CCHP’s factsheet on the impact of Medicare’s CY 2019 changes on FQHC/RHCs.
Although services delivered via audio-only means have been reimbursed throughout the pandemic for certain CPT/HCPCS codes, reimbursement will cease immediately at the end of the pandemic. In the 2021 physician fee schedule, CMS has put in place code C2252 as a temporary code for 2021 and meant to bridge audio only services provided by the telephone evaluation and management calls.
Chronic care management and remote monitoring
In January 2015, CMS created a new chronic care management (CCM) code, which provides for non-face-to-face consultation. Since then, CMS has released several instructional documents on billing the CCM codes, added reimbursement for complex CCM as well as two add-on codes. FQHCs and RHCs are allowed to bill for CCM. Additionally, in the final calendar year 2018 Physician Fee Schedule, CMS unbundled code 99091 allowing providers to get reimbursed separately for time spent on collection and interpretation of health data generated remotely. As is the case with CTBS, by not defining these codes as a “telehealth” service, these services are not subject to the restrictions other telehealth services currently face, such as geographic and location limitations and prohibitions on the use of asynchronous technology in most cases. In the finalized CY 2019 Physician Fee Schedule, CMS added three additional remote physiological codes in order to align with those created by the CPT Editorial Panel. For more information, see CMS’ CY 2019 Physician Fee Schedule, and other resources on the chronic care management codes.
Medicare advantage, APMS, and ACOS
Medicare does offer some exceptions to its geographic and originating site requirements through special programs, including the Next Generation ACO; Shared Savings Program; Episode Payment Models; and Comprehensive Care for Joint Replacement Models. According to the Bipartisan Budget Act of 2018, beginning in 2020, all Medicare two-sided ACOs are able to be reimbursed for telehealth delivered services to the home and be exempt from Medicare’s geographic requirement. CMS has finalized their rule to implement this change in the Shared Savings Program.
Under the Bipartisan Budget Act of 2018, Medicare Advantage (MA) plans are able to (although not required to) offer additional telehealth benefits, without the geographic, site and services restrictions currently imposed by Medicare applying. The list of eligible providers of telehealth services still apply to MA as do state requirements specific to telehealth (for example, if a state requires informed consent prior to a telehealth interaction).