Coverage Policy Manual
Policy #: 2015034
Category: Medicine
Initiated: January 2016
Last Review: May 2018
  Telemedicine

Description:
Telemedicine is the use of telecommunication for the delivery of healthcare when distance separates the provider and the patient. Telemedicine has been advocated as a means to provide healthcare to underserved areas and to facilitate timely consultation in urgent situations.
 
Telemedicine includes consultation, diagnostic, monitoring, and therapeutic services delivered via a two-way, synchronous, HIPAA compliant audio and video telecommunication system. A telemedicine visit involves an exchange between a patient and a provider at geographically different locations.
 
The Originating Site is the location of the patient during a telemedicine encounter..
 
Coding Guidelines:
 
The provider at the Distant Site must submit claims for telemedicine services using the appropriate CPT or HCPCS code for the professional service delivered, along with the telemedicine modifier GT, “via interactive audio and video telecommunications systems” or 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system). The –GT or 95 modifiers should appear in modifier field 1. The provider must also use POS 02 (telemedicine distant site) when billing CPT or HCPCS with a GT or 95 modifier.
 
The Originating Site must submit claims for the facility for telemedicine services using HCPCS code Q3014, “Telehealth Originating Site facility fee.” The Q3014 must be submitted for the same date of service as the professional code, and it must indicate the physical location of the facility where the member was at the time of the telemedicine encounter. Q3014 should be submitted only if the encounter occurs in an outpatient medical facility or clinic; it should not be submitted and is not reimbursable for encounters which occur outside of a clinical setting.  Q3014 should not be submitted for telemedicine encounters in settings which are reimbursed on a global, DRG, or per diem basis.
 
The claim for Q3014 should name a provider who is responsible for care of the member at the Originating Site rather than the name of a facility (except in the case of hospital facility claims). However, this provider is not required to be present in the Originating Site at the time of the visit. For telemedicine visits where the Originating Site is in the outpatient hospital setting, the claim may be submitted as an outpatient hospital claim (place of service 22) with the originating site billing Q3014.  All other Originating Sites must file claims for Q3014 using the HCFA1500 claim form. For inpatient services, Q3014 is not separately reimbursable.
 
Definitions:
 
Synchronous: A term used to describe interactive video connections, indicating that the transmission of information in both directions is occurring at the same time (synchronously). Synchronous telemedicine services are reported using modifier –GT.
 
Asynchronous: A term used to describe store and forward transmission of medical images or information, because the transmission typically occurs in one direction at a time. An example would be sending a photograph to a specialist, who will subsequently provide an interpretation to the sender. Asynchronous telemedicine services are reported using modifier –GQ.
 
Distant Site: Also called the “Hub” or “Consultant” site. The Distant Site is defined as the site where the rovider/specialist is physically located during an encounter with a patient who is at the Originating Site.
 
Originating Site: Also call the “Spoke” or “Patient” site. The Originating Site is defined as the location of the patient during the telehealth encounter or consult.
 
Presenter: Telemedicine encounters require the Distant Site provider to perform an exam of a patient from many miles away. In order to accomplish that task, an individual trained in the use of the equipment must be available at the Originating Site of a medical visit to “present” the patient, manage the cameras, and perform any “hands-on” activities as necessary to successfully complete the exam.

Policy/
Coverage:
EFFECTIVE JANUARY 2018
 
Telemedicine is covered when ALL of the following conditions are met:
 
1. The service is one which is allowed for the specific provider type when done in a face-to-face setting, and can be safely and effectively performed via telemedicine to the same standard of care as with a face-to-face visit.
2. If the originating site is a clinical setting,  a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
3. The encounter is by real-time audio visual communication.  (Store-and-forward, asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
4. A clinical record of the encounter which contains at least the same elements as are included in a face-to-face encounter record is maintained; the location of the Originating Site and Distant Site, along with the date and time of the connection must be recorded in the note.
5. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg stethoscope, otoscope, etc giving a diagnostic-quality signal to the provider) OR a qualified, licensed person capable of performing the exam supplements the examination and relays the findings to the provider.
6. Data transmission must be accomplished using a HIPAA-compliant network, with sufficient bandwidth and screen resolution to permit adequate interaction with the patient and assessment of behavioral and physical features.   The network must maintain a log of connections, with time, date, and duration.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
7. The Distant Site provider must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that provider.
 
The following services are not covered:
 
1. Any other telehealth or telemedicine services not meeting the above criteria.
2. eICU monitoring as an adjunct to intensive care unit services.
3.Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.
4. Telephonic, asynchronous, fax, email, store-and-forward and telemonitoring services.
5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
6. Store and forward interpretation of physical exam findings.
7. An originating site fee is not allowed if a member is on the same campus as the provider at the time of the visit.
8. Prescribing and dispensing durable medical equipment (DME).
 
EFFECTIVE PRIOR TO JANUARY 2018
 
Telemedicine is covered when ALL of the following conditions are met:
 
    1. The service is one which is allowed for the specific provider type when done in a face-to-face setting, and can be safely and effectively performed via telemedicine.
    2. A Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather data.  This is not required if the member has end-stage renal disease and the Originating Site is the home.
    3. The member is physically present during the visit in a hospital facility or provider’s office.   This requirement does not apply to members with end-stage renal disease, who may be in their home at the time of a telemedicine visit.
    4. The telemedicine provider has a professional relationship with the member.  A professional relationship exists if:
        1. The provider has previously established a face-to-face professional relationship with the member  (or)
        2. The member has been referred to the telemedicine provider (or provider group) by a provider who has an on-going professional relationship with the member (and)
        3. The provider (or provider’s group) is able to provide appropriate follow-up care when necessary.
    5. The encounter is by real-time audio visual communication.  (Store-and-forward, asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
    6. A clinical record of the encounter which contains at least the same elements as are included in a face-to-fact encounter record is maintained; the location of the Originating Site and Distant Site, along with the date and time of the connection must be recorded in the note.
    7. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg stethoscope, otoscope, etc giving a diagnostic-quality signal to the provider) OR a qualified, licensed person capable of performing the exam supplements the examination and relays the findings to the provider.
    8. Data transmission must be accomplished using a HIPAA-compliant network, with sufficient bandwidth and screen resolution to permit adequate interaction with the patient and assessment of behavioral and physical features.   The network must maintain a log of connections, with time, date, and duration.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
    9. The Distant Site provider must be licensed as required by the appropriate state's Medical Board. The Distant Site provider must be an allopathic or osteopathic physician, except in the case of bahavioral health/mental health services, in which case, the provider must be a licensed clinical social worker, licensed psychologist, licensed professional counselor,  Certified Nurse Practioners or Clinical Nurse Specialists who meet the criteria for Psychiatric Procedure Scope of Practice (in policy #2008010, 2008015) or a licensed allopathic or osteopathic physician.
    10. The provider at the Distant Site and the provider or facility at the Originating Site is credentialed by Arkansas Blue Cross Blue Shield as telemedicine providers.  This requirement holds regardless of whether the providers are in- or out-of-network.
 
The following services are not covered:
 
        1. eICU monitoring as an adjunct to intensive care unit services.
        2. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.
        3. Telephonic, asynchronous, fax, email, store-and-forward and telemonitoring services.
        4. Any other telehealth or telemedicine services not meeting the above criteria.
        5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
 

CPT/HCPCS:
90791Psychiatric diagnostic evaluation
90792Psychiatric diagnostic evaluation with medical services
90832Psychotherapy, 30 minutes with patient
90833Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834Psychotherapy, 45 minutes with patient
90836Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837Psychotherapy, 60 minutes with patient
90838Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90845Psychoanalysis
90846Family psychotherapy (without the patient present), 50 minutes
90847Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90863Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure)
96150Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96151Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
96152Health and behavior intervention, each 15 minutes, face-to-face; individual
99201Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99212Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99221Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Typically, 30 minutes are spent at the bedside and on the patient's hospital floor or unit.
99222Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.
99231Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit.
99232Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.
99238Hospital discharge day management; 30 minutes or less
99239Hospital discharge day management; more than 30 minutes
99281Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor.
99282Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity.
99283Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.
99284Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function.
99406Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
99408Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
99495Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge
99496Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge
Q3014Telehealth originating site facility fee

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.