Coverage Policy Manual
Policy #: 2015034
Category: Medicine
Initiated: January 2016
Last Review: January 2025
  Telehealth
Description:
Telehealth is a broad term used to refer to electronic and telecommunication technologies and services used to provide care and services at a distance.
 
Telemedicine is the practice of medicine using technology to deliver care at a distance, over a telecommunications infrastructure, between a patient at an originating site and a physician, or other qualified healthcare professional, at a distant site. Telemedicine has been advocated as a means to provide healthcare to underserved areas and to facilitate timely consultation in urgent situations.
 
Telemedicine includes consultation, diagnostic, monitoring, and therapeutic services delivered via a two-way, synchronous, HIPAA compliant audio and video telecommunication system. A telemedicine visit involves an exchange between a patient and a healthcare professional at geographically different locations. This exchange can take place through a traditional office-based telemedicine model where there is an originating site with a presenter (facilitator) and a distant site; or a consumer driven model where the individual initiates the interaction independently of a presenter through an interactive audio device. In both models, during the telemedicine encounter there is an originating site where the patient is located and a distant site where the physician.
 
Other telemedicine services include but are not limited to store and forward transmissions, remote patient monitoring and mobile health.
 
Definitions:
 
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. Asynchronous telemedicine services are reported using modifier –GQ.
 
Distant Site: Also called the “Hub” or “Consultant” site. The Distant Site is defined as the site where the healthcare professional is physically located during an encounter with a patient who is at the Originating Site.
 
Healthcare Professional: A person who is licensed, certified, or otherwise authorized by the laws of the appropriate state to administer health care in the ordinary course of the practice of his or her profession.
 
Interactive Audio Device:   Multimedia communications equipment  permitting two-way, real time interactive communication between the patient and distant site healthcare professional that includes, at a minimum, the following:
 
    • HIPAA compliant patient/healthcare professional communication
    • Patient’s Medical History (Actively updated)
    • Store and Forward capabilities
        • Medical Record of the encounter is securely stored and can be transmitted  to other attending physicians as needed or required
    • E- prescribing tool
    • Interaction tools available for instant use (HIPAA compliant)
        • real-time video
        • text messaging
        • visual imaging
        • audio  
 
*Telephones without the use of a telehealth ecosystem, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.
 
Mobile health: consumer medical and health information includes the use of the internet and wireless devices for consumers to obtain specialized health information and online discussion groups to provide peer-to-peer support.
 
Originating Site: Also call the “Spoke” or “Patient” site. The Originating Site is defined as the location of the patient during the telehealth encounter or consult.
 
Presenter: Telemedicine encounters require the Distant Site healthcare professional 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.
 
Remote patient monitoring: Including home telehealth, uses devices to remotely collect and send data to a distant provider location for interpretation. Such applications might include a specific vital sign, such as blood glucose or heart ECG or a variety of indicators for homebound consumers.
 
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). Synchronous telemedicine services are reported using modifier –GT.
 
Telehealth ecosystem: A software system specifically programmed to facilitate telehealth that offers at a minimum HIPAA compliant patient and healthcare professional communication, access to updated medical history, ability to track the date and time of interactions, interaction tools that are available for instant use including real- time video, text messaging, visual imaging and audio. The telehealth ecosystem allows telemedicine to be conducted through an interactive audio device.
 
Coding
See CPT/HCPCS section below.
 
Coding Guidelines:
 
The healthcare professional 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 GT, “via interactive audio and video telecommunications systems” or 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system). The –GT or 95 modifiers should appear in modifier field 1. The healthcare professional must also use POS 02 (telemedicine distant site) when billing CPT or HCPCS with a GT or 95 modifier. Note: Modifier-GT or -95 is not required for CPT codes 98000-98015
 
The Originating Site must submit claims for the facility for telemedicine services using HCPCS code Q3014, “Telehealth Originating Site facility fee.” The 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. Q3014 should be submitted only if the encounter occurs in an outpatient medical facility or clinic; it should not be submitted and is not reimbursable for encounters which occur outside of a clinical setting.  Q3014 should not be submitted for telemedicine encounters in settings which are reimbursed on a global, DRG, or per diem basis.
 
The claim for Q3014 should name a healthcare professional who is responsible for care of the member at the Originating Site rather than the name of a facility (except in the case of hospital facility claims). However, this healthcare professional 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 outpatient hospital setting, the claim may be submitted as an outpatient hospital claim (place of service 22) with the originating site billing Q3014.  All other Originating Sites must file claims for Q3014 using the HCFA1500 claim form. For inpatient services, Q3014 is not separately reimbursable.
 
Note: CPT 98016 is considered an integral part of the evaluation and management service and is not separately reimbursable.
Policy/
Coverage:
Effective January 2025
 
Telemedicine is covered when ALL of the following conditions are met:
 
    1. A professional relationship exists between the healthcare professional at the distant site and the patient except in the following circumstances:
a. Emergency situations where the life or health of the patient is in danger or imminent danger; or
b. When only providing information of a generic nature, not meant to be specific to an individual
 
2. 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 to the same standard of care as with a face-to-face visit.
 
3. The service is delivered either through:
a. a real-time audio-visual communication system in a traditional telemedicine model;
b. a consumer-driven model through an interactive audio device when performed through an approved telehealth ecosystem.  
 
4. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
 
5. 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 must be recorded in the note.
 
6. For visits which include a physical exam, the equipment allows for remote examination by the healthcare professional (e.g., stethoscope, otoscope, etc giving a diagnostic-quality signal to the healthcare professional) OR a qualified, licensed person capable of performing the exam supplements the examination and relays the findings to the healthcare professional.
 
7. 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 system must maintain a log of connections, with time, date, and duration.
 
8. The Distant Site healthcare professional must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that healthcare professional.
 
The following services are not covered:
 
    1. Any other telehealth or telemedicine services not meeting the above criteria.
 
2. The establishment of a professional relationship cannot be made through any of the following means:
a. Internet questionnaire;
b. Email message;
c. Patient-generated medical history;
d. Audio-only communication, including without limitation, interactive audio;
e. Text messaging;
f. Facsimile machine (fax); or
g. Any combination of the above.
 
3. eICU monitoring as an adjunct to intensive care unit services.
 
4. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.
 
5. Telephonic (when performed outside of an approved telehealth ecosystem and through an interactive audio device), fax, email, remote monitoring and mobile health.
 
6. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
 
7. An originating site fee is not allowed if a member is on the same campus as the healthcare professional at the time of the visit.
 
8. Prescribing and dispensing durable medical equipment (DME).
 
Note: CPT 98016 is considered an integral part of the evaluation and management service and is not separately reimbursable.
 
Effective January 2020 through December 2024
 
Telemedicine is covered when ALL of the following conditions are met:
 
    1. A professional relationship exists between the healthcare professional at the distant site and the patient except in the following circumstances:
        • Emergency situations where the life or health of the patient is in danger or imminent danger; or
        • When only providing information of a generic nature, not meant to be specific to an individual
 
2. 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 to the same standard of care as with a face-to-face visit.
 
3. The service is delivered either through:
        • a real-time audio visual communication system in a traditional telemedicine model;
        • a consumer-driven model through an interactive audio device when performed through an approved telehealth ecosystem.  
 
4. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
 
5. 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 must be recorded in the note.
 
6. For visits which include a physical exam, the equipment allows for remote examination by the healthcare professional (e.g., stethoscope, otoscope, etc giving a diagnostic-quality signal to the healthcare professional) OR a qualified, licensed person capable of performing the exam supplements the examination and relays the findings to the healthcare professional.
 
7. 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 system must maintain a log of connections, with time, date, and duration.
 
8. The Distant Site healthcare professional must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that healthcare professional.
 
The following services are not covered:
 
    1. Any other telehealth or telemedicine services not meeting the above criteria.
 
2. The establishment of a professional relationship cannot be made through any of the following means:
            • Internet questionnaire;
            • Email message;
            • Patient-generated medical history;
            • Audio-only communication, including without limitation, interactive audio;
            • Text messaging;
            • Facsimile machine (fax); or
            • Any combination of the above.
 
3. eICU monitoring as an adjunct to intensive care unit services.
 
4. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.
 
5. Telephonic (when performed outside of an approved telehealth ecosystem and through an interactive audio device), fax, email, remote monitoring and mobile health.
 
6. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
 
7. An originating site fee is not allowed if a member is on the same campus as the healthcare professional at the time of the visit.
 
8. Prescribing and dispensing durable medical equipment (DME).
 
Effective Prior to January 2020
 
Telemedicine is covered when ALL of the following conditions are met:
 
  1. A professional relationship exists between the healthcare professional at the distant site and the patient except in the following circumstances:
      • Emergency situations where the life or health of the patient is in danger or imminent danger; or
      • When only providing information of a generic nature, not meant to be specific to an individual
 
2. The service is one which is allowed for the specific provider type when done in a face-to-face setting through a real-time audio visual communication system or through an interactive audio device when performed through an approved telehealth ecosystem, and can be safely and effectively performed via telemedicine to the same standard of care as with a face-to-face visit.
 
3. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
 
4. 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 must be recorded in the note.
 
5. For visits which include a physical exam, the equipment allows for remote examination by the healthcare professional (eg stethoscope, otoscope, etc giving a diagnostic-quality signal to the healthcare professional) OR a qualified, licensed person capable of performing the exam supplements the examination and relays the findings to the healthcare professional.
 
6. 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.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, healthcare professionals may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
 
7. The Distant Site healthcare professional must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that healthcare professional.
 
 The following services are not covered:
 
    1. Any other telehealth or telemedicine services not meeting the above criteria.
    2. The establishment of a professional relationship cannot be made through any of the following means:
 
        • Internet questionnaire;
        • Email message;
        • Patient-generated medical history;
        • Audio-only communication, including without limitation, interactive audio;
        • Text messaging;
        • Facsimile machine (fax); or
        • Any combination of the above.
 
3. eICU monitoring as an adjunct to intensive care unit services.
 
4. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography,
anesthesia, and endoscopy.  
 
5. Telephonic when performed outside of an approved telehealth ecosystem and through an interactive audio device, fax and  email.  
 
6. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
 
7. An originating site fee is not allowed if a member is on the same campus as the healthcare professional at the time of the visit.  
 
8. Prescribing and dispensing durable medical equipment (DME).   
 
 Effective Prior to July 2019
 
Telemedicine is covered when ALL of the following conditions are met:
 
        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 to the same standard of care as with a face-to-face visit.
        2. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient,
        3. operate the equipment, problem solve, and gather clinical data.
        4. The encounter is by real-time audio visual communication.  (Asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
        5. 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 must be recorded in the note.
        6. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg 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.
        7. 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.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
        8. The Distant Site provider must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that provider.
 
The following services are not covered:
 
        1. Any other telehealth or telemedicine services not meeting the above criteria.
        2. eICU monitoring as an adjunct to intensive care unit services.
        3. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.  
        4. Telephonic, asynchronous, fax, email, and telemonitoring services.  
        5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
        6. An originating site fee is not allowed if a member is on the same campus as the provider at the time of the visit.  
        7. Prescribing and dispensing durable medical equipment (DME).   
 
PRIOR TO JUNE 2019
 
Telemedicine is covered when ALL of the following conditions are met:
 
        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 to the same standard of care as with a face-to-face visit.
        2. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
        3. The encounter is by real-time audio visual communication.  (Store-and-forward, asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
        4. 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 must be recorded in the note.
        5. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg 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.
        6. 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.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
        7. The Distant Site provider must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that provider.
 
The following services are not covered:
 
        1. Any other telehealth or telemedicine services not meeting the above criteria.
        2. eICU monitoring as an adjunct to intensive care unit services.
        3. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.  
        4. Telephonic, asynchronous, fax, email, and telemonitoring services.  
        5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
        6. Store and forward interpretation of physical exam findings.
        7. An originating site fee is not allowed if a member is on the same campus as the provider at the time of the visit.  
        8. Prescribing and dispensing durable medical equipment (DME).   
 
EFFECTIVE PRIOR TO MAY 2019
 
Telemedicine is covered when ALL of the following conditions are met:
 
        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 to the same standard of care as with a face-to-face visit.
        2. If the originating site is a clinical setting, a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
        3. The encounter is by real-time audio visual communication.  (Store-and-forward, asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
        4. 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 must be recorded in the note.
        5. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg 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.
        6. 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.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
        7. The Distant Site provider must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that provider.
 
The following services are not covered:
 
        1. Any other telehealth or telemedicine services not meeting the above criteria.
        2. eICU monitoring as an adjunct to intensive care unit services.
        3. Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.
        4. Telephonic, asynchronous, fax, email, store-and-forward and telemonitoring services.
        5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
        6. Store and forward interpretation of physical exam findings.
        7.  An originating site fee is not allowed if a member is on the same campus as the provider at the time of the visit.  
        8. Prescribing and dispensing durable medical equipment (DME).    
 
EFFECTIVE PRIOR TO APRIL 2019
 
Telemedicine is covered when ALL of the following conditions are met:
 
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 to the same standard of care as with a face-to-face visit.
2. If the originating site is a clinical setting,  a Presenter is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather clinical data.
3. The encounter is by real-time audio visual communication.  (Store-and-forward, asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
4. 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.
5. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg 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.
6. 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.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
7. The Distant Site provider must be licensed as required by the appropriate state's Medical Board, and the service provided must be within the scope of practice for that provider.
 
The following services are not covered:
 
1. Any other telehealth or telemedicine services not meeting the above criteria.
2. eICU monitoring as an adjunct to intensive care unit services.
3.Services which are, by definition, hands-on, such as surgery, interventional radiology, coronary angiography, anesthesia, and endoscopy.
4. Telephonic, asynchronous, fax, email, store-and-forward and telemonitoring services.
5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
6. Store and forward interpretation of physical exam findings.
7. An originating site fee is not allowed if a member is on the same campus as the provider at the time of the visit.
8. Prescribing and dispensing durable medical equipment (DME).
 
EFFECTIVE PRIOR TO JANUARY 2018
 
Telemedicine is covered when ALL of the following conditions are met:
 
    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 is available at the Originating Site to orient the patient, operate the equipment, problem solve, and gather data.  This is not required if the member has end-stage renal disease and the Originating Site is the home.
    3. The member is physically present during the visit in a hospital facility or provider’s office.   This requirement does not apply to members with end-stage renal disease, who may be in their home at the time of a telemedicine visit.
    4. The telemedicine provider has a professional relationship with the member.  A professional relationship exists if:
        1. The provider has previously established a face-to-face professional relationship with the member  (or)
        2. The member has been referred to the telemedicine provider (or provider group) by a provider who has an on-going professional relationship with the member (and)
        3. The provider (or provider’s group) is able to provide appropriate follow-up care when necessary.
    5. The encounter is by real-time audio visual communication.  (Store-and-forward, asynchronous, audio-only, email, fax, and telemonitoring services are not reimbursable.)
    6. A clinical record of the encounter which contains at least the same elements as are included in a face-to-fact 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.
    7. For visits which include a physical exam, the equipment allows for remote examination by the provider (eg 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.
    8. 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.  An example of a compliant network is Arkansas e-Link. (To connect to the Arkansas e-Link network, providers may call the Center for Distance Health at 501-686-6998 or enroll online at arkansaselink.com.)
    9. 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 who meet the criteria for Psychiatric Procedure Scope of Practice (in policy #2008010, 2008015) or a licensed allopathic or osteopathic physician.
    10. The provider at the Distant Site and the provider or facility at the Originating Site is credentialed by Arkansas Blue Cross Blue Shield as telemedicine providers.  This requirement holds regardless of whether the providers are in- or out-of-network.
 
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. Telephonic, asynchronous, fax, email, store-and-forward and telemonitoring services.
        4. Any other telehealth or telemedicine services not meeting the above criteria.
        5. Evaluation and management services of the highest level (eg 99205, 99285) are not covered when performed by telemedicine, because these require a level of interaction not possible by telemedicine.
 
Rationale:
2019 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2019. No new literature was identified that would prompt a change in the coverage statement.
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2020. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2021. No new literature was identified that would prompt a change in the coverage statement.
 
August 2022 Update
A systematic review of eight randomized controlled trials, one nonrandomized trial, and seven observational studies was conducted to evaluate the effectiveness of telehealth for women’s reproductive preventive health services and interpersonal violence (Cantor, 2022). Nine of these studies looked at interpersonal violence and seven evaluated contraceptive care. Two of the studies showed that telehealth was either better or worse than usual care for contraceptive care and interpersonal violence. The other 14 studies showed no difference in effectiveness. Telehealth services replaced usual care in these studies. The outcomes of the trials/studies indicate that telehealth care results in similar outcomes as in-person care. Based on this limited evidence, telehealth interventions for contraceptive care and interpersonal violence services result in equivalent clinical and patient-reported outcomes as in-person care. More research is needed to determine the most effective approach to deliver these services and how to best utilize telehealth care.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2022. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2025 Update
Annual policy review completed with a literature search using the MEDLINE database through December 2024. No new literature was identified that would prompt a change in the coverage statement.
CPT/HCPCS:
90791Psychiatric diagnostic evaluation
90792Psychiatric diagnostic evaluation with medical services
90832Psychotherapy, 30 minutes with patient
90833Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834Psychotherapy, 45 minutes with patient
90836Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837Psychotherapy, 60 minutes with patient
90838Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90845Psychoanalysis
90846Family psychotherapy (without the patient present), 50 minutes
90847Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90863Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure)
90960End stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face to face visits by a physician or other qualified health care professional per month
90961End stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2 3 face to face visits by a physician or other qualified health care professional per month
90966End stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older
90970End stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older
92507Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92521Evaluation of speech fluency (eg, stuttering, cluttering)
92522Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria);
92523Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524Behavioral and qualitative analysis of voice and resonance
92526Treatment of swallowing dysfunction and/or oral function for feeding
96127Brief emotional/behavioral assessment (eg, depression inventory, attention deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
97110Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97116Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
97161Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1 2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face to face with the patient and/or family.
97162Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1 2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face to face with the patient and/or family.
97163Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face to face with the patient and/or family.
97164Re evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face to face with the patient and/or family.
97165Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1 3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face to face with the patient and/or family.
97166Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3 5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face to face with the patient and/or family.
97167Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face to face with the patient and/or family.
97168Re evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face to face with the patient and/or family.
97535Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one on one contact, each 15 minutes
97802Medical nutrition therapy; initial assessment and intervention, individual, face to face with the patient, each 15 minutes
97803Medical nutrition therapy; re assessment and intervention, individual, face to face with the patient, each 15 minutes
98000Synchronous audio video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
98001Synchronous audio video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
98002Synchronous audio video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
98003Synchronous audio video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
98004Synchronous audio video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.
98005Synchronous audio video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
98006Synchronous audio video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
98007Synchronous audio video visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
98008Synchronous audio only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, straightforward medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
98009Synchronous audio only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, low medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
98010Synchronous audio only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, moderate medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
98011Synchronous audio only visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination, high medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
98012Synchronous audio only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, straightforward medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 10 minutes must be exceeded.
98013Synchronous audio only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, low medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
98014Synchronous audio only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, moderate medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
98015Synchronous audio only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, high medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
98016Brief communication technology based service (eg, virtual check in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related evaluation and management service provided within the previous 7 days nor leading to an evaluation and management service or procedure within the next 24 hours or soonest available appointment, 5 10 minutes of medical discussion
99202Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99211Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.
99212Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99221Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99222Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
99231Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
99232Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
99238Hospital inpatient or observation discharge day management ; 30 minutes or less on the date of the encounter
99239Hospital inpatient or observation discharge day management ; more than 30 minutes on the date of the encounter
99281Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional
99282Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making
99283Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making
99284Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making
99406Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
99408Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
99421Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5 10 minutes
99422Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11 20 minutes
99423Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
99441Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 10 minutes of medical discussion
99442Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11 20 minutes of medical discussion
99443Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21 30 minutes of medical discussion
99495Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. At least moderate level of medical decision making during the service period. Face-to-face visit, within 14 calendar days of discharge
99496Transitional care management services with the following requiredelements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. High level of medical decision making during the service period. Face-to-face visit, within 7 calendar days of discharge
G0108Diabetes outpatient self management training services, individual, per 30 minutes
Q3014Telehealth originating site facility fee
References: Cantor A, Nelson HD, Pappas M, Atchison C, Hatch B, Huguet N, Flynn B, McDonagh M.(2022) Effectiveness of Telehealth for Women’s Preventive Services. Comparative Effectiveness Review No. 256. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 22-EHC024. Rockville, MD: Agency for Healthcare Research and Quality; June 2022. DOI: https://doi.org/10.23970/AHRQEPCCER256.
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants.
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