Description
Telehealth is a potentially useful tool that, if employed appropriately, can provide important benefits to patients, including: increased access to health care, expanded utilization of specialty expertise, rapid availability of patient records, and the reduced cost of patient care.

Definition of services:
Telehealth is the interaction of patient and clinician via electronic communications to improve a patient’s clinical health status. Telehealth includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications. It is frequently initiated by the patient through a secure, encrypted interchange.

Policy 
Telehealth services are considered MEDICALLY NECESSARY if they meet the guidelines below. 

Policy Guidelines 
Services using secure telehealth technologies between a provider in one location and a patient in another location may be reimbursed when all of the following conditions are met:

• The patient is present at the time of service.
• All services provided are medically appropriate and necessary.
• The encounter satisfies the elements of the patient-provider relationship, as determined by the relevant healthcare regulatory board of the state where the patient is physically located.
• The service takes place via an interactive audio and video telecommunications system. Interactive telecommunications systems must be multi-media communication that, at a minimum, includes audio and video equipment permitting real-time consultation among the patient, consulting practitioner, and referring practitioner (as appropriate).
• The service is conducted over a secured channel with provisions described in Policy Guidelines.
• A permanent record of online communications relevant to the ongoing medical care and follow-up of the patient is maintained as part of the patient’s medical record.
• The extent of any evaluation and management services (E/M) provided over the Telehealth technology includes at least a problem focused history and straight forward medical decision making, as defined by the current version of the Current Procedural Terminology (CPT) manual.
• The provider is approved to perform telehealth services.

Telehealth services are not reimbursed for the following:

• Telehealth that occurs the same day as a face to face visit, when performed by the same provider and for the same condition.
• Services performed via asynchronous communications systems.
• Services performed via telephonic (audio only) consultations (See Section “Benefits Application” regarding availability of member benefits for telephonic services.) that originates from a related E/M service provided within the previous 7 days or leads to an E/M service or procedure within 24 hours.
• Triage to assess the appropriate place of service and/or appropriate provider type.
• Patient communications incidental to E/M, counseling, or medical services covered by this policy, including, but not limited to:
  • Reporting of test results that are not deemed abnormal and require a face to face visit.
  • Provision of educational materials.
• 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.

Approved Clinicians who may bill for a covered telehealth services are listed below:

• Physician
• Nurse practitioner
• Physician assistant
• Clinical nurse specialist
• Clinical psychologist
• Clinical social worker
• Licensed professional counselor
• Licensed marriage and family therapist
• Physical therapist
• Occupational therapist
• Speech therapist

Telehealth is an effective means of providing health care to patients with accessibility problems, including living in isolated communities, physical disabilities or chronic illnesses. Telehealth has become increasingly important in the healthcare community and general population.

Security and Confidentiality
Providers who utilize telehealth systems must consider security, patient confidentiality, and privacy. A secured electronic channel is required to be utilized by a telehealth provider. The electronic channel must be secured, encrypted, and include and support all of the following:

• A mechanism to authenticate the identity of correspondent(s) in electronic communication and to ensure that recipients of information are authorized to receive it
• The patient’s informed consent to participate in the consultation, including appropriate expectations, disclaimers and service terms, and any fees that may be imposed. Expectations for appropriate use must be specified as part of the consent process including: use of specific written guidelines and protocols, avoiding emergency use, heightened consideration of use for highly sensitive medical topics, relevant privacy issues.
• An established turnaround time for responses from the provider. The system should alert the physician or practice that there is an outstanding request for an e-visit.
• Structured symptom assessment and risk reduction features. (i.e., patients are directed to contact the practice and/or emergency room if certain symptoms are reported).
• An electronic communication system that generates an automatic reply to acknowledge receipt of messages or indicates that the provider is unable to respond
• The name and patient identification number.
• A standard block of text contained in the provider’s response that displays the physician’s full name, contact information and reminders about security and the importance of alternative forms of communication for emergencies
• No inclusion of third party advertising and the patient’s information is not to be used for marketing
• Payment Card Industry Data Security Standard (PCI-DSS) compliant

• A fully executed Business Associate Agreement (BAA) with the telehealth vendor, system or platform

Protocols for the Telehealth Visit

• Dress appropriately for the virtual visit. We recommend the same level of professional attire as in your practice. This is especially true if you are conducting the visit from the privacy of your home office. The telehealth visit should duplicate the same level of professionalism found in your physician office address.
• For recommendations on lighting & cameras, walls & backdrops, etc. please review the document published by the American Telemedicine Association, “Let There Be Light: A Quick Guide to Telemedicine Lighting” (http://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941-c5bf3db5669a/UploadedImages/NEW%20Practice%20Guidelines/Let_There_Be_Light_Quick_Guide.pdf) 

Termination of expanded telehealth services related to the COVID-19 pandemic:

Effective 05/01/2021 the following services will no longer be allowed as telehealth services: 98966 – 98968, 92521,92526, 92610, 97110, 97112, 97162, 97163, 97166, 97167, 97530, 99217 – 99226, 99231 – 99236, 99238 – 99239, 99281 – 99285, 99291 – 99292, 99382 – 99387, 99392 – 99397, 99341 – 99350, G0151 – G0155, G0159 – G0162, S9127 – S9131, G0299, G0300, Q5001, S9123, S9124, T1030, T1031, 99495 and 99496

TEMPORARY EXPANSION OF REIMBURSEMENT FOR TELEHEALTH SERVICES:

In response to the recent coronavirus (COVID-19) outbreak, expanding reimbursement for all services delivered through telehealth that meet the coverage criteria in the policy. The expansion supports the diagnosis and treatment of COVID-19 as well as minimizes unnecessary exposure to individuals needing medical care for other conditions. Reimbursement for the expanded set of services delivered through telehealth will be in place for 30 days starting March 16, 2020, and then be re-evaluated for possible extension. 

Effective April 9, 2020, the expansion of telehealth services has been extended to May 16, 2020, with reevaluation for possible extension on or before May 16, 2020.

Effective May 12, 2020, the expansion of telehealth services has been extended to June 15, 2020, with reevaluation for possible extension on or before June 15, 2020.

Effective June 10, 2020, the expansion of telehealth services has been extended to Aug. 1, 2020, with reevaluation for possible extension on or before Aug. 1, 2020.

Effective July 16, 2020, the expansion of telehealth services has been extended to Oct. 1, 2020, with the following change effective Aug. 1, 2020, no longer pay for telehealth delivered via non-HIPAA compliant technologies. 

Effective Sept. 8, 2020, the expansion of telehealth services has been extended to Dec. 31, 2020, telehealth delivered via non-HIPAA compliant technologies will remain non covered.

Effective Jan. 1, 2021, the expansion of telehealth services will continue to be allowed until further notice. Ongoing coverage will be continually assessed during the COVID-19 pandemic. Telehealth delivered via non-HIPAA-compliant technologies will remain noncovered.

In some settings, video capability may not be available, or the member may ask to discontinue the video. Telehealth consultations during this temporary expansion may be performed telephonically. This includes temporary coverage of the following telephonic evaluation and management services:  

98966: TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5 – 10 MINUTES OF MEDICAL DISCUSSION

98967: TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 11 – 20 MINUTES OF MEDICAL DISCUSSION

98968: TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 21 – 30 MINUTES OF MEDICAL DISCUSSION 

Medical record documentation may be requested and audited to confirm the medical appropriateness of these telephone-based services.  

Effective immediately (03/19/2020) evaluation and management services reflected by the following code sets 99201 – 99203 and 99211 – 99215 with modifier 95 appended. Providers will need to continue to use the previously established application process for this to apply to their practices. This does NOT apply to telephone based visits which are reflected in the code set 99441 – 99443.

In conjunction with the temporary expansion detailed above, speech, physical and occupational therapy visits may be filed with the above criteria and modifier -95. The following codes may be filed to reflect the services provided: 92507, 92521 – 92526, 92610, 97110, 97112, 97129, 97130, 97161-97168 and 97530. Providers will also need to also submit an application for telehealth coverage.

In conjunction with the above expanded services, effective March 19, 2020, CPT code services reflected by 90853 will be added to telehealth coverage.

Additional expansion of telehealth services include the following code sets observation care, Inpatient hospital care (99217 – 99226, 99231 – 99236, 99238 – 99239), emergency department care (99281 – 99285), and Critical Care (99291 – 99292) with modifier 95 appended . Providers will need to continue to use the previously established application process for this to apply to their practices. This does NOT apply to telephone based visits which are reflected in the code set 99441 – 99443. 

Effective April 16, 2020, telehealth services will be expanded to allow for preventive medicine services. Codes 99382 – 99387 or 99392 – 99397 filed with modifier 95 must be utilized to represent these services. Providers will need to use the previously established telehealth application process for this to apply to their practices. This does not apply to telephone based services which are reflected in the code set 99441 – 99443. It is expected that the usual other objective components of a well visit (weight, height, vital signs, physical exam and in-office testing and screening) be completed within 60 days of the pandemic end with no submission of additional E&M codes to BCSBSC. The office records from the completion of the telehealth service must contain the date of the telehealth visit for auditing purposes. Additionally, vaccines and immunizations related to these telehealth visits should be administered and filed with no change to coding or associated reimbursement for those services also within 60 days of the termination of the pandemic. Audit of these visits and follow-up care will be done at the discretion of the plan. 

Effective immediately April 16, 2020, a temporary expansion of home health services and hospice services will allow these services to be provided via telehealth when filed with a 95 modifier subject to the member’s benefits and limitations during the COVID-19 pandemic: 99341 – 99350, G0151 – G0155, G0159 – G0162, S9127 – S9131, G0299, G0300, Q5001, S9123, S9124, T1030, T1031, 92507, 92521-92526, 97110, 97112, 97129, 97130, 97161 – 97168 and 97530. Provider will also need to submit an application for telehealth coverage. 

Effective July 10, 2020, transitional care management services reflected with codes 99495 and 99496 will be included in the expansion of telehealth services related to the COVID-19 outbreak.

The above temporary modifications apply to all licensed and credentialed providers in their scope of practice. While these temporary modifications are in place, there will be a waiver of the portion of the CPT verbiage that relates to visits provided within 7 days. Two telephonic services may occur within 7 days during the temporary modification period.

Effective 01012022 CPT codes 99204 and 99205 will be allowable for specialty types 26, 90 and 91 only.

References 

1. 1997 North Carolina Senate Bill 780
2. Medical Policy Advisory Group - 12/99
3. Medical Policy Advisory Group - 3/1/2001
4. Specialty Matched Consultant Advisory Panel - 9/2002
5. Medical Policy Advisory Group - 10/2003
6. Medical Policy Advisory Group - 9/2005
7. Agency for Healthcare Research and Quality (AHRQ). Telemedicine for the Medicare Population: Update. Evidence Report/Technology Assessment Number 131. Rockville, MD: AHRQ; February 2006. Use update from AHRQ http://www.innovations.ahrq.gov/content.aspx?id=2847
8. Specialty Matched Consultant Advisory Panel- 2/2012
9. Centers for Medicare & Medicaid Services. Available online at http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/
10. Centers for Medicare & Medicaid Services. Telehealth Services. Available online at www.cms.gov/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf . Last accessed February 2013.
11. North Carolina General Assembly. Telemedicine. Available online at: www.ncga.state.nc.us. Last accessed February 2013.
12. North Carolina General Assembly. http://www.ncleg.net/Sessions/2009/Bills/House/PDF/H1189v3.pdf
13. Dixon BE, Hook JM, McGowan JJ. Using Telehealth to Improve Quality and Safety: Findings from the AHRQ Portfolio (Prepared by the AHRQ National Resource Center for Health IT under Contract No. 290-04-0016). AHRQ Publication No. 09-0012-EF. Rockville, MD: Agency for Healthcare Research and Quality. December 2008.Available at http://healthit.ahrq.gov/images/dec08telehealthreport/telehealth_issue_paper.htm. Last accessed February 2013.
14. Specialty Matched Consultant Advisory Panel- 2/2013
15. American Medical Association Policy H-160.937 The Promotion of Quality Telemedicine. https://ssl3.ama-assn.org/apps/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=%2fresources%2fhtml%2fPolicyFinder%2fpolicyfiles%2fHnE%2fH-160.937.HTM
16. North Carolina Medical Board (NCMB). Position Statement: Telemedicine. 11/2014. http://www.ncmedboard.org/position_statements/detail/telemedicine
17. North Carolina Medical Board (NCMB). Position Statement: The physician-patient relationship. 7/2012. http://www.ncmedboard.org/position_statements/detail/the_physician-patient_relationship
18. http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/IDEATel_FirstReport.pdf
19. AMA Guidelines for Physician-Patient Electronic Communications. http://www.ama-assn.org/ama/pub/catergory/print/2386.html
20. The AMA Code of Medical Ethics Opinion 5.026: The Use of Electronic Mail. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion5026.page
21. Council on Ethical and Judicial Affairs Report 3-1-02: Ethical Guidelines for the Use of Electronic Mail between Patients and Physicians, adopted December 2002. http://ppmedmn.com/AMA%20Council%20on%20Ethical%20and%20Judicial%20Affairs%20-%20June%20%2703.doc.pdf
22. H-478.997 Guidelines for Patient-Physician Electronic Mail http://hosted.ap.org/specials/interactives/_documents/patient_physician_email.pdf
23. General assembly of North Carolina. Session 2013. Senate bill 533. Study Telemedicine & Health Home Initiatives.
24. http://www.ncleg.net/Sessions/2013/Bills/Senate/PDF/S533v1.pdf
25. American Telemedicine Association. What is Telemedicine?
26. http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VIrub_ldUVc
27. North Carolina Board of Pharmacy (NCBOP). Rules, Statutes, Board Policies. 1/2015.
28. http://www.ncbop.org/LawsRules/Rules.pdf
29. Medical Director review 12/2014
30. Centers for Medicare & Medicaid Services (CMS). Claims Processing Manual 2015 for Telemedicine (190-190.5). http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
31. American Medical Association (AMA). Chicago. Current Procedural Terminology (CPT) 2015.
32. Medical Director review 7/2015 

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

Disclaimer: Please refer to contract requirements as this policy does not guarantee payment of telehealth services.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,  and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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