Telemedicine and Telehealth Services - Empire Blue Cross Blue ...

Empire BlueCross BlueShieldProfessional Reimbursement PolicySubject: Telemedicine and Telehealth ServicesNY Policy: 0007 Effective: 10/01/2013-01/31/2014Coverage is subject to the terms, conditions, and limitations of an individual member’s programs orproducts and policy criteria listed below.DESCRIPTIONThe Health Plan defines telemedicine as the delivery of healthcare services through the use ofinteractive audio - video, or other electronic media for the purpose of diagnosis, consultation, and/ortreatment. Telemedicine does not include the use of audio-only telephone, facsimile machine, or e-mail.Telehealth is a broader term which includes telemedicine and may also include ancillary preventive,educational, and non clinical or curative services.Telemedicine/telehealth is used to support health care when the provider and patient are physicallyseparated. Typically, the patient communicates with the provider via interactive means that issufficient to establish the necessary link to the provider who is working at a different location fromthe patient.• The presentation/origination site is the place where the patient is located at the time of thetelemedicine/telehealth service.• The provider site is the place where the provider is located at the time the service is provided.This policy documents the Health Plan’s position on services identified as telemedicine/ telehealthand identifies when these services may be eligible for reimbursement.POLICYReimbursement for telemedicine/telehealth services may be available when provided through aHealth Plan approved program (e.g., LiveHealth Online). Programs may be developed by localHealth Plans to support local healthcare initiatives or state mandates.1. Real time (synchronized) telemedicine/telehealth services may be eligible for separatereimbursement as part of a Health Plan approved program when such services are equivalent tosimilar in-person (face-to-face) services. Reimbursement for telemedicine/telehealth servicesis limited to services involving the use of interactive audio-video or other interactive electronicmedia for the purpose of diagnosis, consultation, or treatment.NY 0007 Page 1 of [4]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policy2. In order for telemedicine/telehealth services to be eligible for reimbursement as part of a HealthPlan approved program, the provider’s services must be rendered in one of the followingmedical/behavioral health locations:• Provider’s office• Hospital• Rural health clinic• Federally qualified health center3. Professional services rendered via an interactive telecommunication system as part of a HealthPlan approved program are only eligible for reimbursement to the provider rendering thetelemedicine/telehealth services. A provider rendering in-person services at thepresentation/origination site should report the appropriate code for the in-person services .4. The following are examples of services that are not eligible for reimbursement astelemedicine/telehealth services:a. Non-direct patient services (e.g. coordination of care rendered before or after patientinteraction).b. Services rendered by audio-only telephone communication, facsimile, e-mail, or any othernon-secure electronic communication.c. Any services that are not eligible for separate reimbursement when rendered to the patientin-person.d. Presentation/origination site facility fee.CODINGThe following list of codes is provided as an informational tool only, to help identify some of theapplicable Current Procedural Terminology (CPT ® )′ codes/code ranges and Healthcare CommonProcedure Coding System Level II (HCPCS) codes/modifiers that may be utilized in reportingtelemedicine/telehealth services. The inclusion or exclusion of a specific code does not indicateeligibility for reimbursement and/or coverage in all situations.CPT codes that ordinarily describe direct face-to-face services, but signify telemedicine serviceswhen used with modifier GT:• 99201-99215 -- Office or other outpatient Evaluation and management services• 99241-99245 -- Office or other outpatient consultations• 90791-90792 -- Psychiatric diagnostic evaluation• 90832-90838 -- Individual psychotherapy services• 90863 ----------- Pharmacologic management service (List separately in addition to the code forprimary procedure)NY 0007 Page 2 of [4]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement PolicyCategory III CPT codes specific to telemedicine/telehealth:• 0188T---------- Remote real-time interactive video-conferenced critical care, evaluation andmanagement of the critically ill or critically injured patient; first 30-74 minutes• 0189T---------- Remote real-time interactive video-conferenced critical care, evaluation andmanagement of the critically ill or critically injured patient; each additional 30 minutes (Listseparately in addition to code for primary list)HCPCS codes/modifiers:• G0406 -- Follow-up inpatient consultation, limited, physicians typically spend 15minutes communicating with the patient via telehealth• G0407 -- follow-up inpatient consultation, intermediate, physicians typically spend 25minutes communicating with the patient via telehealth.• G0408 -- Follow-up inpatient consultation, complex, physicians typically spend 35 minutes ormore communicating with the patient via telehealth• G0425 -- Telehealth consultation, emergency department or initial inpatient, typically 30minutes communicating with the patient via telehealth• G0426 -- Telehealth consultation, emergency department or initial inpatient, typically 50minutes communicating with the patient via telehealth• G0427 -- Telehealth consultation, emergency department or initial inpatient, typically 70minutes or more communicating with the patient via telehealth• G0459 -- Inpatient telehealth pharmacologic management, including prescription, use, andreview of medication with no more than minimal medical psychotherapy.• GT ------ Modifier signifying: Via interactive audio and video telecommunicationsHCPCS codes/modifiers that are not eligible for separate reimbursement:• Q3014 -- Telehealth originating site facility fee• T1014 -- Telehealth transmission, per minute, professional services bill separately• GQ ------ Modifier signifying: Via asynchronous telecommunications systemCPT codes that are not eligible for reimbursement in accordance with the Health Plan’s BundledServices and Supplies Reimbursement Policy:• 98966-98968 -- Telephone assessment and management service provided by a qualifiednonphysician health care professional to an established patient, parent, or guardian• 98969 -- Online assessment and management service provided by a qualified non-physicianhealth care professional to an established patient or guardian, using the Internet or similarelectronic communications network.NY 0007 Page 3 of [4]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.

Empire BlueCross BlueShieldProfessional Reimbursement Policy• 99441-99443 --Telephone evaluation and management service provided by a physician or otherqualified health care professional who may report evaluation and management servicesprovided to an established patient, parent, or guardian1 CPT © is a registered trademark of the American Medical AssociationReferences:American Telemedicine Association (http://www.americantelemed.org)Centers for Medicare & Medicaid Services (https://www.cms.hhs.gov/Telemedicine/)Association of Telehealth Service Professionals (http://www.atsp.org)Use of Reimbursement Policy:State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over ReimbursementPolicy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services arerendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically.© 2013 Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by anymeans, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield.NY 0007 Page 4 of [4]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.