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Q: Per Medicare regulations, do the providers at a distant site have to be hospital-based or can they be in a private setting – for example, a group of pulmonologists who want to create a telehealth system on their own?
A: Research indicates that there are no restrictions on the location of the distant site provider. Providers at the distant site, however, must be an eligible provider type, and be able to bill for Medicare services (see list of eligible providers and eligible services – CPT/HCPCS codes – in the Medicare Telehealth booklet linked below) and must be licensed under state law. Also, all telehealth services must meet the Medicare established set of criteria for reimbursement.
This answer is based on the research below:
Medicare recognizes distant site practitioners who may receive payment for covered telehealth services as physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, and clinical social workers (some stipulations exist for social workers billing for mental health). These providers must be licensed under state law.
As a condition of payment, telehealth services must be provided using an interactive audio and video telecommunications system that permits real-time communication between the distant site, and the beneficiary at the originating site. Asynchronous “store and forward” technology, the transmission of medical information the physician or practitioner at the distant site reviews at a later time, is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii.
Medicare defines a distant site as, “the site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system.”
Medicare has an established set of criteria to be met for reimbursement of telehealth services:
- The service must be furnished via an interactive telecommunications system
- The service must be furnished by a physician or authorized practitioner
- The service must be furnished to an eligible telehealth individual
- The individual receiving the service must be located in a rural health professional shortage area or non-Metropolitan statistical area and an eligible telehealth Originating Site (see resources below).
Effective February, 2018, the Medicare Learning Network updated the Telehealth Services booklet, which provides definitions, reimbursement requirements, CPT codes, and links to other Medicare-specific information, such as the Medicare Telehealth Payment Eligibility Analyzer. This booklet targets the Fee-For-Service Provider and may be helpful to you.
Click here to download the Telehealth Services booklet.
Click here to visit the Medicare Eligibility Analyzer site.
The Center for Connected Health Policy (CCHP) is a great resource to stay current on state and national policy. To review CCHP information on Medicare, go to: http://www.cchpca.org/telehealth-and-medicare.
Please remember that information provided by the SCTRC is intended for general information purposes only and is not intended or implied to be a substitute for professional legal and reimbursement advice. We recommend discussing reimbursement and legal decisions with your organization’s compliance officer to ensure agreement or consulting with an attorney regarding any legal issue.