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Claim Payment Policy Bulletin

Telehealth Services
MA00.036i


Policy

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

ORIGINAL MEDICARE
Telehealth services are covered when all of the following criteria are met:
  • 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
      • Mobile Stroke Units
      • Rural hospital emergency department
    • 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
      • Physical therapist
      • Occupational therapist
      • Speech language pathologist
      • Audiologist
  • The encounter takes place via an interactive audio and video telecommunications system that permits synchronous (i.e., real-time) encounters among the professional provider at a distant site and the individual at the originating site ​or for some services via telephone (i.e., audio telecommunication only/telephone call) communications.
    • ​Encounters for the treatment, diagnosis, and evaluation of a behavioral health disorder are covered through audio-only communications for established patients if the individual does not have the technical capacity, does not have the availability of real-time audio and visual interactive telecommunications, or does not provide consent to the use of real-time video technology.  

VIRTUAL CHECK-IN CRITERIA
Virtual check-ins (e.g., phone or video chat) with the individual's provider for 5 to 10 minutes​ is covered when all of the criteria are met:

  • The individual is an established patient
  • The check-in is not related to an office visit in the past 7 days
  • The virtual check-in does not lead to an office visit within 24 hours of the soonest available appointment
E-VISIT CRITERIA
E-visits, an asynchronous communication with established individuals through a patient portal, is covered when the individual initiates the inquiry with communications occuring over a 7-day period. 


ADDITIONAL TELEHEALTH
Additional telehealth services (e.g., Medicare Diabetes Prevention program, cardiac rehabilitaiton, pulmonary rehabilitation) ​are covered when performed by network providers: 

  • Telehealth services for PCP visits  
  • Telehealth services for specialist and other healthcare professional visits 
  • Telehealth services for physical therapy, occupational therapy, and speech therapy visits​​​ ​
NOT ELIGIBLE FOR REIMBURSEMENT

Telemedicine services are not eligible for reimbursement consideration for the following: ​
  • Triage to assess the appropriate place of 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 93, 95, GT, or FQ or place of service 02 or 10
  • 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 physical health services included in this policy​
REIMBURSEMENT

When the eligible physical health services are performed through telehealth by a participating professional provider, reimbursement for the physical health service will be at 85 percent of the provider allowance, subject to the specific terms and conditions of the participation agreement. 

Note: This does not apply to behavioral health services when performed through telehealth by a participating behavioral health 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 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 ​modifier (93, 95, FQ,GT) and appropriate place-of-service (POS) code 02 ​or 10 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.

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]. 2021. Available at: http://www.aafp.org/about/policies/all/primary-care.html. Accessed April 28, 2023.

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 April 28, 2023.

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.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/R178BP.pdf. Accessed April 28, 2023.

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 April 28, 2023.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub 100-04 Medicare Claims Processing. Transmittal 1423. [CMS Web site]. 01/01/2​008. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1423CP.pdf. Accessed April 28, 2023.

Centers for Medicare & Medicaid Services (CMS). CMS Manua​l 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 April 28, 2023.

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 April 28, 2023.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12 Section 190[CMS Web site].02/02/2023. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed April 28, 2023.

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 April 28, 2023.

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 April 28, 2023.

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.federalregister.gov/documents/2017/11/16/2017-24067/medicare-program-cy-2018-updates-to-the-quality-payment-program-and-quality-payment-program-extreme. Accessed April 28, 2023.

Centers for Medicare & Medicaid Services (CMS). Telehealth. [CMS Web site]. 12/01/2021. Available at: http://cms.gov/Medicare/Medicare-General-Information/Telehealth/. Accessed April 28, 2023.

Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare Learning Network. Telehealth Services. Rural Health Fact Sheet Series. [CMS Web site]. June 2021. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf. Accessed April 28, 2023.

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.kff.org/wp-content/uploads/sites/3/2014/10/fsmb_telemedicine_policy.pdf. Accessed April 28, 2023.

Federation of State Medical Boards. The appropriate Use of telemedicine technologies in the practive of medicine. [FSMB Web site]. April 2022. Available at: https://www.fsmb.org/siteassets/advocacy/policies/fsmb-workgroup-on-telemedicineapril-2022-final.pdf. Accessed April 28, 2023.

Health Resources & Services Administration. Telehealth policy changes after the COVID-19 public health emergency. February 2023. Available at: https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/policy-changes-after-the-covid-19-public-health-emergency. Accessed May 5, 2023.

Health Resources & Services Administration. Telehealth policy changes. January 2023. Available at: https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/telehealth-policy-updates. Accessed May 5, 2023.

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

CPT Procedure Code Number(s)
ELIGIBLE 

PHYSICAL HEALTH SERVICES

0591T, 0592T, 0593T, 77427, 90875, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 92002, 92004, 92012, 92014, 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92550, 92552, 92553, 92555, 92556, 92557, 92563, 92565, 92567, 92568, 92570, 92587, 92588, 92601, 92602, 92603, 92604, 92607, 92608, 92609, 92610, 92625, 92626, 92627, 93750, 93797, 93798, 94002, 94003, 94004, 94005, 94625, 94626, 94664, 95970, 95971, 95972, 95983, 95984, 96105, 96110, 96127, 96160, 96161, 97110, 97112, 97116, 97129, 97130, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97537, 97542, 97750, 97755, 97760, 97761, 97763, 97802, 97803, 97804, 98960, 98961, 98962, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99406, 99407, 99441, 99442, 99443, 99468, 99469, 99471, 99472, 99473, 99475, 99476, 99477, 99478, 99479, 99480, 99483, 99495, 99497, 99498

BEHAVIORAL HEALTH SERVICES

0362T, 0373T, 90849, 90875, 90901, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90853, 96110, 96112, 96113, 96116, 96121, 96125, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98960, 98961, 98962, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99406, 99407, 99441, 99442, 99443, 99483

E-VISITS

98970, 98971, 98972, 99421, 99422, 99423

ADDITIONAL PHYSICAL HEALTH SERVICES WHEN PERFORMED BY NETWORK PROVIDERS

97533, 99417, 99418​

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

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

HCPCS Level II Code Number(s)

ELIGIBLE 

PHYSICAL HEALTH SERVICES

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
G0136 Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 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)
G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (do not report g0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418, 99415, 99416). (do not report g0316 for any time unit less than 15 minutes)
G0317 Prolonged nursing facility evaluation and management service(s) beyond the  total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99306, 99310 for nursing facility evaluation and management services). (do not report g0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (do not report g0317 for any time unit less than 15 minutes)
G0318 Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99345, 99350 for home or residence evaluation and management services). (do not report g0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (do not report g0318 for any time unit less than 15 minutes)
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
G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
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
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)
G2025 Distant site telehealth services performed by RHC and FHQC
G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes)
G3002 Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care e.g., physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate. Requires initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using G3002, 30 minutes must be met or exceeded)
G3003 Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded)
G9685 Physician service or other qualified health care professional for the evaluation and management of a beneficiary's acute change in condition in a nursing facility. This service is for a demonstration project
S9152 Speech therapy, re-evaluation

BEHAVIORAL HEALTH SERVICES

G0136 Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes
G0316 Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (do not report g0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418, 99415, 99416). (do not report g0316 for any time unit less than 15 minutes)
G0317 Prolonged nursing facility evaluation and management service(s) beyond the  total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99306, 99310 for nursing facility evaluation and management services). (do not report g0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (do not report g0317 for any time unit less than 15 minutes)
G0318 Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99345, 99350 for home or residence evaluation and management services). (do not report g0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (do not report g0318 for any time unit less than 15 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
G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization or intensive outpatient​ setting, approximately 45 to 50 minutes
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.
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
G2025 Distant site telehealth services performed by RHC and FHQC
G2086 Office-based treatment for opioid use disorder, including dev​​elopment 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)
G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes)
G9685 Physician service or other qualified health care professional for the evaluation and management of a beneficiary's acute change in condition in a nursing facility. This service is for a demonstration project
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

VIRTUAL CARE 

G0071 Payment for communication technology-based services for 5 minutes or more of a virtual (nonface-to-face) communication between a 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
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
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 EM service provided within the previous 7 days nor leading to an EM service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

ADDITIONAL PHYSICAL HEALTH SERVICES WHEN PERFORMED BY NETWORK PROVIDERS​

G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language therapy maintenance program, each 15 minutes
G9873 First Medicare Diabetes Prevention Program (MDPP) core session was attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for core sessions
G9874 Four total Medicare Diabetes Prevention Program (MDPP) core sessions were attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for core sessions.
G9875 Nine total Medicare Diabetes Prevention Program (MDPP) core sessions were attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session is an MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for core sessions
G9876 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 7-9 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary did not achieve at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 7-9.
G9877 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 10-12 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary did not achieve at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 10-12.
G9878 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 7-9 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 7-9
G9879 Two Medicare Diabetes Prevention Program (MDPP) core maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 10-12 under the MDPP Expanded Model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 7 through 12 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at a core maintenance session in months 10-12
G9880 The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her baseline weight in months 1-12 of the MDPP services period under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 5% weight loss from baseline as measured by an in-person weight measurement at a core session or core maintenance session.
G9881 The MDPP beneficiary achieved at least 9% weight loss (WL) from his/her baseline weight in months 1-24 under the MDPP Expanded Model (EM). This is a one-time payment available when a beneficiary first achieves at least 9% weight loss from baseline as measured by an in-person weight measurement at a core session, core maintenance session, or ongoing maintenance session. 
G9882 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 13-15 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 13-15.
G9883 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 16-18 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 16-18.
G9884 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 19-21 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 19-21.
G9885 Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance sessions (MS) were attended by an MDPP beneficiary in months (mo) 22-24 under the MDPP Expanded Model (EM). An ongoing maintenance session is an MDPP service that: (1) is furnished by an MDPP supplier during months 13 through 24 of the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss (WL) from his/her baseline weight, as measured by at least one in-person weight measurement at an ongoing maintenance session in months 22-24.
G9890 Bridge Payment: A one-time payment for the first Medicare Diabetes Prevention Program (MDPP) core session, core maintenance session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP beneficiary during months 1-24 of the MDPP Expanded Model (EM) who has previously received MDPP services from a different MDPP supplier under the MDPP Expanded Model. A supplier may only receive one bridge payment per MDPP beneficiary.
G9891 MDPP session reported as a line-item on a claim for a payable MDPP Expanded Model (EM) HCPCS code for a session furnished by the billing supplier under the MDPP Expanded Model and counting toward achievement of the attendance performance goal for the payable MDPP Expanded Model HCPCS code.(This code is for reporting purposes only).
S9083 Global fee urgent care centers
S9128 Speech therapy, in the home, per diem
S9472 Cardiac rehabilitation program, nonphysician provider, per diem
S9473 Pulmonary rehabilitation program, nonphysician provider, per diem

NON-COVERED

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)

ELIGIBLE

0551 Skilled Nursing- Visit Charge
0561 Home Health (HH) Medical Social Services - Visit Charge
0562 Home Health (HH) Medical Social Services -Hourly Charge
0590 Home Health (HH) Units of Service - General Classification
0651 Hospice Service - Routine Home Care
0652 Hospice Service - Continuous  Home care
0655 Hospice Service - Inpatient Respite Care
0656 Hospice Service - General Inpatient Care Nonrespite
​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
0943 Other Therapeutic Services (see also 095X, an extension of 094X)-Cardiac Rehabilitation
0948 Other Therapeutic Services (see also 095X, an extension of 094X)-Pulmonary Rehabilitation

Modifiers

COVERED

95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications system
FR The supervising practitioner was present through two-way, audio/video communication technology 
G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke
GT Via interactive audio and video telecommunications system

THE FOLLOWING MODIFIERS ARE APPLICABLE FOR BEHAVIORAL HEALTH SERVICES ONLY

93 Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
FQ The service was furnished using audio-only communication technology

NON-COVERED

GQ Via Asynchronous telecommunications system

Policy History

Revisions From MA00.036i :
01/02/2024
The following codes were added to the policy under physical health and behavioral health:

0591T, 0592T, 0593T, 98966, 98967, 98968, 99441, 99442, 99443, G0136

​The following CPT narratives have been revised in this policy:

99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99306, 99308, G0410​

Revisions From MA00.036h:
​01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
06/01/2023This version of the policy will become effective 06/01/2023.​ The following criteria have been updated to address the following for Telehealth services:​
  • ​Home was added as an eligible originating site.
  • Physical therapist, occupational therapist, speech language pathologist, audiologist were added as eligible providers.
  • In-person visit requirements for behavioral health disorders have been added to the criteria
  • Criteria for virtual check-in, e-visits, and additional telehealth coverage was added to the policy
  • Criteria for audio-only communications was added to the policy
  • A change in provider reimbursement for certain services delivered through telemedicine.
  • Criteria for not eligible for reimbursement was updated.
  • As previously communicated through an article, the following codes were added to the policy as eligible to be performed through telemedicine:
    • ​Procedure Codes - 0362T, 0373T, 774​27, 90875, 90901, 90849, 90853, 90953, 90956, 90959, 90962, 92002, 92004, 92012, 92014, 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92550, 92552, 92553, 92555, 92556, 92557, 92563, 92565, 92567, 92568, 92570, 92587, 92588, 92601, 92602, 92603, 92604, 92607, 92608, 92609, 92610, 92625, 92626, 92627, 93750, 93797, 93798, 94002, 94003, 94004, 94005, 94625, 94626, 94664, 95970, 95971, 95972, 95983, 95984, 96105, 96110, 96112, 96113, 96121, 96125, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 97110, 97112, 97116, 97129, 97130, 97150, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97763, 98960, 98961, 98962, 99221, 99222, 99223, 99234, 99235, 99236, 99238, 99239, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99304, 99305, 99306, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99417, 99418, 99468, 99469, 99471, 99472, 99473, 99475, 99476, 99477, 99478, 99479, 99480, 99483, 99495, 99496, 99497, 99498, G0071, G0153, G0161, G0316, G0317, G0318, G0410, G0422, G0423, G2010, G2012, G2025, G2211, G2212, G2250, G2251, G2252, G3002, G3003, G9685, G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880, G9881, G9882, G9883, G9884, G9885, G9890, G9891, H0015, H0035, S0201, S9083, S9128, S9152, S9472, S9473, S9480​

      Modifiers - 93, FQ, FR

      Revenue Codes - 0561, 0562, 0551, 0590, 0905, 0906, 0912, 0913, 0651, 0652, 0655, 0656, 0943, 0948

  • ​Modifiers 93, FQ, and FR and Place of Service 10 was added to the billing requirements.

Revisions From MA00.036g:
04/01/2020This policy has been identified for the HCPCS code update, effective 04/01/2020.

The following HCPCS narratives have been revised in this policy: G2061 G2062 G2063

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 Telehealt​h
01/01/2015This is a new policy.
01/02/2024
03/11/2024
N/A
MA00.036
Claim Payment Policy Bulletin
Medicare Advantage
No