CMS Pub. 100-04, ch. 12, § 190.4

1. Technology

For Medicare payment to occur, interactive audio and video telecommunications must be

used, permitting real-time communication between the distant site physician or

practitioner and the Medicare beneficiary. As a condition of payment, the patient must be

present and participating in the telehealth visit.

2. Exception to the interactive telecommunications requirement

In the case of Federal telemedicine demonstration programs conducted in Alaska or

Hawaii, Medicare payment is permitted for telemedicine when asynchronous “store and

forward technology” in single or multimedia formats is used as a substitute for an

interactive telecommunications system. The originating site and distant site practitioner

must be included within the definition of the demonstration program.

3. “Store and forward” defined

For purposes of this instruction, “store and forward” means the asynchronous

transmission of medical information to be reviewed at a later time by physician or

practitioner at the distant site. A patient’s medical information may include, but not

limited to, video clips, still images, x-rays, MRIs, EKGs and EEGs, laboratory results,

audio clips, and text. The physician or practitioner at the distant site reviews the case

without the patient being present. Store and forward substitutes for an interactive

encounter with the patient present; the patient is not present in real-time.

NOTE: Asynchronous telecommunications system in single media format does not

include telephone calls, images transmitted via facsimile machines and text messages

without visualization of the patient (electronic mail). Photographs must be specific to the

patients’ condition and adequate for rendering or confirming a diagnosis and or treatment

plan. Dermatological photographs, e.g., a photograph of a skin lesion, may be considered

to meet the requirement of a single media format under this instruction.

4. Telepresenters

A medical professional is not required to present the beneficiary to physician or

practitioner at the distant site unless medically necessary. The decision of medical

necessity will be made by the physician or practitioner located at the distant site.