Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Telehealth Services
Policy #:MA00.036f

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy does not describe telehealth services that are provided by a telemedicine vendor.

Remote patient management, telehealth services are covered when all of the following criteria are met:
  • The individual is located in a Rural Health Professional Shortage Area (HPSA) located in a rural census tract, as defined by 332(a)(1)(A) of the Public Health Services Act, or in a county outside of a metropolitan statistical area (MSA), as defined by 1886(d)(2)(D) of the Act .
    • Telehealth services for the purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke are not subject to the location criteria.
  • The following originating site requirements are met:
    • An originating site is the location where an individual receives professional provider medical services through a telecommunications system. The individual must be at one of the following eligible originating sites for the telehealth services:
      • Office of a physician or practitioner
      • Hospitals
      • Critical Access Hospitals (CAH)
      • Rural Health Clinics (RHC)
      • Federally Qualified Health Centers (FQHC)
      • Renal Dialysis Facilities
        • Hospital-based centers
        • CAH-based centers(including satellites)
        • Independent facilities
      • Home of beneficiaries with end-stage renal disease receiving home dialysis
      • Skilled Nursing Facilities (SNF)
      • Community Mental Health Centers (CMHC)
      • Home of individuals receiving treatment for a substance use disorder or a co-occuring mental health disorder
      • Mobile Stroke Units
    • Telehealth services for the purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke are not subject to the origination requirements.
  • The telehealth services are provided by one of the following eligible distant site professional providers:
      • Physicians
      • Nurse practitioners (NP)
      • Physician assistants (PA)
      • Nurse midwives
      • Clinical nurse specialists (CNS)
      • Certified registered nurse anesthetists (CRNA)
      • Clinical psychologists (CP) and clinical social workers (CSW)
      • Registered dietitians or nutrition professionals
  • The encounter takes place via an interactive audio and video telecommunications system which permits synchronous (i.e., real-time) encounters among the professional provider at a distant site and the individual at the originating site.

NOT COVERED

When the criteria outlined above have not been met, telehealth services, are not covered. Therefore these services are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Professional providers performing telehealth services described in this policy must report the appropriate place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telehealth services.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Policy Guidelines

Medicare Telehealth Payment Eligibility Analyzer: http://datawarehouse.hrsa.gov/tools/analyzers/geo/Telehealth.aspx.

This policy is consistent with Medicare’s coverage determination. The Company’s reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, telehealth services, are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

Telehealth can be defined as the exchange of medical information between an individual and professional provider from one site to another via a secure telecommunications system for which there is a reasonable level of certainty in establishing a diagnosis and generating a treatment plan.

Telehealth is often employed to provide healthcare services to rural, remote, and underserved communities that have limited access to medical specialists and professional providers. Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.

Telehealth includes the delivery of remote healthcare via a growing variety of secure applications of telecommunication systems including video, smart phones, and wireless tools that allow for both audio and video transmission, permitting two-way contact that is interactive and real-time (i.e., synchronous) between an individual and a professional provider. Asynchronous or store and forward is the transfer of data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous applications would not be considered telehealth.

Telehealth is used to support healthcare when the professional provider and the individual are physically separated. A telehealth service includes both a distant site and an originating site. A distant site is the site at which the professional provider is delivering the service at the time the service is provided via telecommunications system. An originating site is the location of an individual at the time the service furnished via a telecommunication system occurs.
References

American Academy of Family Physicians. Primary care. [AAFP Web site]. 2019. Available at: http://www.aafp.org/about/policies/all/primary-care.html . Accessed May 3, 2019.

American Telemedicine Association (ATA). Practice guidelines for live, on demand primary and urgent care. [ATA Web site]. November 2014. Available at:
https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/NEW%20Practice%20Guidelines/2017%20Practice%20Guidelines/NEW_ATA%20Live%20On%20Demand%20Primary%20Urgent%20Care%20Guidelines.pdf [via membership only]. Accessed May 3, 2019.

American Telemedicine Association (ATA). State telemedicine gaps analysis. [ATA Web site]. February 2017. Available at: http://www.americantelemed.org/main/policy-page/state-telemedicine-gaps-reports [via membership only]. Accessed May 3, 2019.

American Telemedicine Association (ATA). Core operational guidelines for telehealth services involving provider-patient interactions. [ATA Web site]. May 2014. Available at:
http://hub.americantelemed.org/resources/telemedicine-practice-guidelines

https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/NEW%20Practice%20Guidelines/NEW_ATA%20Core%20Guidelines.pdf [via membership only]. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System Pub 100-04 Medicare Claims Processing, Transmittal 3586 Jan 2017. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3586CP.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub. 100-02: Medicare Benefit Policy. Transmittal 178. Expansion of medicare telehealth services for calendar year (CY) 2014. [CMS Web site]. 01/01/2014. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R178BP-.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub. 100-04: Medicare Claims Processing. Transmittal 1026. Medicare telehealth services.[CMS Web site]. 01/01/2007. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1026cp.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub 100-04 Medicare Claims Processing. Transmittal 1423. [CMS Web site]. 01/01/2008. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1423CP.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub. 100-04: Medicare Claims Processing. Transmittal 2161. Incentive Payment Program for Primary Care Services, Section 5501(a) of the Affordable Care Act .[CMS Web site]. 01/01/2011. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2161CP.pdf . Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Pub. 100-04: Medicare Claims Processing. Transmittal 3157: Telehealth origination site facility fee payment amount update. [CMS Web site]. 12/24/2014. Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R3157CP.html. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 Section 190[CMS Web site]. Available at:http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed May 3, 2019.
Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN) Matters. MM7900: Expansion of medicare telehealth services for calendar year 2013. [CMS Web site]. 01/01/2013. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm7900.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN) Matters. MM10044: Next Generation Accountable Care Organization (NGACO) Year Three Benefit Enhancements. [CMS Web site]. 08/04/2017 Revised 01/23/2018. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10044.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN) Matters. MM10152. Elimination of the GT Modifier for Telehealth Services. [CMS Web site]. 01/01/2018. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10152.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Program: CY 2018 Updates to the Quality Payment Program and Quality Payment Program: Extreme and Uncontrollable Circumstance Policy for the Transition Year. 01/01/2018. Available at: https://www.gpo.gov/fdsys/pkg/FR-2017-11-16/pdf/2017-24067.pdf. Accessed May 3, 2019.

Centers for Medicare & Medicaid Services (CMS). Telehealth. [CMS Web site]. 01/03/2014. Available at: http://cms.gov/Medicare/Medicare-General-Information/Telehealth/. Accessed May 3, 2019.

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. Telehealth Services. Rural Health Fact Sheet Series. [CMS Web site]. January 2019. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf Accessed May 3, 2019.

Federation of State Medical Boards. Model policy for the telemedicine technologies in the practice of medicine. [FSMB Web site]. April 2014. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_Policy.pdf. Accessed May 3, 2019.

Hewitt H, Gafaranga J, McKinstry B. Comparison of face-to-face and telephone consultations in primary care: qualitative analysis. Br J Gen Pract. 2010; 60(574):201-212.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

ELIGIBLE

90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 96116, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 96170, 96171, 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233, 99307, 99308, 99309, 99310, 99354, 99355, 99356, 99357, 99406, 99407, 99495, 99496, 99497, 99498

NON-COVERED

98966, 98967, 98968, 98970, 98971, 98972, 99421, 99422, 99423, 99441, 99442, 99443


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



ELIGIBLE

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes

G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes

G0296 Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making)

G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes

G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes

G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth

G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth

G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes or more communicating with the patient via telehealth

G0420 Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour

G0421 Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour

G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth

G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth

G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes communicating with the patient via telehealth

G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit

G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit

G0442 Annual alcohol misuse screening, 15 minutes

G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

G0444 Annual depression screening, 15 minutes

G0445 Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training & guidance on how to change sexual behavior

G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

G0447 Face-to-face behavioral counseling for obesity, 15 minutes

G0459 Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal psychotherapy

G0506 Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)

G0508 Telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and providers via telehealth

G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

G0513 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)

G0514 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)


G2086 Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month

G2087 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month

G2088 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)

NON-COVERED

G2061 Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes

G2062 Qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes

G2063 Qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes

Q3014 Telehealth originating site facility fee

S0320 Telephone calls by a registered nurse to a disease management program member for monitoring purposes; per month

S5185 Medication reminder services, non-face-to-face; per month



Revenue Code Number(s)

N/A


Misc Code

Modifiers:


COVERED

95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system

G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

GT Via interactive audio and video telecommunications system

NON-COVERED

GQ Via Asynchronous telecommunications system




Coding and Billing Requirements


Cross References




Policy History

Revisions from MA00.036f:
01/01/2020
    The following CPT codes have been termed from this policy:
    96150, 96151, 96152, 96153, 96154, 98969, 99444

    The following CPT and / HCPCS codes have been added to this policy: 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, G2061, G2062, G2063, 98970, 98971, 98972, 99421, 99422, 99423, G2086, G2087, G2088


Revisions from MA00.036e:
12/16/2019
    This version of the policy will become effective 12/16/2019. This policy has been updated to remove the requirement for modifier GT and add a requirement of Place of Service code 02.

    The following codes were added to the policy:

    90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 96116, 96150, 96151, 96152, 96153, 96154, 96160, 96161, 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233, 99307, 99308, 99309, 99310, 99354, 99355, 99356, 99357, 99406, 99407, 99495, 99496, 99497, 99498, G0108, G0109, G0270, G0296, G0396, G0397, G0420, G0421, G0438, G0439, G0442, G0443, G0444, G0445, G0446, G0447, G0459, G0506, G0513, G0514

    The following codes were removed from the policy, which was communicated via a Newsflash. The Newsflash indicated the changed position of the codes to not eligible for separate reimbursement:

    99446, 99447, 99448, 99449, 99451, 99452, G0459


Revisions from MA00.036d :
01/01/2019The following CPT codes have been termed from this policy: 0188T, 0189T.

The following CPT codes have been added to this policy: 99451, 99452

The following modifier has been added to the policy: G0


Revisions from MA00.036c :
01/01/2018This policy has undergone a routine review and the medical necessity criteria have been revised to include dermatology and ophthalmology as specialties allowed for asynchronous telehealth.

Revisions from MA00.036b:
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
01/01/2017This version of the policy will become effective 01/01/2017.

The following HCPCS codes have been added to this policy:

G0508 Telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and providers via telehealth

G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

Revisions from MA00.036a:
05/04/2016This version of the policy will become effective 05/04/2016.

The following criteria have been added to this policy:
  • Certified Registered Nurse Anesthetists added to distant site professional providers
  • Non-covered statement added for when criteria not met for remote patient management, telemedicine services.
  • Required documentation

Clarification language has been added for claims submitted for telemedicine services with the telemedicine modifier:
  • GT Via interactive audio and video telecommunications system modifier

Revisions from MA00.036:
02/04/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Remote Patient Management: Telemedicine and Telehealth
01/01/2015This is a new policy.





Version Effective Date: 01/01/2020
Version Issued Date: 01/01/2020
Version Reissued Date: N/A