JOHNS HOPKINS HEALTHCARE

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1 Page 1 of 16 ACTION: New Policy Effective Date: 10/01/2013 Revising : Review Dates: 03/29/16, 06/29/17, Superseding 09/01/17, 12/01/17 Archiving Retiring Johns Hopkins HealthCare LLC (JHHC) provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, Advantage MD and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. POLICY: For US Family Health Plan see TRICARE Policy Manual M, February 1, 2008, Telemental Health (TMH) / Telemedicine: Chapter 7, Section 22.1 For Advantage MD: Medicare does not have a National Coverage Determination (NCD) for telemedicine services. Local Coverage Determinations (LCDs) do not exist at this time. (Accessed May 1, 2017) In addition to following the requirements in this policy, see Department of Health and Human Services, Centers for Medicare and Medicaid Services, Telehealth Services: For Priority Partners: In addition to following the requirements of this policy, see Maryland Medicaid Telehealth Program: AND COMAR Remote Patient Monitoring regulations at: RPM transmittals: and Note ~ All providers rendering care and reporting telemedicine services for PPMCO members must be enrolled in Maryland Medical Assistance Program and register as an originating or distant site via an online form before rendering telehealth services. I. COVERED SERVICES: When benefits are provided under the member s contract, JHHC considers video-visit, E- health, E-visit, E-consultation (see definitions), and transitional care management services medically necessary for new or established patients who require communication with their provider for patient engagement, improved outcomes and transitional care when ALL of the

2 Page 2 of 16 following criteria have been met: A. E-Visits, E-consultation OR E-health: 1. The service is provided by a practitioner legally permitted and qualified to practice, AND; 2. The extent of services includes at least a problem focused history and straight forward medical decision making as defined by the CPT manual, AND; 3. The E-visit is reported per documentation standards, AND; Note ~ E-visits billed within the post-operative period of a previously completed major or minor surgical procedure will be considered part of the global payment for the procedure and not paid separately. 4. The service may be either for a new or established patient with a new problem or for an exacerbation of an existing problem per documentation standards, AND; 5. The service is conducted over a secured channel with provisions described in Policy Guidelines, AND; 6. A permanent record of online communications relevant to the ongoing medical care of the patient is maintained as part of the patient s medical record consistent with American Medical Association (AMA) and Evaluation and Management documentation requirements. B. Synchronous Video Visits: 1. The service is provided by a practitioner legally permitted and qualified to practice, AND; 2. Is scheduled in parity to a face to face visit, AND; 3. Is documented as a permanent record as per item A, 6 above, AND; 4. Is not a follow up telephone call from an in-person visit, AND; 5. The patient is present at the time of consultation, AND; 6. The medical examination of the patient is under the control of the consulting practitioner, AND; 7. Services provided are medically appropriate and necessary, AND; 8. Visit takes place via an interactive audio and video telecommunications system which, at a minimum, with provision of real-time consultation among the patient, consulting practitioner, and/or referring practitioner (as appropriate). Note ~ Medically necessary Remote Patient Monitoring (RPM) is permitted for the treatment of *chronic and acute conditions via wearable, platform, or self-reported. *These conditions include: 1. Chronic Obstructive Pulmonary Disease 2. Congestive Heart Failure 3. Diabetes Type 1, AND;

3 Page 3 of Diabetes Type 2 Member should have had one (1) hospital admission and one (1) separate ER visit within the prior twelve (12) months, with the same qualifying condition(s) (which are listed in items 1-4 above) as the primary diagnosis. Providers may include any practitioner legally permitted and qualified to practice. Physician Assistants (PAs) will also be a qualifying provider. RPM is for specified time periods as indicated by the ordering provider. II. NON-COVERED SERVICES: A. Unless specific benefits are provided under the member s contract, JHHC considers video-visit, E-health, E-visit, E-consultation (see definitions), and transitional care management services failing to meet the above criteria ineligible for reimbursement. B. Unless specific benefits are provided under the member s contract, JHHC considers video-visit, E-health, E-visit, E-consultation (see definitions), and transitional care management services ineligible for reimbursement in the following situations: 1. Request for medical refills or referrals, OR: 2. Reporting of test results, OR: 3. Provision of education materials, OR: 4. Scheduling, OR: 5. Registration or updating billing information, OR: 6. Reminders, OR: 7. Interpretation of lab or radiology services by providers who are non-licensed (for telemedicine services) DEFINITIONS Electronic Evaluation and Management (E/M) Services - An on-line electronic medical evaluation, also refer to as a non-face-to-face E/M service, provided by a physician to a patient using Internet resources in response to a patient s on- line inquiry. Reportable services involve the physician s personal timely response to the patient s inquiry and must involve permanent storage (electronic or hard copy) of the encounter. This service is reported only once for the same episode of care during a seven-day period, although multiple physicians could report their exchange with the same patient. If the on- line medical evaluation refers to an E/M service previously performed and reported by the physician within the previous seven days (either physician requested or unsolicited patient follow-up) or within the postoperative period of the previously completed procedure, then the service(s) are considered covered by the previous E/M service or procedure. A reportable service encompasses the sum of communication (related telephone calls, the prescription provision, laboratory orders) pertaining to the on-line patient encounter.

4 Page 4 of 16 Interprofessional Telephone / Internet Consultations / E-Consultation - An assessment and management service in which a patient s treating physician or other qualified health care professional requests the opinion and/or treatment advice of a physician with a specific specialty (consultant) to assist the treating physician or health care professional in the diagnosis and/or management of the patient s problem without the need for the patient s face-to-care contact with the consultant, such as in the ambulatory / outpatient / emergency department or inpatient setting. Telemedicine - The exchange of medical information between sites via electronic communication for the purpose of transmitting clinical information. The terms telemedicine and telehealth are used interchangeably, although telehealth is intended to include a broader range of services such as education. The main proposed advantage of telehealth is the capability of providing clinical support by overcoming geographical barriers, connecting users who are not in the same physical location. Some systems allow remote assessment and monitoring of patient status. The devices collect physiological data through medical peripherals (blood pressure/pulse meter, ECG lead, thermometer, weight scale, pulse oximeter, glucose meter, and PT/ INR device) and transmit the information to an agency over the telephone lines or wireless computer networks. The medical services do not involve direct, in-person patient contact, but could prompt and initiate video visit as medically appropriate. Telehealth - The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administrations. Examples of telehealth include store-and-forward imaging, remote patient monitoring, E-visits and E-consults. Digital medical images and other clinical data can be captured by one provider and sent electronically to another provider such as radiology reports. Patients with hypertension can use home monitors to routinely track their blood pressure and upload the data via the Internet to their provider in the form of remote patient monitoring. Health care providers can offer E-visits or E-consults through a secure web portal. Transitional Care Management Services (TCM) - Services for an established patient whose medical and/or psychosocial problems required moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient s community setting (home, domiciliary, rest home or assisted living.) TCM services commence on the date of discharge and continue for the next 29 days. TCM includes a face-to-face visit within the specified time frame in combination with non-face-to-face services that may be performed by the physician or other qualified health care professional and/or licensed clinical staff under his or her direction. TCM requires an interactive contact with the patient or caregiver, as appropriate, within two business days of discharge. The contact may be direct (face-to-face), telephonic, or by electronic means. Medication reconciliation and management must occur no later than the date of the face-to- face visit.

5 Page 5 of 16 E-Visits - Also referred to as E-health, communication and online medical evaluation is the ability for health providers to respond or interact with patients through a secured electronic channel. E-visits can be member-initiated, used to address non-urgent symptoms and manage chronic health conditions. Synchronous Video Visits- Also referred to as Video Visit is defined as services rendered through an interactive audio and video telecommunications system which, at a minimum, includes provision of real-time consultation among the patient, consulting practitioner, and/or referring practitioner. The American Medical Association (AMA) issued an opinion and associated guidelines for electronic communications, focusing on maintaining the physician-patient relationship, ethical responsibilities and notification to patients of the inherent limitations of such communications. As mentioned in the AMA Guidelines, electronic communications should never replace interpersonal contacts between the physician and patient, but rather electronic mail and other forms of internet communication should be used to enhance such contacts. Practitioners who use electronic communication systems should be in compliance with online secure transmission of private patient health information (e.g., HIPAA regulations, encryption.)the handling of electronic patient information is considered the same as for an in-office environment, and patient privacy must be maintained. CODING INFORMATION: CPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member's specific benefit plan determines coverage and referral requirements. All inpatient admissions require preauthorization. NOT AN ALL-INCLUSIVE LIST The following list identifies services eligible for reporting and reimbursement under telemedicine, however, as this field is constantly expanding it does not represent an exhaustive list of coverable services. Services meeting contract and policy guidelines, when billed with the correct modifier, may be submitted for reporting and reimbursement purposes. Compliance with the provision in this policy may be monitored and addressed through post payment data analysis and/or medical review audits

6 Page 6 of 16 Employer Health Programs (EHP) **See Specific Summary Plan Description (SPD) Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply policy criteria US Family Health Plan (USFHP), TRICARE Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE, apply the Medical Policy Criteria Advantage MD, LCD and NCD Medical Policy supersedes JHHC Medical Policy. If there is no LCD or NCD, apply the Medical Policy Criteria CPT CODES DESCRIPTION Psychiatric diagnostic evaluation Psychiatric diagnostic evaluation with medical services Psychotherapy, 30 minutes with patient Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 45 minutes with patient Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 60 minutes with patient Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychoanalysis Family psychotherapy (without the patient present), 50 minutes Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes End-stage renal disease (ESRD) related services monthly, for patients younger than years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month End-stage renal disease (ESRD) related services monthly, for patients younger than years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional per month End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional per month

7 Page 7 of End-stage renal disease (ESRD) related services monthly, for patients years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health care professional per month End-stage renal disease (ESRD) related services monthly, for patients years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional per month End-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 End-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 End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents End-stage renal disease (ESRD) related services for home dialysis per full month, for patients years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients years of age End-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 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment

8 Page 8 of 16 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment Health and behavior intervention, each 15 minutes, face-to-face; individual Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) Medical nutrition therapy; initial assessment and intervention, individual, face-toface with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion Online assessment and management service provided by a qualified non- physician healthcare professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communication network Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-toface with the patient and/or family.

9 Page 9 of Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Office 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. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15

10 Page 10 of minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

11 Page 11 of Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family. Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside

12 Page 12 of and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

13 Page 13 of 16 Online evaluation and management service provided by a physician or other qualified health care professional who may report an evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network. Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional minutes of medial consultative discussion and review minutes of medical consultative discussion and review minutes of medical consultative discussion and review minutes or more of medical consultative discussion and review. Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. Transitional 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 Medical decision making of at least moderate complexity during the service period Face-Face visit, within 14 calendar days of discharge Transitional 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 Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-toface with the patient, family member(s), and/or surrogate Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes

14 Page 14 of 16 HCPCS CODES G0108 G0109 G0270 G0396 G0397 G0406 G0407 G0408 G0420 G0421 G0425 G0426 G0427 G0438 G0439 G0442 G0443 G0444 G0445 G0446 G0447 DESCRIPTION Diabetes outpatient self-management training services, individual, per 30 minutes Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-toface with the patient, each 15 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit Annual alcohol misuse screening, 15 minutes Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Annual depression screening, 15 minutes Semiannual high intensity behavioral counseling to prevent STIs, individual, face-toface, includes education skills training & guidance on how to change sexual behavior Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Face-to-face behavioral counseling for obesity, 15 minutes

15 Page 15 of 16 G0459 G0508 G0509 Q3014 S9110 T1014 Modifier GT Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth Telehealth originating site, facility fee. Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month Telehealth transmission, per minute. DESCRIPTION Via interactive audio and video telecommunication systems; Modifier used to indicate telehealth services. Except for demonstrations in Alaska and Hawaii, all telehealth must be interactive. ICD10 CODES ICD10 CODES ARE FOR INFORMATIONAL PURPOSES ONLY DESCRIPTION Multiple Codes DESCRIPTION REVENUE CODES 0581 Home Health (HH)-Other Visits-Visit Charge 0900 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)- General: Hospital; outpatient 0915 Behavioral Health Treatments/Services-Extension of 090X-Group Therapy; Hospital; outpatient REFERENCE STATEMENT: Analyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCare LLC (JHHC) Medical Policy Team during the development and implementation of this medical policy. Per NCQA standards, the Medical Policy Team will continue to monitor and review any newly published clinical evidence and adjust the references below accordingly if deemed necessary. REFERENCES: American Medical Association, Opinion The Use of Electronic Mail. Issued June 2003 based on the report Ethical Guidelines for the Use of Electronic Mail between Patients and Physicians. December 2002, AJOB, 2003, 3 (3).

16 Page 16 of 16 American Telemedicine Association, Core Standards for Telemedicine Operations. November 2007 Code of Maryland Regulations, COMAR , Standards Related to Telemedicine. Maryland Register and COMAR, Issue Date: October 13, 2017, Volume 44, Issue: 21, pp , Subtitle 09 Medical Care Programs: Remote Patient Monitoring, pp Retrieved from: Medicaid 2013 Legislative Bill Tracking, Senate Bill 76, Task Force on the Use of Telehealth to Improve Maryland Health Care Telemedicine Program under Federal Medicaid, Retrieved from: The Code of Federal Regulations, 42 CFR, Ch. IV ( Edition), (1), Telehealth Services.