Telehealth, Telemedicine, And Telemonitoring

Transcription

1 Care1st Health Plan Arizna, Inc. Easy Chice Health Plan Harmny Health Plan f Illinis Missuri Care Ohana Health Plan, a plan ffered by WellCare Health Insurance f Arizna OneCare (Care1st Health Plan Arizna, Inc.) Staywell f Flrida WellCare (Arkansas, Cnnecticut, Flrida, Gergia, Illinis, Kentucky, Luisiana, Mississippi, Nebraska, New Jersey, New Yrk, Suth Carlina, Tennessee, Texas) WellCare Prescriptin Insurance Telehealth, Telemedicine, And Telemnitring Plicy Number: Original Effective Date: 1/21/2010 Revised Date(s): 1/21/2011; 1/5/2012; 12/6/2012; 1/9/2014; 11/6/2014; 1/8/2015; 1/7/2016; 1/12/2017; 6/1/17; 8/18/2017 APPLICATION STATEMENT The applicatin f the Clinical Guideline is subject t the benefit determinatins set frth by the Centers fr Medicare and Medicaid Services (CMS) Natinal and Lcal Determinatins and state-specific Medicaid mandates, if any. DISCLAIMER The Clinical Guideline (CCG) is intended t supplement certain standard WellCare benefit plans and aid in administering benefits. Federal and state law, cntract language, etc. take precedence ver the CCG (e.g., Centers fr Medicare and Medicaid Services [CMS] Natinal Determinatins [NCDs], Lcal Determinatins [LCDs] r ther published dcuments). The terms f a member s particular Benefit Plan, Evidence f, Certificate f, etc., may differ significantly frm this Psitin. Fr example, a member s benefit plan may cntain specific exclusins related t the tpic addressed in this CCG. Additinally, CCGs relate exclusively t the administratin f health benefit plans and are NOT recmmendatins fr treatment, nr shuld they be used as treatment guidelines. Prviders are respnsible fr the treatment and recmmendatins prvided t the member. The applicatin f the CCG is subject t the benefit determinatins set frth by the Centers fr Medicare and Medicaid Services (CMS) Natinal and Lcal Determinatins and state-specific Medicaid mandates, if any. All links are current at time f apprval by the Medical Plicy Cmmittee (MPC) and are subject t change prir t the annual review date. Lines f business (LOB) are subject t change withut ntice; current LOBs can be fund at All guidelines can be fund at this site as well but selecting the Prvider tab, then Tls and Clinical Guidelines. BACKGROUND Telehealth and telemedicine are ften used interchangeably; WellCare uses the fllwing distinctin: Telemedicine. Remte cmmunicatin using vice and visual technlgy between a prvider and a member used fr health check-up and diagnstic purpses. Telemedicine is ften used as a substitute fr an in-ffice visit and des nt invlve cntinuus mnitring f the member. Telehealth. A rbust cntinuus mnitring f the member s health (see infrmatin in the criteria set). Clinical Guideline page 1

2 Telehealth allws prviders t maintain cnsistent cntact with clients at reduced csts. As expenses escalate, there is significant pressure n prviders t lwer csts and maintain quality f care, while increasing client satisfactin. In rder t meet these challenges, prviders are utilizing telehealth technlgies. Studies demnstrate remte mnitring with telehealth serves as an extremely useful healthcare delivery tl that imprves quality f care fr thse wh require r benefit frm clse mnitring by their prvider rganizatin. Operatinal Mdes f Telehealth There are tw primary mdes f telehealth - real-time (synchrnus) and stre-and-frward (asynchrnus). Realtime telehealth sessins are live and interactive, and frequently use videcnferencing technlgies. Often, special telehealth-enabled instruments (peripherals), such as a vide tscpe (t examine the ear) r an electrnic stethscpe, are perated by a nurse r technician at the cnsulting prvider s directin t remtely perfrm a physical examinatin. In stre-and-frward telehealth, data (such as digital phtgraphs) are captured lcally, then temprarily stred (cached) fr transfer at a later time, either via a secure web server, encrypted , speciallydesigned stre-and-frward sftware, r electrnic health recrd. The cnsulting prvider then reviews the stred data and makes diagnsis, treatment, and planning recmmendatins that are electrnically transferred r faxed back t the referring prvider. Prvider benefits f telehealth include: Imprve quality care thrugh imprved assessment and mnitring capabilities Reduce current perating csts Efficient and imprved use f caregiver/care manager time Enhance and embellish current service fferings with new value added features Develp new marketing pprtunities that attract and maintain clients and custmers Create a new revenue stream Member benefits f telehealth include: Earlier recgnitin and interventin Imprved quality f life Decreased ER visits and hspital re-admissins Member and care giver supprt Reduced anxiety Increased cmpliance in medicatin and treatments Imprved empwerment and self-management skills Increased independence Privacy and Cnsent Prir t receiving telehealth r telemedicine services the member must agree t participate and sign an infrmed cnsent. Fr members wh are minrs, their parent r guardian must sign the cnsent frm unless exempted by State r Federal Law. The minr s parents r guardian need nt be present fr the telehealth r telemedicine appintment unless it is deemed therapeutically apprpriate. 3 Member has the right t withdraw frm the telehealth r telemedicine appintment at any time during the sessin. 3 The telehealth r telemedicine appintment must meet all cnfidentiality requirements required in HIPAA (here) and HITECH (here) regulatins and the sessins may nt be recrded. All telehealth and telemedicine services must be perfrmed using a secure line including and encryptin prcess t ensure cnfidentiality. There can be n use f the member s images r infrmatin withut the member s written cnsent. 3,4 Clinical Guideline page 2

3 POSITION STATEMENT Applicable T: Medicaid Flrida, Gergia, Illinis, Nebraska, New Jersey, New Yrk, Suth Carlina NOTE: SEE BELOW FOR MEDICARE COVERAGE ITEMS Flrida 5, 6 Per Flrida Statue 59G-1.057, cverage is applied t the practice f health care delivery by a practitiner wh is lcated at a site ther than the site where a recipient is lcated fr the purpses f evaluatin, diagnsis, r treatment. 5 Practitiners licensed within their scpe f practice t perfrm the service. Flrida Medicaid reimburses fr telemedicine services using interactive telecmmunicatins equipment that includes, at a minimum audi and vide equipment permitting tw-way, real time, interactive cmmunicatin between a recipient and a practitiner, and meet the technical safeguards by 45 CFR , where applicable. The services must cmply with all HIPAA and ther state and federal laws pertaining t privacy. The fllwing applies t practitiners rendering services in the fee-fr-service delivery system: Flrida Medicaid reimburses the practitiner wh is prviding the evaluatin, diagnsis, r treatment recmmendatin lcated at a site ther than where the recipient is lcated. Prvider shall ensure the enrllee has a chice f whether t access services thrugh a face-t-face r telemedicine encunter, and shall dcument such chice in the enrllee s medical/case recrd. Prviders must include mdifier GT n the CMS-1500 claim frm, incrprated by reference in Rule 59G , F.A.C. Gergia 3 Telemedicine cnsultatins are cvered when medically necessary and when the fllwing requirements are met: 1. The referring prvider must be licensed and practicing within the state f Gergia; AND, 2. The member must be present and participating in the visit; AND, 3. The referring prvider must be the members attending prvider in charge f their care and the request must be dcumented in the member s recrd. Pertinent medical infrmatin and/r recrds must be transmitted t the distant site prvider via a secure transmissin; AND, 4. The referring prvider must be requesting the pinin, advice r service f anther prvider fr a specific medical prblem, illness r injury; AND, 5. The cnsulting prvider be licensed in the state f Gergia and must dcument all findings and recmmendatins in writing, in the frmat nrmally used fr recrding services in the patients medical recrds; AND, 6. The referring health care practitiner must btain written cnsent frm the eligible Gergia Medicaid member prir t rendering service. The cnsent frm must include a descriptin f the risks, benefits and cnsequences f telemedicine and be included in the member s medical recrd; AND, 7. If the member is a minr child, a parent/guardian must present the child fr telemedicine services and sign the cnsent frm unless therwise exempted by State r Federal law. All telemedicine activities must cmply with the requirements f the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA): Standards fr Privacy f individual identifiable health infrmatin and all ther applicable state and federal laws and regulatins. By cding and billing the GT mdifier with a cvered telemedicine prcedure cde, yu are certifying that the beneficiary was present at an eligible riginating site when yu furnished the telemedicine service. By cding and billing the GT mdifier with a cvered ESRD-related service telemedicine cde, yu are certifying that yu furnished ne hands n visit per mnth t examine the vascular access site. Clinical Guideline page 3

4 Exclusins 1. Telephne cnversatins. 2. Electrnic mail messages. 3. Facsimile. 4. Services rendered via a webcam r internet based technlgies (i.e., Skype, Tang, etc.) that are nt part f a secured netwrk and d nt meet HIPAA encryptin cmpliance. 5. Vide cell phne interactins. 6. The cst f telemedicine equipment and transmissin. 7. Stre and frward transactins (as defined belw). 8. Failed r unsuccessful transmissins. Illinis Exclusins Grup psychtherapy is nt a cvered telepsychiatry service. Telemedicine Cnsultatins are cvered when medically necessary and when the fllwing requirements are met: 1. A physician r ther licensed health care prfessinal must be present at all times with the patient at the riginating site; AND, 2. The distant site prvider must be a physician, physician assistant, pdiatrist r advanced practice nurse wh is licensed by the State f Illinis r by the state where the patient is lcated; AND, 3. The riginating and distant site prvider must nt be terminated, suspended r barred frm the Department's medical prgrams; AND, 4. Medical data may be exchanged thrugh a telecmmunicatin system; AND, 5. The interactive telecmmunicatin system must, at a minimum, have the capability f allwing the cnsulting distant site prvider t examine the patient sufficiently t allw prper diagnsis f the invlved bdy system. The system must als be capable f transmitting clearly audible heart tnes and lung sunds, as well as clear vide images f the patient and any diagnstic tls, such as radigraphs. Telepsychiatry Cnsultatins are cvered when medically necessary and when the fllwing requirements are met: 1. A physician, licensed health care prfessinal r ther licensed clinician, mental health prfessinal (MHP), r qualified mental health prfessinal (QMHP), as defined in 59 Ill. Adm. Cde , must be present at all times with the patient at the riginating site; AND, 2. The distant site prvider must be a physician licensed by the State f Illinis r by the state where the patient is lcated and must have cmpleted an accredited general psychiatry residency prgram r an accredited child and adlescent psychiatry residency prgram; AND, 3. The riginating and distant site prvider must nt be terminated, suspended r barred frm the Department's medical prgrams; AND, 4. The distant site prvider must persnally render the telepsychiatry service; AND, 5. Telepsychiatry services must be rendered using an interactive telecmmunicatin system. Kentucky 8 Exclusins If a service is nt cvered in a face-t-face setting, it is als nt cvered if prvided thrugh telehealth. A service prvided thrugh telehealth is subject t the same prgram restrictins, limitatins and cverage which exist fr the Clinical Guideline page 4

5 service when nt prvided thrugh telehealth. 8. The prvider must be enrlled in the KY Medicaid Telehealth Netwrk; AND, 9. The agency requires the fllwing fr a telehealth cnsult: Kentucky s Medicaid prgram (state agency) des nt currently cver stre and frward telehealth; AND, 10. A telehealth cnsultatin shall require: The use f tw (2) way interactive vide; AND, A referral by a health care prvider; AND, A referral by a recipient s lck-in prvider if the recipient is lcked in pursuant t 42 C.F.R ; AND, 907 KAR 1:677. Nebraska Tele-mnitring invlves easy-t-use equipment t help members track their vital signs at hme. Vitals are transmitted autmatically t a prvider and mnitred by a nurse. WellCare has begun discussins with several tele-mnitring cmpanies and is currently evaluatin platfrms and services fr tele-mnitring. WellCare believes that tele-mnitring can be used t prevent hspital admissins and readmissins. At a minimum, WellCare will cver tele-mnitring services when the fllwing cnditins have been met: 1. Member has been hspitalized tw r mre times in the last 12 mnths fr cnditins related t the disease. (Nt required fr infant apnea mnitring); AND, 2. Member is cgnitively capable f perating the equipment r has a willing and able persn t assist in the transmissin f the electrnic data; AND, 3. Originating site has space fr all prgram equipment and full transmissin capability; AND, 4. Prvider s recrd cntains data that supprts the medical necessity f the service, all transmissins, and subsequent review received frm the member, and hw the data transmitted frm the member is used in the cntinuus develpment and implementatin f the member s plan f care. Children (Age < 19) In additin t the abve criteria, fr services related t members < age 19, the fllwing als applies: 8 1. An apprpriately trained staff member r emplyee familiar with the child's treatment plan r familiar with the child shall be immediately available in persn t the child receiving a telehealth behaviral health service in rder t attend t any urgent situatin r emergency that may ccur during prvisin f such service. This requirement may be waived by the child's parent r legal guardian; AND, 2. In cases in which there is a threat that the child may harm himself r herself r thers, befre an initial telehealth service the health care practitiner shall wrk with the child and his r her parent r guardian t develp a safety plan. Such plan shall dcument actins the child, the health care practitiner, and the parent r guardian will take in the event f an emergency r urgent situatin ccurring during r after the telehealth sessin. Such plan may include having a staff member r emplyee familiar with the child's treatment plan immediately available in persn t the child, if such measures are deemed necessary by the team develping the safety plan; AND, 3. Services prvided by means f telecmmunicatins technlgy, ther than telehealth behaviral health services received by a child, are nt cvered if the child has access t a cmparable service within thirty miles f his r her place f residence. Clinical Guideline page 5

6 New Jersey 4 Telepsychiatry is defined as a psychiatric service prvided by a psychiatrist r psychiatric advance practice nurse frm a remte lcatin ver secure, tw-way, interactive, audivisual equipment. Telepsychiatry may be utilized by mental health clinics and/r hspital prviders f utpatient mental health services t meet their physician related requirements including but nt limited t intake evaluatins, peridic psychiatric evaluatins, medicatin management and/r psychtherapy sessins fr clients f any age. Telepsychiatry cnsultatins are cvered when medically necessary and when the fllwing requirements are met: 1. Member must prvide infrmed cnsent t participate in any service utilizing telepsychiatry; AND, 2. All telepsychiatry transmissins must be n a secure line which utilizes an encryptin prcess that ensures cnfidentiality and the integrity f the infrmatin being transmitted; AND, 3. Telepsychiatry services must be prvided frm, and in, a lcatin that is prperly lit allwing fr clear visual cntact; AND, 4. The Medicaid client must receive services at the mental health clinic r utpatient hspital prgram and the mental health clinic/hspital must bill fr all services under their Medicaid prvider number; AND, 5. The psychiatrist r psychiatric APN may be ff-site but must be a practitiner currently licensed t practice within the State f New Jersey; AND, 6. In the event that the psychiatrist r psychiatric APN require a physical evaluatin as part f their clinical assessment, the hsting prvider shall have an RN available t cmplete and share the results f the physical evaluatin. New Yrk 12 Exclusins Prvider CANNOT bill fr telehealth services prvided t members wh have Medicare, cmmercial insurance r are insured thrugh ther payers, during the time perid r episde in which the prvider is billing r is being paid by anther insurer. Telehealth services are NOT a cvered benefit fr Family Health Plans r Child Health Plus enrllees. When the criteria belw are met, hme telehealth hme care services are eligible fr cverage when prvided t assist in the effective mnitring and management f members whse medical, functinal, and/r envirnmental needs can be apprpriately and cst-effectively met at hme thrugh the applicatin f telehealth interventin. Cnditins and clinical circumstances eligible fr telehealth services shall include, but are nt limited t, cngestive heart failure, behaviral prblems limiting self-management, and technlgy-dependent care (e.g., cntinuus xygen, ventilatr care, ttal parenteral nutritin and enteral feeding). The fllwing are required befre the initiatin f telehealth hme care services: A request fr initial certificatin shuld be submitted. Recertificatin will be required quarterly, with member specific dcumentatin and physician rders, thereafter.; AND, Only members wh qualify fr hme care services will be cnsidered fr telehealth hme services; AND, Members whse risks are assessed in-persn prir t the receipt f telehealth services will be eligible. The fllwing dcumentatin is required fr cnsideratins f services: A physician rder fr telehealth services; AND, An apprved member risk assessment is required t be perfrmed by the agencies t assess high-risk members. The tl must incrprate such variables as whether the member: Is at risk fr hspitalizatin r emergency care visits; AND, Lives alne; AND, Clinical Guideline page 6

7 Has a dcumented histry f r is at high risk f requiring nursing visits r interventins; AND, Has a histry f nn-cmpliance adhering t disease management recmmendatins; AND, Requires n-ging symptm management related t dyspnea, fatigue, pain, edema, r medicatin side effects r adverse effects; AND, Resides in a medically under-served, rural, r gegraphically inaccessible area: AND, Has difficulty traveling t and frm hme fr medical appintments; AND, Has the functinal ability t wrk with telehealth mnitring equipment, in terms f sight, hearing, manual dexterity, cmprehensin and ability t cmmunicate. Hme telehealth services are a New Yrk Medicaid cvered benefit when prvided by ne f the fllwing: Certified Hme Health Agencies (CHHAs); OR, Lng-term health care prgrams; OR, AIDS hme care prgrams. Telehealth services accunt fr daily variatin in the intensity and cmplexity f the member s telehealth service needs. Rates shuld include the fllwing functins: Mnitring f member vital signs; AND, Medicatin management; AND, Member educatin; AND, Equipment management; AND, Review f member trends and/r changes in member cnditin necessitating interventin; AND, Such ther activities deemed necessary and apprpriate by the plan. Retractive t February 1, 2010, Medicaid is expanding cverage fr physician specialist telemedicine cnsultatins t patients in hspital utpatient departments. Additinally, physicians may bill separately fr their hspital services using the physician fee schedule in bth the inpatient and utpatient setting, including fr telemedicine cnsultatins. Physician reimbursement fr the telemedicine cnsultatin will be fr the same amunt as an inpersn specialist cnsultatin. Telemedicine cnsultatins are nt limited t any specific physician specialty. Cvered physician specialties include, but are nt limited t, neurlgy, endcrinlgy, nclgy, etc. Telemedicine cnsultatins must be cnducted using a real-time fully interactive, secure tw-way audi and vide telecmmunicatins system that supprts review f diagnstic tests integral t the cnsultatin. Reimbursement is based n a tier-pricing system. The tier-pricing system is determined by the level f system interperability. Tier 1. Class 2 Medical Device that is FDA apprved with interperability Tier 2. Tier 1, plus a standard intercnnectin with a hme care pint f care system. Tier 3. Tier 2, plus a standard intercnnectin with electrnic health recrd and statewide health infrmatin netwrk. Requirements (per New Yrk Department f Health 2011 Update) Telemedicine cnsultatins are cvered when medically necessary and when the fllwing requirements are met: Member must be physically present at the riginating "spke" site; the physician specialist and/r CDE/CAE is lcated at the "hub" site. Physician specialist at the "hub" site, wh is perfrming the cnsult, must be licensed in New Yrk State, enrlled in New Yrk State Medicaid and be credentialed and privileged at bth the "hub" and "spke" site hspital and/r D&TC. The CDE/CAE at the "hub" site must be enrlled in New Yrk State Medicaid as either a billing prvider (i.e., MD, Nurse Practitiner, and Licensed Midwife) r a nn-billing prvider. CAEs and CDEs, wh are nn-billing prviders, cannt bill Medicaid directly. They must enrll as nn-billing Medicaid prviders and be emplyed by r cntracted with a billing Medicaid prvider. A cmplete listing f prfessinal entities that are qualified t prvide CDE/CAE services is available in the Octber 2008 Medicaid Update at the fllwing Website: Clinical Guideline page 7

8 The request and medical need fr the telemedicine cnsult and the findings f the cnsulting physician r CDE/CAE must be dcumented in the patient's medical recrd. The telemedicine cnsultatin must be "real time," and prvided via a fully interactive, secure tw-way audi visual telecmmunicatin system ("stre and frward" is nt cvered by Medicaid). Medicaid currently cvers medically necessary physician specialist cnsultatins prvided via telemedicine t patients in Article 28 emergency rms, hspital utpatient departments and hspital inpatient settings. In respnse t a Medicaid Redesign Team (MRT) initiative, Medicaid has taken steps t expand and enhance cverage f telemedicine. The gal f this undertaking is t prvide Medicaid enrllees with greater access t specialty care by reducing the barriers encuntered by prviders requesting and delivering care via telemedicine. Telemedicine "hub" sites will include: Article 28 Hspitals; Article 28 Diagnstic and Treatment Centers (D&TCs); and Federally Qualified Health Centers (FQHCs) that have "pted int" APGs. Telemedicine riginating "spke" sites will include: Article 28 Hspitals (Emergency Rm, Outpatient Department, Inpatient); Article 28 Diagnstic and Treatment Centers (D&TCs); and FQHCs that have "pted int" APGs and nn-fqhc Schl Based Health Centers (SBHCs). Rate cdes are being develped t permit FQHCs that have nt "pted int" APGs, as well as SBHCs that are FQHCs, t bill fr the administrative csts assciated with telemedicine. Prviders will be ntified when these rate cdes becme active. Practitiners, wh may prvide telemedicine services at the "hub" site will include: Physician Specialists (including Psychiatrists);, Certified Diabetes Educatrs (CDEs); and Certified Asthma Educatrs (CAEs r A-ECs). Physician specialist telemedicine cnsultatins are cvered when medically necessary and when the: Patient is lcated at the spke site and the physician specialist is lcated at the hub site; Spken site is the hspital where the patient and referring physician are lcated; Hub site is the ffice r ther hspital where the physician specialist is lcated; Patient is present during the telemedicine cnsultatin; Specialist is nt available at the spke site t prvide a timely cnsultatin; Physician specialist is nt cnducting the telemedicine cnsultatin at the spke site; Telemedicine cnsult request and the ratinale fr the request are dcumented in the patient's medical recrd; Patient recrd includes dcumentatin that the telemedicine cnsultatin ccurred and that the results and findings were cmmunicated t the requesting prvider; Cnsulting physician is licensed in NYS; is practicing within his/her scpe f specialty practice; is enrlled in New Yrk Medicaid; and is credentialed and privileged at the spke site hspital. Physician Billing Requirements Physicians billing fr telemedicine cnsultatins must include the mdifier - GT "via interactive audi and vide telecmmunicatins systems" with the apprpriate cnsultatin E&M cde t indicate services were perfrmed via telemedicine; The place f service entered n the claim is the lcatin f the patient. Use "21" fr hspital inpatient, "22" fr hspital utpatient, r "23" fr hspital emergency rm. The attending physician bills the apprpriate E&M cde withut the GT mdifier; Payment will be made t nly ne physician fr the prfessinal cmpnent (reading and interpretatin) f diagnstic tests such as radilgical prcedures and diagnstic assessments. Clinical Guideline page 8

9 Telepsychiatry Medicaid will reimburse fr cnsultatins prvided by a psychiatrist thrugh an audi/visual link as well as nging therapy prvided by a psychiatrist. As with all ther telemedicine services, if the riginating "spke" site is an Article 28 facility (hspital utpatient department r diagnstic and treatment center), the "spke" site is directly respnsible fr all patient care, and is als required t credential and privilege the psychiatrist wh is lcated at the distant "hub" site (see the infrmatin belw n credentialing/privileging requirements). In additin t psychiatric cnsultatins, nging therapy prvided by the psychiatrist at the distant "hub" site may be billed t Medicaid. Diabetes Self-Management Training (DSMT) / Asthma Self-Management Training (ASMT) Medicaid will reimburse fr CDE/CAE diabetes and asthma self-management training services prvided thrugh telemedicine. As with all ther telemedicine services, if the distant "spke" site is an Article 28 facility (hspital utpatient department r diagnstic and treatment center), the "spke" site is directly respnsible fr all patient care. The decisin whether a medical practitiner needs t be present t assist the patient receiving CDE/CAE services thrugh telemedicine rests with bth the practitiner at the "spke" site as well as the CDE/CAE prviding the educatin, e.g., it may be advantageus fr a practitiner (physician, physician assistant, nurse practitiner, r RN) t be physically present with the patient when certain prcedures are taught r presented such as insulin injectin, use f an insulin pump, apprpriate and effective use f a nebulizer, etc. Suth Carlina 13 Exclusins The fllwing interactins d nt cnstitute reimbursable telemedicine r telepsychiatry services and will nt be reimbursed: Vide cell phne interactins Telephne Cnversatins messages Facsimile transmissins Services prvided by allied health prfessinals CPT prcedure cdes 99075, 99078, 99080, and indicating medical testimny, special reprts fr insurance, educatinal services fr grups, and data analysis are nn-cmpensable by Medicaid. Services that are eligible fr reimbursement include cnsultatin, ffice visits, individual psychtherapy, pharmaclgic management, and psychiatric diagnstic interview examinatins and testing, delivered via a telecmmunicatin system. A licensed physician and/r nurse practitiner are the nly prviders f telepsychiatry services. As a cnditin f reimbursement, an audi and vide telecmmunicatin system that is HIPAA cmpliant must be used that permits interactive cmmunicatin between the physician r practitiner at the cnsultant site and the beneficiary at the referring site. Office and utpatient visits that are cnducted via telemedicine are cunted twards the applicable benefit limits fr these services. Medicaid cvers telemedicine when the service is medically necessary and under the fllwing circumstance: The medical care is individualized, specific, and cnsistent with symptms r cnfirmed diagnsis f the illness r injury under treatment, and nt in excess f the beneficiary s need; and The medical care can be safely furnished, and n equally effective and mre cnservative r less cstly treatment is available statewide. Telemedicine services are cvered when the fllwing requirements are met: 1. The beneficiary must be present and participating in the telemedicine visit, AND 2. The referring prvider must prvide pertinent medical infrmatin and/r recrds t the cnsulting prvider via a secure transmissin, AND Clinical Guideline page 9

10 3. Interactive audi and vide telecmmunicatin must be used; permitting encrypted cmmunicatin between the distant site physician r practitiner and the Medicaid beneficiary. The telecmmunicatin service must be secure and adequate t prtect the cnfidentiality and integrity f the Telemedicine infrmatin transmitted, AND 4. The telemedicine equipment and transmissin speed and image reslutin must be technically sufficient t supprt the service billed. Staff invlved in the telemedicine visit must be trained in the use f the telemedicine equipment and cmpetent in its peratin, AND 5. An apprpriate certified r licensed health care prfessinal at the referring site is required t present (patient site presenter) the beneficiary t the physician r practitiner at the cnsulting site and remain available as clinically apprpriate, AND 6. If the beneficiary is a minr child, a parent and/r guardian must present the minr child fr telemedicine service unless therwise exempted by State r Federal law. The parent and/r guardian need nt attend the telemedicine sessin unless attendance is therapeutically apprpriate, AND 7. The beneficiary retains the right t withdraw at any time, AND 8. All telemedicine activities must cmply with the requirements f the Health Insurance Prtability and Accuntability Act f 1996: Standards fr Privacy f individually identifiable Health Infrmatin and all ther applicable state and federal laws and regulatins, AND 9. The beneficiary has access t all transmitted medical infrmatin, with the exceptin f live interactive vide, as there is ften n stred data in such encunters, AND 10. There will be n disseminatin f any beneficiary s images r infrmatin t ther entities withut written cnsent frm the beneficiary, AND 11. The prvider at the distant site must btain prir apprval fr service when services require prir apprval, based n service type r diagnsis. CODING CPT * Cdes N applicable cdes. HCPCS * Level II Cdes Q3014 Telehealth riginating site facility fee **(NMN) T1014 Telehealth transmissin, per minute, prfessinal services bill separately **(NMN) **Cdes are nt medically necessary (NMN) except fr Managed Medicaid Members. ICD-10-CM Diagnsis Cdes Diagnses are cvered when the abve criteria is met. Cding infrmatin is prvided fr infrmatinal purpses nly. The inclusin r missin f a CPT, HCPCS, r ICD-10 cde des nt imply member cverage r prvider reimbursement. Cnsult the member's benefits that are in place at time f service t determine cverage (r nncverage) as well as applicable federal / state laws. REFERENCES 1. Cre standards f telemedicine peratins. American Telemedicine Assciatin Web site. Accessed December 21, Hme telehealth clinical guidelines. American Telemedicine Assciatin Web site. (2003). Published Accessed December 21, GA Department f Cmmunity Health Telemedicine Handbk. Effective January 1, pdf. Accessed April 14, Vlume 23 N. 21 (New Jersey). Department f Human Service Divisin f Medical Assistance & Health Services website. Effective December Accessed April 14, Rule: 59G Telemedicine. Flrida Administrative Cde & Flrida Administrative Register Web site. Effective June 20, Accessed May 1, Rule 64BB Standards fr Telemedicine Practice. Flrida Administrative Cde & Flrida Administrative Register Web site. Effective March 7, Accessed May 1, Sectin telehealth services (Illinis). Jint Cmmittee n Administrative Rules Web site. ftp:// Effective January 29, Accessed December 30, Clinical Guideline page 10

11 8. Kentucky Legislature. 907KAR 3:170. Telehealth cnsultatin cverage and reimbursement. Kentucky Legislature Web site. Accessed May 26, Nebraska Revised Statute : Telehealth and telemnitring services cvered under plicy, certificate, cntract, r plan; insurer; duties. Nebraska Legislature Web site. Published Telehealth services fr physical and behaviral health services (1-006). Nebraska Department f Health and Human Services Website. Revised Nvember 22, Statues relating t Nebraska Telehealth Act. Nebraska Department f Health and Human Services Web site. Published Accessed December 30, New Yrk state Medicaid update: expanded cverage f telemedicine. New Yrk Department f Health Web site. Published Accessed December 21, Healthy Cnnectins Prvider Manual Physicians Prvider Manual Sectin 2 Plicies and Prcedures. Suth Carlina Department f Health and Human Services. Effective February 1, 2005 (Updated April 1, 2017). Accessed May 1, MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Actin 8/18/2017 Apprved by MPC. Updated Flrida specific criteria. 6/1/2017 Apprved by MPC. Added additinal lines f business. 1/12/2017 Apprved by MPC. Inclusin f Nebraska and Illinis cverage language. 1/7/2016, 1/8/2015 Apprved by MPC. N changes. 11/6/2014 Apprved by MPC. Inclusin f KY HIX criteria. Plicy previusly applied t NY nly. 1/9/2014, 12/6/2012 Apprved by MPC. N changes since 2011 update. 1/5/2012 Apprved by MPC. Refrmatted references. Added NY DOH cverage update re: expanded cverage (2011) and specialist cnsultatins (2010). Tw new references added. 12/1/2011 New template design apprved by MPC. Clinical Guideline page 11