Virginia Telemedicine & Telehealth Reimbursement Overview

Provider Reimbursement Eligibility
Consent for Telemedicine Live Video Reimbursement Store & Forward Reimbursement Originating Site & Transmission Fees Eligible Practitioners
State Law

Informed consent must be obtained and maintained.

See Telemedicine Guidance Doc. 85-12

Private payers are required to reimburse for telemedicine, subject to their own terms and conditions.
See Bill 38.2-3418.16

Telemedicine services are required to be interactive and store & forward appears to be excluded
See Virginia Act 38.2-3418.16 (b)

Reimbursement is allowed but not required.
See Bill 38.2-3418.16

 

No Reference Found

Medicaid

No Reference Found

Medicaid will reimburse subject to coverage requirements.
See Practitioner Manual Chapter IV Pg. 16

Medicaid will reimburse for radiology, diabetic retinopathy, and outpatient teledermatology.
See Practitioner Manual Pg. 20

Medicaid will reimburse a facility fee.
See Medicaid Memo Pg.5

To find out if your provider class is eligible for Medicaid reimbursement reference the appropriate Medicaid manual for your specialty.
See Medicaid Memo Pg.5

Medicare

No Reference Found

Mostly applicable for rural areas with several exceptions detailed below.  See Rural Telehealth Services Document for core benefits.

 

Primary Care | Medicare does offer new telehealth reimbursement opportunities for chronic care management and behavioral health integration.  This initiative removes previous face-to-face requirements and geographic restrictions.  Download the FREE guides for Primary Care.

 

Substance Abuse Treatment |  Services furnished after July 1, 2019, Medicare removed geographic limitations and allows the home to be an originating site. (See CMS Manual Pub 100-04 Page 4)

 

End Stage Renal Disease | For Prolonged Preventative Service Codes HCPCS G0513 & GO514, effective January 1, 2019 patients in end-stage renal disease can use the home and renal dialysis facilities as originating sites. (See CMS Manual Pub 100-04 Page 5)

 

Acute Stroke Care – Telestroke | Effective January 1, 2019, any hospital, critical access hospital, or mobile stroke unit is eligible to serve as an originating site for acute stroke care; however, these sites are not eligible for originating site fee reimbursement unless they meet the pre-existing requirements for an originating site. G0 (G Zero), to be appended on claims for telehealth services related to acute stroke care.

 

Virtual Check-ins | Effective January 1, 2019, the home can serve as an originating site for 5-10 minute brief technology-based check-ins for evaluation and management of established patients.  (HCPS code G2012)

No Reference Found

Originating Site | Medicare will pay 80% of the lesser of the actual charge of $26.15 per live video session to the originating site(patient location). See “Originating Site Section” for Medicare’s definition of an originating site.

 

Exceptions | There are new exceptions for the originating site rule for Chronic Care Management & Behavioral Health Integration in Primary Care, End Stage Renal Disease,  Acute Stroke Care, and Evaluation & Management brief Check-ins.  See “live video reimbursement” two columns to the left.

List of Medicare Approved Practitioners (see page 2)

Private Payors

Private payors are actively exploring telemedicine and telehealth, but each provider is different. If you are in network with a specific provider, call and request documentation of their policy related to telehealth.

Self Pay

There are no limitations for self pay patients/clients, and providing telehealth services is a great way to increase revenue with patients that are selfpay or value premium services.

Provider Reimbursement Eligibility
Consent for Telemedicine
State Law

Informed consent must be obtained and maintained.

See Telemedicine Guidance Doc. 85-12

Medicaid

No Reference Found

Medicare

No Reference Found

Live Video Reimbursement
State Law

Private payers are required to reimburse for telemedicine, subject to their own terms and conditions.
See Bill 38.2-3418.16

Medicaid

Medicaid will reimburse subject to coverage requirements.
See Practitioner Manual Chapter IV Pg. 16

Medicare

Mostly applicable for rural areas with several exceptions detailed below.  See Rural Telehealth Services Document for core benefits.

 

Primary Care | Medicare does offer new telehealth reimbursement opportunities for chronic care management and behavioral health integration.  This initiative removes previous face-to-face requirements and geographic restrictions.  Download the FREE guides for Primary Care.

 

Substance Abuse Treatment |  Services furnished after July 1, 2019, Medicare removed geographic limitations and allows the home to be an originating site. (See CMS Manual Pub 100-04 Page 4)

 

End Stage Renal Disease | For Prolonged Preventative Service Codes HCPCS G0513 & GO514, effective January 1, 2019 patients in end-stage renal disease can use the home and renal dialysis facilities as originating sites. (See CMS Manual Pub 100-04 Page 5)

 

Acute Stroke Care – Telestroke | Effective January 1, 2019, any hospital, critical access hospital, or mobile stroke unit is eligible to serve as an originating site for acute stroke care; however, these sites are not eligible for originating site fee reimbursement unless they meet the pre-existing requirements for an originating site. G0 (G Zero), to be appended on claims for telehealth services related to acute stroke care.

 

Virtual Check-ins | Effective January 1, 2019, the home can serve as an originating site for 5-10 minute brief technology-based check-ins for evaluation and management of established patients.  (HCPS code G2012)

Store & Forward Reimbursement
State Law

Telemedicine services are required to be interactive and store & forward appears to be excluded
See Virginia Act 38.2-3418.16 (b)

Medicaid

Medicaid will reimburse for radiology, diabetic retinopathy, and outpatient teledermatology.
See Practitioner Manual Pg. 20

Medicare

No Reference Found

Originating Site & Transmission Fees
State Law

Reimbursement is allowed but not required.
See Bill 38.2-3418.16

 

Medicaid

Medicaid will reimburse a facility fee.
See Medicaid Memo Pg.5

Medicare

Originating Site | Medicare will pay 80% of the lesser of the actual charge of $26.15 per live video session to the originating site(patient location). See “Originating Site Section” for Medicare’s definition of an originating site.

 

Exceptions | There are new exceptions for the originating site rule for Chronic Care Management & Behavioral Health Integration in Primary Care, End Stage Renal Disease,  Acute Stroke Care, and Evaluation & Management brief Check-ins.  See “live video reimbursement” two columns to the left.

Eligible Practitioners
State Law

No Reference Found

Medicaid

To find out if your provider class is eligible for Medicaid reimbursement reference the appropriate Medicaid manual for your specialty.
See Medicaid Memo Pg.5

Medicare

List of Medicare Approved Practitioners (see page 2)

Private Payors

Private payors are actively exploring telemedicine and telehealth, but each provider is different. If you are in network with a specific provider, call and request documentation of their policy related to telehealth.

Self Pay

There are no limitations for self pay patients/clients, and providing telehealth services is a great way to increase revenue with patients that are selfpay or value premium services.

Telemedicine CPT Codes

Unique CPT codes do not exist specifically for telemedicine or telehealth. Instead a modifier is applied to existing codes.

  • For interactive audio and video sessions, place a GT modifier in front of the CPT codes you typically use for in person services.
  • For services provided via an asynchronous telecommunication system, simply add a GQ modifier in front of the CPT codes you typically use for in person services.

Telehealth Parity

There is a parity law that requires private payers and state employee health plans to reimburse on the basis of in-person care.

See Bill 38.2-3418.16 Section D.

Definitions

Telehealth Parity

Telehealth services are equal to in person services and reimbursed at the same rate.

Asynchronous Communication

The exchange of messages, such as among the hosts on a network or devices in a computer, by reading and responding as schedules permit rather than according to some clock that is synchronized for both the sender and receiver or in real time. Email, chat and text messaging are primary examples of asynchronous communication.

Distant or Hub Site

The location or site where the practitioner or provider is located while utilizing telemedicine services to meet with patients.

Originating Site

The location of the patient at the time services are provided. An originating site can be the client's home or a public facility like a rural hospital or physician's office. Many payors will reimburse for an originating site fee if it meets specific requirements. Rural use cases provide an applicable example for an eligible originating site fee where the patient will go to a local medical facility like a primary care physician's office and meet with a specialist located in distant urban health facility.

Additional Telemedicine Resources

Telehealth and telemedicine are fast growing and changing segments. Both state licensure and state legislation are changing rapidly along with federal legislation and for this reason the information provided cannot be considered legal advice. We make every attempt to keep state specific information up to date, but encourage you to validate this information through the following sites: