Notification



Notification Issue Date:



Claim Payment Policy


Title:Telemedicine Services (Independence)

Policy #:00.10.41f

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. Individual benefits must be verified.

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

TELEMEDICINE FOR PRIMARY CARE SERVICES

COVERED AND ELIGIBLE FOR REIMBURSEMENT
Telemedicine technology as a method of delivery of primary care medical services is covered and eligible for reimbursement consideration by the Company when all of following requirements are met:
  • The individual is seeking primary care services from a professional provider in a primary care specialty (i.e., family medicine, internal medicine, general medicine, geriatric medicine, pediatric medicine) who is licensed in the state in which the member originates the telemedicine encounter.
    • Members enrolled in a Health Maintenance Organization (HMO) or HMO Point-of-Service (HMO-POS) products may only seek telemedicine services from their selected primary care professional provider.
  • The individual seeking medical care is present at the time of service (i.e., real-time interaction between the individual and primary care professional provider).
  • The encounter takes place via a secure Health Insurance Portability and Accountability Act (HIPAA)--compliant interactive audio and video telecommunications system.
    • Interactive telecommunications system must include audio and video equipment permitting synchronous (i.e., real-time) encounter between the individual and primary care professional provider.

TELEMEDICINE FOR BEHAVIORAL HEALTH SERVICES

Refer to the contracted behavioral health vendor for behavioral health services eligible for coverage for telemedicine.

TELEMEDICINE FOR OTHER SPECIALTY CARE SERVICES

Telemedicine technology as a method of delivery for other specialty care services (i.e., non-primary care services) is not covered and, therefore, not eligible for reimbursement.

NOT ELIGIBLE FOR REIMBURSEMENT

Telemedicine technology is not eligible for reimbursement consideration for the following:
  • The sole purpose is to obtain a referral to specialty care services (i.e., non-primary care services).
  • Triage to assess the appropriate place of service or provider type.
  • Services performed via asynchronous (i.e., store and forward) delayed communications (e.g., telecommunication systems that transfer diagnostic images or video from one site to another for viewing in preparation for a later encounter). Asynchronous, store and forward technology does not permit real-time interaction between the individual and primary care professional provider.
  • Telecommunication systems that do not have HIPAA-compliant encryption.
  • When billed by a professional provider in a medical specialty type other than family medicine, internal medicine, general medicine, geriatric medicine, behavioral health, and pediatric medicine.
  • Services not related to primary care medical services (e.g., inpatient, remote critical care) or behavioral health services.

BENEFIT CONTRACT EXCLUSION

A telephone consultation (i.e., audio telecommunication only/telephone call) is not covered by the Company because it is a benefit contract exclusion and is, therefore, not eligible for reimbursement consideration.

CAPITATION SERVICES AND REIMBURSEMENT
  • For products with primary care provider capitation, telemedicine services are also considered included in capitation.
  • For most plans, members enrolled in HMO or HMO Point-of-Service (HMO-POS) products using their referred benefit are required to obtain telemedicine services from their participating primary care professional provider.
  • For members enrolled in HMO or HMO-POS products with primary care physician capitation; any capitated services (e.g., laboratory testing, radiology studies, physical therapy, occupational therapy) must be referred to the primary care professional provider's capitated sites.

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 professional 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

Primary care and behavioral health professional providers performing telemedicine services described in this policy must report the appropriate modifier (modifier GT, GQ, or 95) and place-of-service code 02 (Telehealth) to represent telemedicine services. Modifier GQ is asynchronous, (i.e., store and forward) telemedicine, and therefore a noncovered service.

The services described in this policy are only reimbursed as telemedicine services when reported with eligible procedure codes, appropriate modifiers, and the place of service code identified in this policy. Any applicable member cost-share will be applied.

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

Other telemedicine coverage options may be available, such as those administered by a third party vendor. The options may differ from the primary care and behavioral health telemedicine addressed in this policy.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, telemedicine as described in this policy is covered under the medical benefits of the Company's products.

BILLING GUIDELINES

Primary care telemedicine as described in this policy would typically not occur more than once within seven days for the same episode of care.

Description

TELEMEDICINE

Telemedicine 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. Telemedicine 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 between an individual and a professional provider. Telemedicine does not address communications between professional providers and individuals via short message service, telephone communication, social network sites, or the use of telemedicine for primary care services when facilitated by a professional provider connecting to another professional provider.

Telemedicine was originally created as a way to treat individuals who were located in remote places, long distances from local health facilities or in areas of with shortages of medical professional providers. While telemedicine is still used today to address these challenges, rapid changes in technology have transformed telemedicine into a tool for an accessible, convenient healthcare delivery system for primary care services.

Telemedicine is used to support healthcare when the professional provider and the individual are physically separated. A telemedicine 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 is located 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.

PRIMARY CARE

Primary care is that care provided by professional providers specifically trained for and skilled in comprehensive first contact and continuing care for individuals with any undiagnosed sign, symptom, or health concern (the "undifferentiated" individual) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Primary care specialists are identified as family medicine, internal medicine, general medicine, geriatric medicine, and pediatric medicine.

EXAMPLES OF CONDITIONS THAT ARE COMMONLY TREATED VIA TELEMEDICINE
Telemedicine is not intended to be used for any condition where an in-person exam is required because of severe symptoms, or where aggressive interventions are required. Telemedicine is used for common, uncomplicated, non-emergency medical issues. The following are examples of common conditions a primary care professional provider may treat via telemedicine:
  • Arthritic pain
  • Bronchitis
  • Colds and flu
  • Conjunctivitis
  • Genitourinary conditions
  • Low back pain
  • Otitis media
  • Respiratory infections
  • Uncomplicated cases of allergy/asthma

BEHAVIORAL HEALTH CARE

Behavioral health care, also known as mental health care, is the care, treatment, service or procedure to maintain, diagnose, or treat for mental health when provided by a Behavioral Health/Substance Abuse Provider.

References


American Academy of Family Physicians. E-visits. [AAFP Web site]. 2013. Available at:http://www.aafp.org/about/policies/all/e-visits.html [via membership only]. Accessed January 4, 2019.

American Academy of Family Physicians. Primary care. [AAFP Web site]. 2016. Available at: http://www.aafp.org/about/policies/all/primary-care.html . Accessed January 4, 2019.

American Telemedicine Association (ATA). Evidence-based Practice for Telemental Health. [ATA Web site]. October 2009. Available at: https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/New%20Guideline%20Cover%20May%2017/NEW_ATA%20Evidence%20Based%20Practice.pdf. Accessed January 4, 2019.

American Telemedicine Association (ATA). Practice guidelines for live, on demand primary and urgent care. [ATA Web site]. November 2014. Available at: http://www.americantelemed.org/docs/default-source/standards/primary-urgent-care-guidelines.pdf?sfvrsn=4 [via membership only]. Accessed January 4, 2019.

American Telemedicine Association (ATA). State telemedicine gaps analysis. [ATA Web site]. January 2016. Available at: http://www.americantelemed.org/main/policy-page/state-telemedicine-gaps-reports [via membership only]. Accessed January 4, 2019.

American Telemedicine Association (ATA). Core operational guidelines for telehealth services involving provider-patient interactions. [ATA Web site]. May 2014. Available at: https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/NEW%20Practice%20Guidelines/NEW_ATA%20Core%20Guidelines.pdf [via membership only]. Accessed January 4, 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 January 4, 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 January 4, 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 January 4, 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 January 4, 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 January 4, 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]. 12/29/2014. Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R3157CP.html. Accessed January 4, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 Section 190.3 [CMS Web site]. 04/11/2016. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed January 4, 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 January 4, 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 January 4, 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]. February 2018. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf Accessed January 4, 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 January 4, 2019.

Federation of State Medical Boards. Federation of state medical boards applauds enactment of interstate medical licensure compact in Pennsylvania. [License portability Web site]. 10/26/2016. Available at: http://www.licenseportability.org/wp-content/uploads/2016/10/2016.10.26PACompactEnactment.pdf Accessed January 4, 2019.

General Assembly of Pennsylvania. House Bill #1619. [State of Pennsylvania Web site]. 10/14/2015. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=2015&sessInd=0&billBody=H&billTyp=B&billNbr=1619&pn=2348. Accessed January 4, 2019.

General Assembly of Pennsylvania. House Bill 491. An act amending Title 40 (insurance) of the Pennsylvania consolidated statutes, providing for health care coverage for telehealth. [Pennsylvania General Assembly Web site]. 02/04/2014, Available at: http://www.legis.state.pa.us/cfdocs/billinfo/bill_history.cfm?syear=2013&sind=0&body=H&type=B&bn=491. Accessed January 4, 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.

Interstate Medical Licensure Compact Commission. Interstate medical licensure
compact. [License Portability Web site]. 2016. Available at: http://www.licenseportability.org/ Accessed January 4, 2019.

Pennsylvania House of Representatives. House co-sponsorship memoranda. Interstate medical licensure compact legislation. [Legislature State Pennsylvania Web site]. 06/03/2015. Available at: http://www.legis.state.pa.us//cfdocs/Legis/CSM/showMemoPublic.cfm?chamber=H&SPick=20150&cosponId=18472 Accessed January 4, 2019.




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)

THE FOLLOWING CODES ARE USED TO REPRESENT ELIGIBLE PRIMARY CARE TELEMEDICINE SERVICES ONLY:


99421, 99422, 99423, 99441, 99442, 99443

THE FOLLOWING CODES ARE USED TO REPRESENT ELIGIBLE BEHAVIORAL HEALTH TELEMEDICINE SERVICES ONLY:

90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233, 99307, 99308, 99309, 99310, 99354, 99355, 99356, 99357

THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES NOT CONSIDERED TELEMEDICINE AND ARE NOT ELIGIBLE FOR REIMBURSEMENT:

98970, 98971, 98972, 99446, 99447, 99448, 99449, 99451, 99452

THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES NOT CONSIDERED TELEMEDICINE AND ARE CONSIDERED BENEFIT EXCLUSIONS:

98966, 98967, 98968



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)



THE FOLLOWING CODES ARE USED TO REPRESENT ELIGIBLE BEHAVIORAL HEALTH TELEMEDICINE SERVICES ONLY:

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

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

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


THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES NOT CONSIDERED TELEMEDICINE AND ARE NOT ELIGIBLE FOR REIMBURSEMENT:

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

THE FOLLOWING CODES ARE NOT ELIGIBLE FOR REIMBURSEMENT:

G0071 Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only

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

G2010 Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment

G2012 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Q3014 Telehealth originating site facility fee

THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES NOT CONSIDERED TELEMEDICINE AND ARE CONSIDERED BENEFIT EXCLUSIONS:

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

GT Via interactive audio and video telecommunications system

NOT ELIGIBLE FOR REIMBURSEMENT

GQ Via Asynchronous telecommunications system



Coding and Billing Requirements



Policy History

Revisions for 00.10.41f
01/01/2020This policy has been identified for the CPT and HCPCS code update, effective 01/01/2020.

The following ICD-10 CM codes have been added to this policy: 98970 98971 98972 99421 99422 99423 G2061 G2062 G2063

The following CPT codes have been termed from this policy: 98969 99444


Revisions from 00.10.41e
01/02/2019The policy criteria section was updated to allow behavioral health providers to perform telemedicine.

The following codes were added under the behavioral health section: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233, 99307, 99308, 99309, 99310, 99354, 99355, 99356, 99357, G0406, G0407, G0408, G0425, G0426, G0427, G0459, Q3014.


Revisions from 00.10.41d
01/01/2019The following CPT codes have been termed from this policy: 0188T, 0189T.

The following CPT codes have been added to this policy as not eligible for reimbursement: 99451, 99452.

The following HCPCS codes have been added to this policy as not eligible for reimbursement: G0071, G2010, G2012.


Revisions from 00.10.41c:
11/07/2018This policy has been reissued in accordance with the Company's annual review process.
01/12/2018The policy was updated to remove the billing requirement for modifiers.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.