Billing & Reimbursement

Basic Definitions

The following definitions are based on CMS Medicare and Medicaid services, and also used by many private payers.

Telemedicine: South Carolina definition: “The practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location with or without an intervening practitioner.  S.1035 was signed into law June 2016. One of the key features sets standard of care when establishing patients via synchronous communications (video visits).

Originating site, aka referring site = Location of the patient

  • Covered originating sites vary by payer. Examples are: PCP offices, hospitals, rural health clinics (RHCs), federally qualified health centers (FQHCs). *NOTE: Independent renal dialysis facilities are not covered originating sites.

  • Originating sites are paid an originating site facility fee for telehealth services as described by HCPCS code Q3014. Coverage and billing varies by payer. Please check payer policies for guidance.

Distant site, aka consulting site = Location of the distant/consulting provider. Coverage is based on the provider type and not the location of the distant site provider.

  • Covered provider types vary by payer. Examples are: physician, nurse practitioner, physician assistant, nurse midwife, clinical psychologist or clinical social worker.

Telehealth service = CPT code with the GT modifier: Distant site providers must submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT).

  • The GT modifer is added to the CPT code to alert the insurance company that the service was provided via telehealth. Per CMS, “by coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth service.” CPT and HCPCS code coverage varies by payer. Please check payer policies for guidance.

In typical FFS (fee-for-service) reimbursement, a covered originating site + a covered provider type + covered service (CPT code) =
Telehealth Coverage

Find out if your service is covered with the online search tool.

Health Professional Shortage Area (HPSA), aka rural area: Applies to Medicare coverage only. Patients must be in an HPSA for services to be covered for telemedicine service.

Health Plan Telehealth Policies

**Distant or consulting providers may use this online search tool to see available coverage to deliver care using telemedicine.