Billing And Reimbursement

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. This definitiondoes not, on its face, explicitly require synchronous interactive audio-video communications technology. However, licensees must use technology sufficient to accurately diagnose and treat the patient in conformity with the applicable standard of care.” Former Governor Nikki Haley signed S.1035 into law in 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

  • Current covered originating sites, varies by payer:
  • Physician or practitioner offices
  • Hospitals
  • Critical access hospitals
  • Rural health clinics
  • Federally qualified health centers
  • Hospital based or CAH-based renal dialysis center
  • Skilled nursing facilities
  • Community mental health centers

*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 or consulting provider

  • Current covered distant providers, varies by payer:
  • Physician
  • Nurse practitioner
  • Physician assistant
  • Nurse midwife
  • Clinical nurse specialist
  • Certified registered nurse anesthetist
  • Clinical psychologist
  • Clinical social worker
  • Registered dietitian

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

Billing professional fee 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 modifier 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.

Health Professional Shortage Area (HPSA),aka rural area:Applies toMedicare coverage only.

Patients must be in an HPSA for services to be covered for telemedicine service.

Health Plan Telehealth Policies

MEDICARE REIMBURSEMENT

Medicare reimburses telemedicine services at the same rate as the comparable-in-person medical service, based on the current Medicare physician fee schedule. As mentioned above, the originating site can charge an additional facility fee and must be rural, accordingto HRSA.

Additional Resources and Information

VisitCMS’ Medicare Telehealth for more information.

MEDICAID REIMBURSEMENT

Medicaid will reimburse covered telehealth services as long as the following criteria are met:

Medicaid beneficiaries (patient) are eligible for telemedicine services only if they are presented from a referring or originating site located in the South Carolina Medical Service Area (SCMSA). The referring site presenters may be required to facilitate the delivery of this service. Referring site presenters should be provider knowledgeable in how the equipment works and can provide the clinical support if needed during a session.

Only certain CPT codes are eligible for telemedicine reimbursement.

Medicaid has specific list of CPT codes that are covered under telemedicine services. For more information, see SC Department of Health and Human Services.

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