Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2017 Title: Telemedicine Payment Policy
Revision Date: 07/01/2020 Document: BI529:00
CPT Code(s): 0780, 90785, 90791, 90792, 90832-90834, 90836-90840,90863, 90951-90962, 99201-99205, 99211-99215, 99285, G2010, G2012, Q3014, 0607T, 0608T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, there is no coverage.

Telemedicine is the use of electronic information and communication technology to deliver healthcare services, including without limitation the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient. It includes store-and-forward technology and remote patient monitoring.

Telemedicine visit requires a two-way, 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 any location where the patient is located during provision of telemedicine services

 

Remote Intraoperative Neurophysiologic Monitoring is not covered. Please refer to

BI381 for Intraoperative Neurophysiologic Monitoring.

 

Remote monitoring of an external continuous pulmonary fluid monitoring system is not covered.

 

Reimbursement for telemedicine services requires one time submission of signed

 

Please see the Provider forms at QualChoice.com.


Medical Statement

Coverage for Telemedicine services requires ALL of the following: 

  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 may be available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather data.
  3. The member does not have to be physically   at a hospital facility or provider’s office during the telemedicine visit.
  4. The telemedicine provider has a professional relationship with the member.  A professional relationship exists if:

a)    The healthcare professional has previously conducted an in-person examination or personally knows the member and the member`s relevant health status through an ongoing personal or professional relationship and is available to provide appropriate follow-up care, when necessary, at medically necessary intervals.

b)    The treatment is provided by a healthcare professional in      consultation with, or upon referral by, another healthcare professional who has an ongoing relationship with the member and who has agreed to supervise the member`s treatment, including follow-up care;

                                    i.        An on-call or cross-coverage arrangement exists with the patient`s regular treating healthcare professional or another healthcare professional who has established a professional relationship with the patient;

                                   ii.        A relationship exists in other circumstances as defined by

the Arkansas State Medical Board for healthcare professionals.

                                  iii.        A relationship exists in other circumstances as defined by

licensing or certification board for other healthcare professionals, if the rules are not less restrictive than the rules of the Arkansas State Medical Board;

 

               The existence of a professional relationship is not required in Emergency

             situations where the life or health of the patient is in danger or imminent danger

             or providing generic information.

 

The encounter for telemedicine visit requires following:

1.    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 and available on request

2.    For visits which include a physical exam, the equipment allows for remote examination by the provider (e.g. 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.

3.    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.

4.    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 behavioral health/mental health services, in which case, the provider must be a licensed clinical social worker, licensed psychologist, licensed professional counselor, Certified Nurse Practitioners or Clinical Nurse Specialists or a licensed allopathic or osteopathic physician.

5.    The provider at the Distant Site and the provider or facility at the Originating Site has completed trainings and has Certification for providing Telemedicine services by a nationally or locally recognized organization, such as The American Telemedicine Association or Arkansas eLink.  

Definitions:

Telemedicine:  Is the use of electronic information and communication technology to deliver healthcare services, including without limitation the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient. Telemedicine includes store-and-forward technology and remote patient monitoring.

 

"Telemedicine" does not include the use of:

(i)  Audio-only communication, including without limitation interactive audio;

(ii)  A facsimile machine;

(iii) Text messaging; or

(iv) Electronic mail systems

 

Remote patient monitoring: Use of synchronous or asynchronous electronic information and communication technology to collect personal health information and medical data from a patient at an originating site that is transmitted to a healthcare professional at a distant site for use in the treatment and management of medical conditions that require frequent monitoring;

Store-and-forward technology: Is the asynchronous transmission of a patient`s medical information from a healthcare professional at an originating site to a healthcare professional at a distant site;

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).

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.

Distant Site: Also called the “Hub” or “Consultant” site. The Distant Site is defined as the site where the provider/specialist is physically located during an encounter with a patient who is at the Originating Site.

Originating Site: Also called the “Patient” site. The Originating Site is defined as the location of the patient during the telemedicine services encounter.

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.

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 95, “Synchronous Telemedicine Service Rendered via a Real-Time Interactive Audio and Video Telecommunications System.” The provider must also use Place of Service 02 (Telemedicine Distant Site) when billing CPT codes with a modifier 95.

The Originating Site must submit claims for the facility for telemedicine services using HCPCS code Q3014, “Telehealth Originating Site facility fee.” Code 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. In the case of a member with end-stage renal disease and the place of service is Home, code Q3014 does not apply and should not be submitted.  

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. 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 hospital setting, the claim may be submitted as an outpatient hospital claim. All other Originating Sites must file claims for Q3014 using the HCFA1500 claim form. For inpatient services, Q3014 is not separately reimbursable.

 

90847 Family Counseling is only covered for CHI members via Telemedicine.

Codes Used In This BI:

0780

REV Code for TeleHealth Site Fee

90785

Interactive complexity

90791

Psychiatric diagnostic evaluation

90792

Psychiatric diagnostic evaluation w/medical svcs

90832

Psychotherapy, 30 mn w/patient

90833

Psychotherapy, 30 mn w/patient when performed w/an E/M svc

90834

Psychotherapy, 45 mn w/patient

90836

Psychotherapy, 45 mn w/patient when performed w/an E/M svc

90837

Psychotherapy, 60 mn w/patient

90838

Psychotherapy, 60 mn w/patient when performed w/an E/M svc

90839

Psychotherapy for crisis; first 60 mn

90840

       ea addt’l 30 mn

90863

Pharmacologic mgmt, incl prescr & rvw of medication, when perf w/psychotherapy svcs

90951

ESRD related svcs mthly, patients <2 yrs to incl monitoring for nutrition, assess of grwth & dvlpmnt, counslng of parents; w/4 or more face-to-face visits by a physician or othr qual hlth care prof per mth

90952

       w/2 - 3 face-to-face visits by a physician or othr qual hlth care prof per mth

90953

       w/1 face-to-face visit by a physician or othr qual hlth care prof per mth

90954

ESRD related svcs mthly, patients 2 - 11 yrs to incl monitoring for nutrition, assess of grwth & dvlpmnt, counslng of parents; w/4 or more face-to-face visits by a physician or othr qual hlth care prof per mth

90955

       w/2 - 3 face-to-face visits by a physician or othr qual hlth care prof per mth

90956

       w/1 face-to-face visit by a physician or othr qual hlth care prof per mth

90957

ESRD related svcs mthly, patients 12 - 19 yrs to incl monitoring for nutrition, assess of grwth & dvlpmnt, counslng of parents; w/4 or more face-to-face visits by a physician or othr qual hlth care prof per mth

90958

       w/2 - 3 face-to-face visits by a physician or othr qual hlth care prof per mth

90959

       w/1 face-to-face visit by a physician or othr qual hlth care prof per mth

90960

ESRD related svcs mthly, patients age 20 yrs and older to incl monitoring for nutrition, assess of grwth & dvlpmnt, counslng of parents; w/4 or more face-to-face visits by a physician or othr qual hlth care prof per mth

90961

       w/2 - 3 face-to-face visits by a physician or othr qual hlth care prof per mth

90962

       w/1 face-to-face visit by a physician or othr qual hlth care prof per mth

99201

Office or other outpt visit for the eval/mgmt of a new patient; Straightforward MDM (code deleted and replaced by 99202 eff 01-01-2021)

99202

Ofc or other outpt vst for the eval/mgt of a new pt, which requires a medically appropriate history and/or exam and straightforward mdm. When using time for code selection, 15-29 min of total time is spent on the date of the encounter. (code revised eff 01-01-2021)

99203

Ofc or other outpt vst for the eval/mgt of a new pt, which requires a medically appropriate history and/or exam and low level of mdm. When using time for code selection, 30-44 min of total time is spent on the date of the encounter. (code revised eff 01-01-2021)

99204

Ofc or other outpt vst for the eval/mgt of a new pt, which requires a medically appropriate history and/or exam and moderate level of mdm. When using time for code selection, 45-59 min of total time is spent on the date of the encounter (code revised eff 01-01-2021)

99205

Ofc or other outpt vst for the eval/mgt of a new pt, which requires a medically appropriate history and/or exam and high level of mdm. When using time for code selection, 60-74 min of total time is spent on the date of the encounter. (code revised eff 01-01-2021)

99211

Ofc or other outpt vst for the eval/mgt of an est pt, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. (code revised eff 01-01-2021)

99212

Ofc or other outpt vst for the eval/mgt of an est pt, which requires a medically appropriate history and/or exam and straightforward mdm. When using time for code selection, 10-19 min of total time is spent on the date of the encounter. (code revised eff 01-01-2021)

99213

Ofc or other outpt vst for the eval/mgt of an est pt, which requires a medically appropriate history and/or exam and low level of mdm. When using time for code selection, 20-29 min of total time is spent on the date of the encounter. (code revised eff 01-01-2021)

99214

Ofc or other outpt vst for the eval/mgt of an est pt, which requires a medically appropriate history and/or exam and moderate level of mdm. When using time for code selection, 30-39 min of total time is spent on the date of the encounter. (code revised eff 01-01-2021)

99215

Ofc or other outpt vst for the eval/mgt of an est pt, which requires a medically appropriate history and/or exam and high level of mdm. When using time for code selection, 40-54 min of total time is spent on the date of the encounter (code revised eff 01-01-2021)

99285

Emergency dept visit for the eval/mgmt of a patient; High MDM

G2010

Rem eval of rec video or image (store & fwd) w interp & f/u w pt in 24 hrs

G2012

Brief (5-10 min) remote, tech-based communication w est pt.

Q3014

Telehealth originating site facility fee

0607T

Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment (new code 7/1/2020): E/I

 

0608T

Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency-derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional (new code 7/1/2020): E/I

 


Limits

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)    Use of Telemedicine services for providing Applied Behavioral analysis (refer to BI 322), Psychological testing (refer to BI174) and Neuropsychological testing (refer to BI005) is not covered.

4)    Any other telehealth or telemedicine services not meeting the above criteria.

5)    Remote monitoring of external continuous pulmonary fluid monitoring system

Evaluation and management services of the highest level (e.g. 99205, 99215, and 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.

90847 Family Counseling is only covered for CHI members via Telemedicine.

Professional relationship does not include a relationship between a healthcare professional and a patient established only by the following:

(1) An internet questionnaire; 

(2) An email message;

(3) Patient-generated medical history;

(4) Audio-only communication, including without limitation interactive audio;

(5) Text messaging;

(6) A facsimile machine; or

(7) Any combination thereof


Background

Refer to Arkansas Act 887.


Reference

References:

Arkansas Code A.C.A. 17-80-118

Addendum:

Effective 01/01/2018: Updated definitions of Originator site per AR Law update, Place of service 02 (home) can be used as the originator site for any telemedicine visit irrespective of the diagnosis. Modifiers GT or 95 can be used with telemedicine visits.

Effective 01/01/2018: Use of Telemedicine services for providing Applied Behavioral analysis (refer to BI 322), Psychological testing (refer to BI174) and Neuropsychological testing (refer to BI005) is not covered. Providers are required to submit, one time, a signed Telemedicine Attestation form to QualChoice in order to be reimbursed for telemedicine services.

 Effective 01/01/2018: Added new codes.

Effective 07/01/2020: Added new E/I codes (0607T, 0608T)

Effective 01/01/2021: Deleted code 99201 and replaced by 99202.  Updated revised codes 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214 & 99215.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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