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Issue Number - Name
0125-Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
Review Type
Automated
Claim Type
Professional Services (Physician/Non-physician Practitioners
Region and State
RAC 1-4
All States
Date Approved
02/12/2019

Description

Medicare reimbursement for telehealth services include subsequent hospital care services and subsequent nursing facility care services. However, subsequent hospital care visits are limited to one telehealth visit every three days for hospital inpatients and one subsequent nursing facility telehealth visit every 30 days for nursing facility residents.

Affected Codes

Telehealth eligible CPT Codes-99231, 99232, 99233, 99307, 99308, 99309, 99310 (Please see Appendix D for a detail list of codes and descriptions)

Applicable Policy References

Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
42 CFR, Section 405.980-Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor, and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
42 CFR, Section 405.986-Good Cause for Reopening  
42 CFR, Section 424.5(a)(6) Basic conditions/Sufficient information
42 CFR, Section 411.15(k)(l) Particular services excluded from Coverage/Any services that are not reasonable and necessary
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.3.5–Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services, Issued 03-11-16, Effective Date 01-01-15, Effective Date 04-11-16
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.3-List of Medicare Telehealth Services, Rev. 3476, Issued 03-11-16, Effective Date 01-01-15, Effective Date 04-11-16
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.2-Eligibility Criteria, Rev. 2848, Issued 12-30-13, Effective Date 01-01-14, Implementation Date 01-06-14
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.6-Payment Methodology for Physician/Practitioner at the Distant Site, Rev. 3586, Issued 08-12-16, Effective Date 01-01-17, Implementation Date 01-03-17
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 190.6.1-Submission of Telehealth Claims for Distant Site Practitioners, Rev. 3817, Issued 07-28-17, Effective Date 01-01-18, Implementation Date 01-02-18