CAM 176

Telehealth

Category:Medicine   Last Reviewed:October 2019
Department(s):Medical Affairs   Next Review:October 2020
Original Date:October 2017    

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, smartphones, wireless tools and other forms of telecommunication. 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 health care 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 straightforward 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 telephone (audio only) consultations. (See Section “Benefits Application” regarding availability of member benefits for telephone 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 

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 health care community and general population.

Security and Confidentiality
Providers who use telehealth systems must consider security, patient confidentiality, and privacy. A secured electronic channel is required to be used 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.

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)

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 and Medicaid Services. Available online at http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/
  10. Centers for Medicare and 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 

Code Number Description
 CPT 90791-90792   Psychiatric diagnostic evaluation services
  90832-90838  Psychotherapy services 
  90845  Psychoanalysis 
  90847  Family psychotherapy 
  96040, S0265  Genetic counseling 
  96116  Neurobehavioral status exam 
  96156 Health behavior assessment or reassessment
  96158

Health and behavior intervention, initial 30 minutes; individual

  96159

Health and behavior intervention, each 15 minutes; individual

  96164

Health and behavior intervention, initial 30 minutes; group

  96165 Health and behavior intervention, each 15 minutes; group
  96167 Health and behavior intervention, initial 30 minutes; family plus patient
  96168 Health and behavior intervention, each 15 minutes; family plus patient
  96170 Health and behavior intervention, initial 30 minutes; family without patient
  96171 Health and behavior intervention, each 15 minutes; family without patient
  99201 New outpatient evaluation and management 
  99211-99213  Established outpatient evaluation and management 
  99241-99243 Outpatient consultation evaluation and management 
  99402  Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes 
  99404  Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes 
  99406  Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 
  99407  Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 
  99408  Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 min 
  99409  Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 min 
  99497  Advance care planning by the physician or other qualified health care professional, first 30 minutes, face-to-face; patient, family and/or surrogate 
  99498  Advance care planning by the physician or other qualified health care professional, first each additional 30 minutes, face-to-face; patient, family and/or surrogate 
  G0108-G0109  Diabetic training 
Modifiers  95  Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system

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, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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

History From 2017 Forward     

10/01/2019 

Annual review, updating to add protocols for telehealth visits, updated coding and clarified services available for telehealth. 

04/24/2019 

Interim review to add licensed professional counselor and licensed marriage and family therapist as specialty types approved to file for telehealth services. No other changes made. 

03/28/2019 

Interim Review. Updated Policy Guidelines  and definition of services and updated coding.

10/18/2018 

Annual review of policy, multiple revisions to description and policy for clarity, intent of policy unchanged.  Removing  modifier  GT  from  coding  section. 

01/08/2018 

Formatting policy. 

10/30/2017

New Policy


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