JOHNS HOPKINS HEALTHCARE

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1 Page 1 of 19 ACTION: New Policy Effective Date: 10/01/2013 Revising : Review Dates: 03/29/16, 06/29/17, Superseding 09/01/17, 12/01/17, 05/15/18 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 April 5, 2018) Refer to Title 42 CFR at: 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 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, Remote Patient Monitoring(RPM), (see definitions), and

2 Page 2 of 19 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 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). C. Remote Patient Monitoring: (Information below applies to PPMCO Plan) 1. The service is permitted for the treatment of *chronic and acute conditions via wearable, platform or self-reported. These conditions include: a. Chronic Obstructive Pulmonary Disease, OR; b. Congestive Heart Failure, OR;

3 Page 3 of 19 c. Diabetes Type 1, OR; d. Diabetes Type 2, AND; 2. The provision of RPM may reduce the risk of preventable hospital utilization and promote improvement in control of the chronic condition. 3. To receive RPM, the participants must be enrolled in Medicaid(on the date the service is rendered), consent to RPM, have the internet connections and capability to use the monitoring tools in their homes, and have one of the following scenarios within the most recent 12-month period: a. Member should have had two (2) hospital admissions with the same qualifying medical condition (COPD, Congestive Heart Failure, or Diabetes (Type 1 or Type 2)) as the primary diagnosis, OR; b. Member should have had two (2) emergency department visits with the same qualifying medical condition as the primary diagnoses (which are listed in items a-d above), OR; c. 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 a-d above) as the primary diagnosis. 4. Referrals for RPM may cover an episode of up to 60 days of monitoring. Eligible participants may only receive two episodes of RPM during a rolling 12-month period. 5. Providers can prescribe RPM; however, the authorization limits apply across provider types. Therefore, a participant cannot receive two episodes of RPM from a home health agency and two episodes of RPM from another provider during a rolling 12-month period. 6. Remote Patient Monitoring can be provided by licensed Physicians, Nurse Practitioners and Physician Assistants (PAs) 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, Remote Patient Monitoring (RPM), (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, Remote Patient Monitoring (RPM), (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:

4 Page 4 of 19 DEFINITIONS 7. Interpretation of lab or radiology services by providers who are non-licensed (for telemedicine services) 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. 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. 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.

5 Page 5 of 19 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. Telehealth means the use of interactive audio, video, or other telecommunications or electronic technology by a licensed health care practitioner to deliver clinical services within the scope of practice of the health care practitioner at a location other than the location of the patient. It includes, but is not limited to: 1. Interactive audio-visual synchronous encounters; 2. Store-and-forward technology; 3. Interpretive services; and 4. Remote patient monitoring. Telehealth does not include: a. an audio-only telephone conversation between a health care practitioner and a patient; b. an electronic mail message between a health care practitioner and a patient; c. a facsimile transmission between a health care practitioner and a patient. 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. 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. Remote Patient Monitoring (RPM) - is a service which uses digital technologies to collect medical and other forms of health data from individuals and electronically transmits that information securely to health care providers for assessment, recommendations, and interventions. Providers should order RPM when it is medically necessary to improve chronic disease control and it is expected to reduce potentially preventable hospital utilization.

6 Page 6 of 19 Store and forward technology means the asynchronous transmission of digital images, documents and videos electronically through secure means. Interpretive services mean reading and analyzing images, tracings, or specimens through telehealth or giving interpretations based on visual, auditory, thermal, ultrasonic patterns or other patterns as may evolve with technology. BACKGROUND 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 2018 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

7 Page 7 of 19 Employer Health Programs (EHP) refer to specific Summary Plan Description (SPD) then apply Medical Policy criteria Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply Medical 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, then apply the Medical Policy Criteria CPT CODES 0188T 0189T DESCRIPTION Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; first minutes Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) Interactive complexity (List separately in addition to the code for primary procedure) 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) Psychotherapy for crisis; first 60 minutes Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service) Psychoanalysis Family psychotherapy (without the patient present), 50 minutes Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure) End-stage renal disease (ESRD) related services monthly, 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; with 4 or more face-to-face visits by a physician or other qualified health care professional per month

8 Page 8 of End-stage renal disease (ESRD) related services monthly, 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; 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 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

9 Page 9 of 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 Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, review and interpretation by a physician or other qualified health care professional External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, recording, and disconnection) External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; transmission and analysis External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; review and interpretation by a physician or other qualified health care professional Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results

10 Page 10 of 19 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family 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 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) Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument 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 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients 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

11 Page 11 of 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. 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.

12 Page 12 of 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 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

13 Page 13 of 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. 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

14 Page 14 of 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. Inpatient 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, 20 minutes are spent at the bedside and on the patient's hospital floor or unit. Inpatient 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, 40 minutes are spent at the bedside and on the patient's hospital floor or unit. Inpatient 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, 55 minutes are spent at the bedside and on the patient's hospital floor or unit. Inpatient 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, 80 minutes are spent at the bedside and on the patient's hospital floor or unit. Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical

15 Page 15 of 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, 110 minutes are spent at the bedside and on the patient's hospital 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 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 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

16 Page 16 of HCPCS CODES G0108 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 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes 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. 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 DESCRIPTION Diabetes outpatient self-management training services, individual, per 30 minutes

17 Page 17 of 19 G0109 G0270 G0296 G0396 G0397 G0406 G0407 G0408 G0420 G0421 G0425 G0426 G0427 G0438 G0439 G0442 G0443 G0444 G0445 G0446 G0447 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 Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making) 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