Commercial

Telemedicine Services (Independence)
00.10.41h

Policy

The Com​pany 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 policy does not describe telemedicine services that are provided by a telemedicine vendor.


TELEMEDICINE FOR MEDICAL SERVICES

 
SERVICES COVERED AND ELIGIBLE FOR REIMBURSEMENT
Telemedicine technology as a method of delivery of medical services between a provider and an individual that is reported by one of the procedure codes in the coding section below is covered and eligible for reimbursement consideration by the Company when all of following requirements are met:

  • Eligible Services
    • The medical services performed are any of the following:
      • Evaluation and management services (e.g. office visits)
      • End-stage renal disease services
      • Medical genetics and genetic counseling
      • Medical nutrition therapy
      • Transitional care management
      • Lactation counseling 
      • Hospice care
  • Specialty Eligibility
    • The medical services are medically necessary when performed by a primary care provider (PCP) or an eligible medical specialty provider who is licensed in the state in which the individual originates the telemedicine encounter. 
    • Note: the following specialties are NOT eligible for reimbursement of telemedicine services:
      • Manipulative Therapy
      • Neuromuscular Manipulative Medicine
      • Respiratory Therapy
      • Anesthesiology
      • Radiology
      • Pathology
      • Emergency Medicine
      • Medical Microbiology
      • Medical Toxicology
      • Nuclear Medicine
      • Immunology (Note: This is different from allergy and immunology medical specialty)  
      • Medical and Clinical Biochemical Genetics
      • Clinical Cytogenetics
      • Critical Care Services
  •   Modes of Communication
    • Telemedicine services may be covered when the encounter takes place via a secure Health Insurance Portability and Accountability Act (HIPAA)--compliant telecommunications system using one of the following modes of communication:  
      • Interactive, synchronous (real-time) two-way audio and video communications for all eligible specialties
      • Asynchronous telecommunication (store and forward transmission) in conjunction with synchronous audio interaction (i.e. telephone call) for the following specialties ONLY:
        • Optometry
        • Ophthalmology
        • Dermatology
      • Telephone (i.e., audio telecommunication only/telephone call) communication for the following specialties ONLY:
        • Clinical Genetics
        • Medical Genetics
​​​​​​​
TELEMEDICINE FOR BEHAVIORAL HEALTH SERVICES

The Company has delegated the responsibility for utilization management activities for behavioral health services to Magellan Behavioral Health. 

Telemedicine coverage ​for behavioral health services does not apply to self-funded groups for whom Magellan Behavioral Health is not responsible for utilization management activities; individual benefits must be verified.

Telemedicine coverage for behavioral health services are eligible for reimbursement consideration by the Company when all the following criteria are met: 

  • The services are medically necessary and able to be delivered using one of the following modes of communication: 
    • Interactive, synchronous (real­-time) two­-way audio and video communications 
    • A telephone (i.e., audio telecommunication only/telephone call) or online digital communication
  • The telemedicine services are reported with one of the procedure codes listed in the coding section below. ​​

​​NOT ELIGIBLE FOR REIMBURSEMENT

Telemedicine services are not eligible for reimbursement consideration for the following: ​
  • Triage to assess the appropriate place of service.
  • The telemedicine service occurs on the same day or within 24 hours of a face to face visit, when performed by the same provider and for the same condition.
  • Transmission of digitalized data between the provider and individual reported with modifier GQ is not reimbursed separately from the subsequent sychronous service.​
  • Administrative matters, including but not limited to, scheduling, registration, updating billing information, reminders, requests for medication refills or referrals, ordering of diagnostic studies, and medical history intake completed by the patient.
  • Any CPT or HCPCS code that is not listed in the eligible code section of this policy if billed with modifier 95 or GT or place of service 02.
  • The originating site of service fee or facility fee. 
  • Any equipment used for telemedicine communications.
  • Communications including, but not limited to, reporting of test results and provision of educational materials are incidental to E/M services, counseling, or medical services included in this policy. 
CAPITATION SERVICES AND REIMBURSEMENT

  • For Health Maintenance Organization (HMO) or HMO Point-of-Service (HMO-POS) products with capitation arrangements, services delivered through telemedicine are considered included in capitation, with the exception of those services identified in applicable policies identifying fee-for-service reimbursement. Refer to the appropriate claim payment policies for a list of exceptions to capitation arrangements.
  • For members enrolled in HMO or HMO-POS products with primary care provider capitation, any capitated services (e.g., laboratory testing, radiology studies, physical therapy, occupational therapy) must be referred to the primary care provider's designated capitated sites.
  • Members enrolled in HMO or HMO-POS products seeking primary care services through telemedicine from a primary care provider must obtain services from their selected primary care provider.
​​
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

Professional providers performing telemedicine services described in this policy must report the appropriate modifier (modifier GT or 95) and place-of-service code 02 (Telehealth) to represent telemedicine services.

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 medical services and behavioral health services for 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.​


Description

Telemedicine is the delivery of healthcare services to a member at an originating site by a professional provider at a distant site via a secure audiovisual telecommunications system. 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, or social network sites. 


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 ​healthcare 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 location at which the professional provider delivering the service is located during the time the service is provided. An originating site is the location of the individual seeking healthcare services at the time the service is initiated.​


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 August 3, 2020.


American Academy of Family Physicians. Primary care. [AAFP Web site]. 2016. Available at: http://www.aafp.org/about/policies/all/primary-care.html . Accessed August 3, 2020.

 
American Telemedicine Association (ATA). Practice guidelines for telemental health with children and adolescents. March 2017. Available at: https://www.cdphp.com/-/media/files/providers/behavioral-health/hedis-toolkit-and-bh-guidelines/practice-guidelines-telemental-health.pdf?la=en. Accessed August 3, 2020.


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 August 3, 2020.


Department of Health and Human Services.  Centers for Medicare & Medicaid Services. Medicare Learning Network. Telehealth Services. [CMS Web site]. March 2020. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf  Accessed August 3, 2020. 


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 August 3, 2020.


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 August 3, 2020.


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 August 3, 2020.


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 August 3, 2020.


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 http://www.legis.state.pa.us//cfdocs/Legis/CSM/showMemoPublic.cfm?chamber=H&SPick=20150&cosponId=18472​ August 3, 2020.


Pennsylvania House of Representatives. House co-sponsoring memoranda. Interstate medical licensure compact legislation. [Legislature State Pennsylvania Web site]. 06/03/15. Available at:    Accessed August 3, 2020​.


Coding

CPT Procedure Code Number(s)



MEDICAL SERVICES ELIGIBLE FOR COVERAGE VIA TELEMEDICINE

 

90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 92227, 92228, ​96040, 96110, 96127, 97802, 97803, 97804, ​99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99406, 99407, 99408, 99409, 99421, 99422, 99423, 99441, 99442, 99443, 99483, 99495, 99496, 99497, 99498


THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES FOR LACTATION COUNSELING:

 

99401, 99402, 99403, 99404, 99411, 99412


THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES FOR APPLIED BEHAVORIAL ANALYSIS (ABA):

 

0362T, 0373T, 97151, 97153, 97154, 97155, 97156, 97157, 97158

​ 
BEHAVIORAL HEALTH SERVICES ELIGIBLE FOR COVERAGE VIA TELEMEDICINE
 

90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90875, 96116, 96121, 96125, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357



MEDICAL AND BEHAVIORAL HEALTH SERVICES NOT ELIGIBLE FOR COVERAGE VIA TELEMEDICINE

 

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




ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)

MEDICAL SERVICES ELIGIBLE FOR COVERAGE VIA TELEMEDICINE

 

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


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


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


S0265 Genetic counseling, under physician supervision, each 15 minutes


THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES FOR LACTATION COUNSELING:

 

S9443 Lactation classes, nonphysician provider, per session

 

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


BEHAVIORAL HEALTH SERVICES ELIGIBLE FOR COVERAGE VIA TELEMEDICINE

 

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 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 or more communicating with the patient via telehealth


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


H0015  Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education


H0035  Mental health partial hospitalization, treatment, less than 24 hours


S0201   Partial hospitalization services, less than 24 hours, per diem


S9480   Intensive outpatient psychiatric services, per diem


​MEDICAL AND BEHAVIORAL HEALTH SERVICES NOT ELIGIBLE FOR COVERAGE VIA TELEMEDICINE

 

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

 

G2061 Qualified nonphysician healthcare professional online assessment and management service, 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 and management 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 and management 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


G2025 Distant site telehealth services performed by RHC and FHQC


G2250 Remote assessment 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 service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment


G2251 Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion


G2252 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; 11-20 minutes of medical discussion​


Q3014 Telehealth originating site facility fee


Revenue Code Number(s)

MEDICAL SERVICES ELIGIBLE FOR COVERAGE VIA TELEMEDICINE
 
0651 Hospice Service - Routine Home Care
 
0652 Hospice Service - Continuous Home Care

BEHAVIORAL HEALTH SERVICES ELIGIBLE FOR COVERAGE VIA TELEMEDICINE

0905 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Psychiatric

0906 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Chemical Dependency

0912 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Less Intensive

0913 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Intensive​




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 COVERED

GQ Via Asynchronous telecommunications system

Coding and Billing Requirements


Policy History

7/1/2021
7/1/2021
8/6/2021
00.10.41
Claim Payment Policy Bulletin
Commercial
No