Highmark Medicare Advantage Medical Policy in West Virginia

Section: Miscellaneous
Number: Z-68
Topic: Telemedicine/Telehealth Services
Effective Date: August 8, 2011
Issued Date: August 8, 2011

General Policy

Telemedicine is described as the use of medical information exchanged from one site to another via electronic communications. Another term that is often used in conjunction with telemedicine is "telehealth," which is intended to include a broader range of services involving electronic transmission (e.g., videoconferencing and transmission of still images). Telehealth is also referred to as "e-health," which includes patient portals and remote monitoring of vital signs. The main proposed advantage of telemedicine and telehealth is their capability of delivering medical services to distant areas with low access to medical specialists. Telemedicine combines traditional medicine and modern technology to extend the capabilities of the traditional health care system and encompasses a broad variety of medical and health services, including:

  1. Clinician-interactive telemedicine services - real time clinician-patient interactions that, in the conventional approach, require face-to-face encounters between a patient and a physician or other health care provider. Examples of clinician-interactive services that might be delivered by telemedicine include on-line office visits, hospital visits, and home visits, as well as a variety of specialized examinations and procedures.

  2. Store-and-forward telemedicine services - collect clinical data, store them, and then forward them to be interpreted later. These systems have the ability to capture and store digital still or moving images of patients, as well as audio and text data. A store-and-forward system eliminates the need for the patient and the clinician to be available at the same time and place. Store-and-forward is therefore an asynchronous, non-interactive form of telemedicine.

  3. Self-monitoring/testing telemedicine services - enable physicians and other health care providers to monitor physiologic measurements, test results, images, and sounds, usually collected in a patient's residence or a care facility. Post-acute-care patients, patients with chronic illnesses, and patients with conditions that limit their mobility often require close monitoring and follow-up. Telemedicine programs use a variety of strategies to accomplish this monitoring while reducing the need for face-to-face visits that may be inconvenient or costly for the patient. The close monitoring afforded by these approaches may allow better care through earlier detection of problems, and may therefore reduce costs.

Indications and Limitations of Coverage

Medicare reimbursement for telemedicine or telehealth services is divided into three areas:

  1. Remote patient face-to-face services seen via live video conferencing

  2. Non face-to-face services that can be conducted either through live video conferencing or via store and forward telecommunication services.

  3. Home telehealth services
  1. Remote Patient Face-To-Face, Interactive Services

    Reimbursement is limited to the type of services provided, geographic location, type of institution delivering the services and type of health care provider.

    Medicare members are eligible for telehealth services only if they are located in either a rural health professional shortage area (HPSA) as defined by  §332(a)(1)(A) of the Public Health services Act or in a county outside of a metropolitan statistical area (MSA) as defined by §1886(d)(2)(D) of the Act. Telehealth services reported for members located outside of either a HPSA or inside a MSA will be denied as non-covered. The provider can bill the member for the non-covered service.

    Reimbursement to the health professional delivering the medical service is the same as the current amount for the service provided. In addition, the non-metropolitan facility with the patient is eligible to receive a facility fee.

    Location of Facility
    The service must be provided to an eligible member in an eligible facility (originating site) located outside of a metropolitan area. However, there is no limitation on the location of the health professional delivering the medical service (distant site).

    Eligible Medical Services
    Services that are eligible for reimbursement are listed below.

    - Office or other outpatient visits (99201-99215)
    - Individual psychotherapy (90804-90809)
    - Pharmacologic management (90862)
    - Psychiatric diagnostic interview examination (90801)
    - End stage renal disease related services (90951-90958, 90960, 90961)
    - Individual Medical Nutrition Therapy (G0270, 97802, and 97803)
    - Neurobehavioral status exam (96116)
    - In-patient initial telehealth consultations (G0425-G0427)
    - In-patient follow-up telehealth consultations (G0406-G0408)
    - Individual and group health and behavior assessment and intervention (HBAI) services (96150-96154)
    - Individual and group kidney dialysis education services (G0420 or G0421, respectively)
    - Individual and group diabetic self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training (G0108 and G0109, respectively)
    - Group medical nutrition therapy (97804)
    - Group health and behavior intervention services (96153, 96154)
    - Subsequent hospital care services, with the limitation of one telehealth visit every 3 days (99231- 99233)
    - Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days (99307-99310)

    Refer to Medical Policy Bulletin N-4 for information and guidelines on Medical Nutrition Therapy.

    Stroke Telemedicine (Telestroke)
    Stroke telemedicine is a consultative modality that facilitates care of patients with acute stroke at underserviced hospital emergency departments by specialists (vascular neurologists) at stroke centers. The emergency department visit codes 99281-99285 appended with the GT modifier - "via interactive audio and video telecommunications system” - should be used to report the vascular neurologist’s service. Codes G0425-G0427 (In-patient initial telehealth consultations) or G0406-G0408 (In-patient follow-up telehealth consultations) should be reported by the vascular neurologist if the patient is an in-patient.

    NOTE:
    Reimbursement for telestroke services is not limited to members located in either a rural health professional shortage area (HPSA) as defined by §332(a)(1)(A) of the Public Health services Act or in a county outside of a metropolitan statistical area (MSA) as defined by §1886(d)(2)(D) of the Act.

    Eligible Providers
    Only the following health professionals may claim reimbursement for remote telehealth services:

    - Physician;
    - Nurse practitioner;
    - Physician assistant;
    - Nurse midwife;
    - Clinical nurse specialist;
    - Clinical psychologist;*
    - Clinical social worker;* and
    - Registered dietitian or nutrition professional.

    *Clinical psychologist and clinical social workers cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for the following codes: 90805, 90807, and 90809.

    NOTE:
    It is permissible for another practitioner to present the patient instead of the referring practitioner. However, if a practitioner other than the actual referring practitioner presents the patient, he or she must be an employee of the referring practitioner.

    • Participation of a referring practitioner as appropriate to the medical needs of the patient, and as needed to provide information to and at the direction of the consultant; and
    • Feedback of the consultation assessment to the referring practitioner.

    The above telecommunications requirements do not mandate the use of full motion video. If the telecommunications technology permits two way interactive audio and video communications that allow the consultant practitioner to conduct a medical exam, Medicare may make payment for a teleconsultation. For Medicare payment to be made the patient must be present and the telecommunications technology must allow the consultant to conduct a medical examination of the patient.

    Eligible Facilities
    Only the following facilities are eligible to be an originating site under the rules of the program:

    • The office of a physician or practitioner;
    • A hospital;
    • A critical access hospital;
    • A rural health clinic;
    • A federally qualified health center;
    • Hospital-based or critical access hospital-based renal dialysis centers (including satellites);
    • Skilled nursing facilities;
    • Community mental health centers (CMHCs).

    Telephones, facsimile machines, and electronic mail systems do not meet the requirements of interactive telecommunications systems.

  2. Remote Non Face-to-Face Services

    Non-covered Services

    Remote critical care services (0188T, 0189T) - Remote critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient from an off-site location. Remote critical care is intended to supplement on-site critical care services at times when a critically ill or injured patient requires additional critical care resources than are available on-site. Code 0188T is used to report the first 30 to 74 minutes of remote critical care on a given date. Code 0189T is used to report additional block(s) of time, of up to 30 minutes each, beyond the first 74 minutes. Remote critical care of less than 30 minutes total duration on a given date should not be reported. Remote critical care services (0188T, 0189T) are considered experimental/investigational and therefore, will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

    Services delivered using telecommunications technology but not requiring the patient to be present during their implementation are covered the same as services delivered when on-site at the medical facility. "A service may be considered to be a physician's service where the physician either examines the patient in person or is able to visualize some aspect of the patient's condition without the interposition of a third person's judgment. Direct visualization would be possible by mean of x-rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc. For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service." These remote services are NOT considered "telehealth" or "telemedicine."  Rather, they are considered the same as services delivered on-site and are to be coded and will be paid in the same way. There are no geographic or facility limitations on these services.

    The largest single specialty providing remote services under this policy is radiology. However, the use of telecommunications in delivering pathology, cardiology, physician team conferences and other services are also covered. Special codes are used for the remote assessment of pacemakers as well as the collection and assessment of data from cardiac event recorders.

  3. Home Telehealth

    Section 1895(e) of the Act states that telehealth services are outside the scope of the Medicare home health benefit and home health PPS. This provision does not provide coverage or payment for Medicare home health services provided via a telecommunications system. The law does not permit the substitution or use of a telecommunications system to provide any covered home health services paid under the home health PPS, or any covered home health service paid outside of the home health PPS. As stated in 42 CFR 409.48(c), a visit is an episode of personal contact with the beneficiary by staff of the home health agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service. However, this provision clarifies that there is nothing to preclude a home health agency from adopting telemedicine or other technologies that they believe promote efficiencies, but that those technologies will not be specifically recognized or reimbursed by Medicare under the home health benefit. This provision does not waive the current statutory requirement for a physician certification of a home health plan of care under current §§1814(a)(2)(C) or 1835(a)(2)(A) of the Act. Within its home health agency manual CMS has stated that "An HHA may adopt telehealth technologies that it believe promote efficiencies or improve quality of care. Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR 409.48(c) and the telehealth services may not be counted as Medicare covered home health visits or used as qualifying services for home health eligibility.  An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to it clients, a doctor may take their availability into account when he or she prepares a plan of treatment (i.e., may write requirements for telehealth services into the plan of treatment). Medicare eligibility and payment would be determined based on the patient's characteristics and the need for and receipt of the Medicare covered services ordered by the physician. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished." 

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

90801 90804 90805 90806 90807 90808
90809 90862 90951 9095290953 90954
9095590957 90958 90960 90961 96116
9615096151 961529615396154 97802
97803 97804 99201 9920299203 99204
99205 99211 99212 9921399214 99215
992319923299233 99281 99282 99283
99284 9928599307993089930999310
G0108G0109G0270 G0406 G0407 G0408
G0420G0421G0425 G0426 G0427 Q3014
0188T 0189T    

Coding Guidelines

Physicians/practitioners submit the appropriate procedure code for covered professional telehealth services along with the "GT" modifier ("via interactive audio and video telecommunications system"). By coding and billing the "GT" modifier with a covered telehealth procedure code, the distant site physician/practitioner certifies that the member was present at an eligible originating site when the telehealth service was furnished. To claim the facility payment, physicians/practitioners will bill code "Q3014, telehealth originating site facility fee." For professional claims, the "office" place of service is the only payable setting for code Q3014. By submitting code "Q3014," the biller certifies that the originating site is located in either a rural HPSA or a non-MSA county. Physicians and practitioners at the distant site bill for covered telehealth services, for example, "99215 GT." Physicians' and practitioners' offices serving as a telehealth originating site bill for the originating site facility fee.

Code 0188T is used to report the first 30 to 74 minutes of remote critical care on a given date. Code 0189T is used to report additional blocks(s) of time, of up to 30 minutes each, beyond the first 74 minutes. Remote critical care of less than 30 minutes total duration on a given date should not be reported.

The diagnosis codes for occlusion and stenosis of precerebral arteries with cerebral infarction, or occlusion of cerebral arteries with cerebral occlusion should be reported with procedure codes 99281-99285 appended with the GT modifier and codes G0406-G0408 and G0425-G0427 to indicate telestroke services. See the "Diagnosis Codes" section of this policy for specific diagnosis codes.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease or illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Publications

Provider News

08/2010, Stroke Telemedicine (telestroke) covered under Medicare Advantage products
04/2011, Telemedicine services expanded for Medicare Advantage
04/2011, Denial reasons changing for selected services

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1895(e) state that telehealth services are outside the scope of the home health benefit and home health PPS.

CMS On-Line Pub. 100-2, Chapter 15, Section 270

CMS On-Line Pub. 100-4, Chapter 12, Section 190

Transmittal 1277 and 74, CR 5628

Transmittal 1528, CR 6087

Transmittal 1654 and 99, CR 6130

Transmittal 97 and 1635, CR 6215

Transmittal 105 and 1716, CR 6458

Transmittal 1875, CR 6740

Transmittal 1881 and 118, CR 6705

Transmittal 140 BP, CR 7049

Transmittal 2168 CP, CR 7049

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Covered Diagnosis Codes

Applicable to codes 99281, 99282, 99283, 99284, 99285 reported with the GT modifier and G0406-G0408, G0425-G0427

433.01433.21433.31433.81
433.91434.01434.11434.91

Glossary

TermDescription

Distant Site

The Centers of Medicare and Medicaid Services (CMS) define the distant site as the telehealth site where the provider/specialist is seeing the patient at a distance or consulting with a patient's provider.  Other common names for this term include - hub site, specialty site, provider/physician site and referral site.

 

Originating Site

CMS defines originating site as the site where the patient and/or the patient's physician is located during the telehealth encounter or consult.  Other common names for this term include - spoke site, patient site, remote site, and rural site.

 

Presenter (Patient Presenter)

Telehealth encounters require the distant provider to perform an exam of a patient from many miles away.  In order to accomplish that task an individual with a clinical background (e.g., LPN, RN, etc.) trained in the use of the equipment must be available at the originating site to "present" the patient, manage the cameras and perform any "hands-on" activities to successfully complete the exam.  For example, a neurological diagnostic exam usually requires a nurse capable of testing a patient's reflexes and other manipulative activities.  It should be noted that in certain cases (e.g., some dermatology or mental health encounters) a presenter with a clinical background is not always necessary, because the encounter may only require camera management skills.

 

Store and Forward (S&F)

S&F is a type of telehealth encounter or consult that uses still digital images of a patient for the purpose of rendering a medical opinion or diagnosis.  Common types of S&F services include radiology, pathology, dermatology and wound care.  Store and forward also includes the asynchronous transmission of clinical data, such as blood glucose levels and electrocardiogram (ECG) measurements, from one site (e.g., patient's home) to another site (e.g., home health agency, hospital, clinic).

 

Telecommuting/Networking Terms Asynchronous

This term is sometimes used to describe store and forward transmission of medical images or information because the transmission typically occurs in one direction in time.  This is the opposite of synchronous (see below).

 

Interactive Video/Television

This is an analogous with video conferencing technologies that allow for two-way, synchronous, interactive video and audio signals for the purpose of delivering telehealth, telemedicine or distant education services.  It is often referred to by the acronyms - ITV, IATV or VTC (video teleconference).

 

Synchronous

This term is sometimes used to describe interactive video connections because the transmission of information in both directions is occurring at exactly the same period.

 

Telehealth and Telemedicine

Telemedicine and telehealth both describe the use of medical information exchanged from one site to another via electronic communications to improve patients' health status.  Although evolving, telemedicine is sometimes associated with direct patient clinical services and telehealth sometimes associated with a broader definition of remote healthcare and is sometimes also perceived to be more focused on other health related services.






This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.