Telehealth These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. Administrative Process Prior authorization is not required for Telehealth services. Coverage HealthPartners supports the use of Telehealth as an alternative to an office visit. Access to these services is limited to care that meets all of the conditions of this policy. HealthPartners defines covered Telehealth as: 1. Electronic visit (e-visit) - a web-based exchange of non-urgent clinical information between a provider and an established patient conducted over a secure encrypted web site. For behavioral health services, an established patient means a psychiatrist has had a previous assessment face-to-face with the patient. E-visits aren t typically considered real time visits. 2. Scheduled Visit (STV) - a telephone encounter between a provider and an established patient conducted over the phone 3. Telemedicine Telemedicine means the delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site. A communication between licensed health care providers that consists solely of a telephone conversation, e-mail, or facsimile transmission does not constitute telemedicine consultation services. A communication between a licensed health care provider and a patient that consists solely of an e-mail or facsimile transmission does not constitute telemedicine consultations or services. Telemedicine may be provided by means of real-time twoway, interactive audio and visual communications, including the application of secure video conferencing to provide or support health care delivery, which facilitate the assessment, diagnosis, consultation, treatment, education, and care management of a patient s health care. Practitioners eligible to provide Telehealth services are licensed and have one of the following designations: MD (medical doctor), DO (doctor of osteopathy), Podiatrist, Dentist, PA (physician s assistant), CNM (certified nurse midwife) NP (nurse practitioner), Clinical nurse specialist, CNS (certified nurse specialist), CRNA (certified registered nurse anesthetist), RD (registered dietician) or nutrition professional, or Pharmacist, Physical, Occupational or Speech Therapist, Certified genetic counselor Practitioners eligible to provide Telemedicine services are licensed and have one of the following designations: Clinical Psychologist Clinical Social Worker All applications used for the provision of Telehealth services must be Health Insurance Portability and Accountability Act (HIPAA) compliant and follow all applicable state and federal rules. Indications that are covered Covered technologies used for electronic communication may include e-mail over a secure encrypted web site with an established patient and a provider, telephone encounters between an established patient and a provider or consultation between a patient and a provider via video conference. For Behavioral Health services delivered via e-mail or phone, established patient means the psychiatrist has had a Page 1 of 8
previous assessment face-to-face with the patient. Video conference with a psychiatrist does not require a previous face-to-face visit. Indications that are not covered The following services would not be reimbursed as part of Telehealth: Definitions 1. Electronic connections that are not conducted over a secure encrypted web site as specified by the Health Insurance Portability & Accountability Act of 1996 Privacy & Security Rules. (e.g., Skype) 2. Initial inpatient consultation or emergency room visit 3. Asynchronous store and forward technology 4. Prescription renewals 5. Scheduling a test or appointment 6. Call to nurse line for questions or standing orders, e.g. sinusitis or conjunctivitis 7. Clarification of issues from previous visit 8. Other non-clinical communication 9. Updating patient demographic information 10. Reporting test results 11. Requesting a referral 12. Any consultation with another physician in reference to the patient 13. Phone, e-mail or interactive video visits not initiated by the member 14. Reminders 15. Providing educational materials Electronic visit (e-visit) E-visits are member initiated, online evaluation and management (E/M) services by a physician or assessment and management services when provided by a qualified non-physician. Services provided to an established patient through the internet. E-visit are used to address non-urgent, new or ongoing symptoms to which providers respond with substantive medical advice. Established patient patient who has been seen by a provider or by another provider with the same specialty in the same group practice at least once in the past three years. Scheduled Visit (STV) a telephone encounter between a provider and an established patient conducted over the phone. Telemedicine Consultation (interactive audio visual) a secure, real time consultation between a patient at a provider s office/facility (originating site provider) and a consulting provider (distant site provider) via a secure two-way interactive video connection. Originating Site (referring provider) an office/clinic, hospital or skilled nursing facility where the member is located. Distant Site (consulting provider) an office/clinic, hospital or skilled nursing facility where the consulting provider is located at the time the service is provided. Telemedicine Consultation (online video consult) a secure consultation between a patient and a provider using online video technology. This service is typically covered under the member s Office Visit benefit. Codes If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive. CPT Codes Description Service Provided By: 0188T Remote real-time interactive videoconferenced critical care, evaluation and Video management of the critically ill or critically injured patient; first 30-74 minutes 90791 Psychiatric diagnostic evaluation 90792 Psychiatric diagnostic evaluation with medical services Page 2 of 8
90832 Psychotherapy, 30 minutes with patient and/or family member 90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90834 Psychotherapy, 45 minutes with patient and/or family member 90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90837 Psychotherapy, 60 minutes with patient and/or family member 90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 90951 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 90952 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 90954 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 90955 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 90957 End-stage renal disease (ESRD) related services monthly, for patients 12-19 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 90958 End-stage renal disease (ESRD) related services monthly, for patients 12-19 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 90960 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 90961 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 96150 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 96151 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 96152 Health and behavior intervention, each 15 minutes, face-to-face; individual 96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) 96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 98966 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 Page 3 of 8
98967 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; 11-20 minutes 98968 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; 21-30 minutes 98969 On-line assessment and management service provided by a qualified nonphysician health care 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 communications network 99201 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. 99202 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. 99203 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. 99204 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. 99205 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. 99211 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. 99212 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. e-visit Page 4 of 8
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. 99213 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. 99214 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. 99215 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-toface with the patient and/or family. 99231 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. 99232 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. 99233 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. 99307 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 Page 5 of 8
patient's facility floor or unit. 99308 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. 99309 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. 99310 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. 99354 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service) 99355 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service) 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 99441 evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes 99442 evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes 99443 evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes 99444 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 99495 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or e-visit Page 6 of 8
caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge 99496 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 HCPCS Codes Description Service provided by: G0108 Diabetes outpatient self-management training services, individual, per 30 minutes G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes G0270 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 G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via Telehealth G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via Telehealth G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via Telehealth G0420 Face-to-face educational services related to the care of chronic kidney disease; G0421 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 G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via Telehealth G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via Telehealth G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via Telehealth G0436 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes G0437 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 10 minutes G0438 Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit G0439 Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit G0442 Annual alcohol misuse screening, 15 minutes G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes G0444 Annual depression screening, 15 minutes G0445 Semiannual high intensity behavioral counseling to prevent STIs, individual, face-toface, includes education skills training & guidance on how to change sexual behavior G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes G0447 Face-to-face behavioral counseling for obesity, 15 minutes G0459 Inpatient telehealth pharmacologic management, including prescription, use and review of medication with no more than minimal medical psychotherapy Q3014 Telehealth originating site facility fee Video S0265 Genetic counseling, under physician supervision, each 15 minutes CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Claims for services provided through video for consultation services should be submitted using the appropriate CPT or HCPCS Code for the professional service and GT modifier via interactive audio and video telecommunications system (e.g., 99243 GT). Page 7 of 8
Claims for facility services provided by the referring site should be submitted using Q3014 Originating Site Facility Fee Products This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645. Approved Medical Director Committee 12/19/12; Revised 2/3/2014, 5/14/14, 11/9/15, 11/24/2017; Annual review 12/2013, 11/2014, 11/2015, 11/2016, 11/2017 Page 8 of 8