Medicare Clarifies 2022 Telehealth Coverage

Telehealth is a broad term that generally refers to the provision of healthcare services at a distance through the use of telecommunications technologies. It is generally thought to be a broader term than telemedicine which, given its name, is focused on the care provided by healthcare professionals trained in the tradition of medicine. However, in modern healthcare services, there are a wide range of clinicians that may deliver telehealth services, thus the term is broader. 

With the growth of the internet and the plight of the Covid-19 pandemic, telehealth services grew in adoption by both providers and patients as coverage improved. Medicare has greatly expanded the services that can be offered via telehealth, in response, and thus it has become more common. 

Medicare telehealth services include common office visit-like care, psychotherapy and counseling services, consultations with a clinician, and certain other medical or health services that are provided by a licensed clinician and are delivered remotely via a smartphone or computer. It is important to note that other remote, technologically enhanced services such as remote-patient monitoring (RPM) (also known as remote-physiological monitoring) are not included in this list, but are also considered to be telehealth services. You can learn more about RPM, here. 

With the recent changes during the Covid-19 pandemic, Medicare-covered telehealth services are available to beneficiaries that are located in both rural and urban environments. 

How does Medicare make changes to telehealth coverage?

Medicare makes additions or deletions to the list of services defined as Medicare telehealth services effective on a January 1st basis–similar to the cycle of coverage determinations included in the typical physician fee schedule process. The annual physician fee schedule proposed rule published in the summer and the final rule (published by November 1) is used as the vehicle to make these changes. The general public and healthcare organizations have the opportunity to submit requests to add or delete telehealth services on an ongoing basis. This can be done here. 

Medicare Evaluation Criteria for Telehealth Coverage

Once a request is made CMS will evaluate it based on the following criteria. Each request for adding services to the list of Medicare telehealth services are assigned by CMS to one of the following categories. The following criteria are shared verbatim from the CMS telehealth resource:

  • Category 1: Services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the list of telehealth services.  In reviewing these requests, we look for similarities between the requested and existing telehealth services for the roles of, and interactions among, the beneficiary, the physician (or other practitioner) at the distant site and, if necessary, the telepresenter. We also look for similarities in the telecommunications system used to deliver the proposed service, for example, the use of interactive audio and video equipment.
  • Category 2: Services that are not similar to the current list of telehealth services. Our review of these requests will include an assessment of whether the service is accurately described by the corresponding code when delivered via telehealth and whether the use of a telecommunications system to deliver the service produces demonstrated clinical benefit to the patient. Requestors should submit evidence indicating that the use of a telecommunications system in delivering the candidate telehealth service produces clinical benefit to the patient. The evidence submitted should include both a description of relevant clinical studies that demonstrate the service furnished by telehealth to a Medicare beneficiary improves the diagnosis or treatment of an illness or injury or improves the functioning of a malformed body part, including dates and findings and a list and copies of published peer reviewed articles relevant to the service when furnished via telehealth. Our evidentiary standard of clinical benefit will not include minor or incidental benefits. Some examples of clinical benefit include the following:
    • Ability to diagnose a medical condition in a patient population without access to clinically appropriate in person diagnostic services.
    • Treatment option for a patient population without access to clinically appropriate in person treatment options.
    • Reduced rate of complications.
    • Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due to reduced rate of recurrence of the disease process).
    • Decreased number of future hospitalizations or physician visits.
    • More rapid beneficial resolution of the disease process treatment.
    • Decreased pain, bleeding, or other quantifiable symptom.
    • Reduced recovery time.

Medicare Telehealth Determination Outcomes

Upon successful review of a submitted telehealth service, Medicare will perform one of the following actions based on the request: 

  • Adding an existing HCPCS code to the list of Medicare telehealth services.
  • Determining that the requested service is already described by an existing telehealth service.
  • Creating a new HCPCS code to describe the requested service and adding it to the list of Medicare telehealth services.
  • Requesting further information.
  • Notifying the requestor that a national coverage determination is necessary before a decision to accept or reject a proposal can be made.
  • Rejecting the request.

Find the 2022 Covered Service List

For 2022, Medicare has released the covered telehealth services and corresponding CPT codes. You can access the codes at the link, below. 

Click here

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