Clinical Policy Title: Telehealth Clinical Policy Number: 18.01.02 Effective Date: June 17, 2015 Initial Review Date: June 19, 2013 Most Recent Review Date: May 19, 2017 Next Review Date: May 2018 Policy contains: Asynchronous transfer. Distant or hub site. Distant site practitioner. Originating or spoke site. Synchronous transfer. Related policies: CP# 04.01.03 CP# 09.01.05 CP# 11.02.00 CP# 09.01.01 CP# 03.03.06 CP# 12.01.01 CP# 17.01.02 CP# 06.02.02 CP# 04.01.01 CP# 05.01.02 Ambulatory blood pressure monitoring Ambulatory and video electroencephalogram (AEEG, VEEG) Apnea monitors for infants in-home use Autonomic nervous system monitoring for neuropathy Biofeedback for chronic pain Home uterine activity monitoring Medical alert devices Outpatient diabetes self-management training (DSMT) Real-time outpatient cardiac monitoring Prothrombin international normalized ratio self-testing ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health Choice s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice s clinical policies are reflective of evidencebased medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice s clinical policies are not guarantees of payment. Coverage policy Prestige Health Choice considers telemedicine to be a covered service for members who meet the following criteria: A member for whom access to necessary medical services is not readily available. 1
Prestige Health Choice does not consider telemedicine to be a substitute for direct member-provider encounters. For Prestige Health Choice Medicaid members, the service is listed among one of the following: Provider office visit (CPT 99201-99215). A follow-up inpatient telehealth consultation furnished to beneficiaries in hospitals or Skilled Nursing Facilities (HCPCS codes G0406 G0408, CPT 99231-99233, or 99307-99310). Mental health diagnostic visits and psychotherapy based upon coverage requirements. End-stage renal disease service applicable to telemedicine (CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961). Individual and group medical nutritional counseling within benefits limits (HCPCS code G0270 and CPT codes 97802 97804). Limitations: Coverage determinations are subject to benefit limitations and exclusions as delineated by the state Medicaid authority. The Florida Medicaid website may be accessed at http://ahca.myflorida.com/medicaid/. Telemedicine and telehealth services for which there is no evidence of improved outcomes or for which there is no defined benefit in state or federal policy are not covered. Prestige Health Choice does not provide coverage for the transmission of telemedicine data such as teleradiology or telecardiology as such transmission services are integral to the procedures being covered. Fundus photography (CPT 92250) is a covered service but the transmission of the retinal photographs is included in the CPT code. Telephone consultation codes 99441 99243 are not considered integral to the physician office visit codes and are not separately reimbursable. Similarly, CPT code 99444 for email consultation is not a covered benefit. Alternative covered services: Office visit for diabetic retinal screening by ophthalmologist or optometrist. Background As defined by the American Telemedicine Association: telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient s clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology. The tradition of patient evaluation solely in direct face-to-face encounter has been altered forever. 2
Advances in communications technology now afford the patient and physician greater opportunities for interaction. Physicians have traditionally engaged in telephonic communication to extend the physicianpatient relationship beyond office hours or hospital rounds. In today's world, electronic technology puts faster and more secure means of communication at one's fingertips. Telemedicine in its current sense grew from the needs for access to care in rural areas of the United States. In the 1960s through the 1980s, telemedicine was conducted in demonstration projects by NASA on space flights, and in remote areas in Nebraska, New Hampshire, and Georgia. Transmission of digital imaging data afforded superior results than previous analog technology. Telepsychiatry and teledermatology subsequently initiated a wave of new applications for transmission of synchronous data between provider and patient. Telemedicine may be divided into distinct technical categories: Telephonic. Telephonic communication has defined CPT codes for third-party coverage. However, when the use of telephone communication is an extension of an office, hospital, or emergency room visit, it is considered part of the original encounter. Telephonic consultation is a uni-modality employment of telemedicine. Remote patient data transfer. Remote data transfer requires no active participation by the patient. The treating provider uploads and sends imaging or pathologic information to a remote consultant for interpretation. This transmission generally is asynchronous. Remote patient monitoring. Remote monitoring of patient data does not convey verbalized communication by the patient. Biophysical data (e.g., cardiac telemetry) is transmitted to a physician or medical facility for synchronous or asynchronous interpretation. The so-called tele-icu in which data from intensive care unit patients is monitored synchronously by a nurse or physician is an example. Video consultation. The patient is in live synchronous video and audio communication with the provider. Telehealth. Telemedicine may be considered a part of the global term "telehealth." In common use it refers to a patient encounter with a provider by electronic means either synchronously or asynchronously. Not everyone who resides remotely may benefit from this technology. There are identifiable populations for which telepsychiatry or telemental health is most appropriate (Hilty, 2013): " for diagnosis and assessment, across many populations (adult, child, geriatric and ethnic); and in disorders in many settings (emergency, home health) it is comparable to in-person care, and complements other services in primary care." Searches: Prestige Health Choice searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. 3
Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on April 12, 2017. Search terms were: telemedicine (MeSH), telehealth (MeSH), and teleconsultation. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings While telemedicine has been perceived as a way to expand health care services to individuals who reside remotely from the appropriate providers, early experience did not demonstrate consistently positive clinical outcomes. Recent studies indicate that when the technology is applied selectively, improved outcomes can be achieved. Teledermatology studies (Whited, 1999) have shown that the diagnostic agreement rates of teledermatologists and clinic dermatologists are comparable for a broad range of dermatological conditions. Teleconsultation also decreases appointment wait times for a dermatology provider (Whited, 2002), and in a significant proportion (20 percent) it eliminates the need for a face-to-face encounter entirely. However, a comprehensive analysis of the literature (Hayes, 2015) on diagnosis of malignant skin neoplasms concluded that: "Overall, teledermatology appears somewhat inferior to in-person dermatology for the diagnosis of skin neoplasms, both in terms of accuracy (compared with histopathology) and concordance among teledermatologists. In addition, the shift of responsibility to primary care physicians may lead to underdiagnosis as physicians may not recognize clinically significant lesions. The accuracy of teledermatology appears to be somewhat inferior compared with in-person dermatology for the management of skin neoplasms." Policy updates: 4
A systematic review and meta-analysis (Heitkemper, 2017) evaluated glycemic control in 3,257 remote, medically underserved patients. Studies reporting either hemoglobin A1c pre- and post-intervention or its change at six or 12 months were eligible for inclusion. Pooled A1c decreases were found at six months (-0.36 (95 percent CI, -0.53 and -0.19]; I 2 = 35.1 percent, Q = 5.0), with diminishing effect at 12 months (-0.27 [95 percent CI, -0.49 and -0.04]; I 2 = 42.4 percent, Q = 10.4). Interventions varied by tele-intervention type: computer software without internet (n = 2), cellular/automated telephone (n = 4), internet-based (n = 4), and telemedicine/telehealth (n = 3). The authors concluded that medically underserved patients with diabetes achieve glycemic benefit following telehealth interventions, with dissipating but significant effects at 12 months. Digital self-management interventions for adults with asthma show potential for benefit, with evidence of improvements in some outcomes, and no evidence of harm from software packages that can combine health information with decision support to help inform behavior in patients, and are typically delivered through the internet or via smartphones. Bender (2010) in a study of self-reported asthmatic medication compliance found that a hand-held corticosteroid index (determined by dividing the number of inhaler puffs taken each day by the number of puffs prescribed to be taken each day, and then averaged over a 10- week interval) was higher in the intervention than in the control group by a margin of 64.5 percent to 49.1 percent (p=0.03). However, the evidence base was weak, and it is not yet possible to recommend this intervention for routine use in clinical practice due to the current lack of large, robust studies conducted and published. Summary of clinical evidence: Citation Heitkemper (2017) Do health information technology selfmanagement interventions improve glycemic control in medically underserved adults with diabetes? Hayes (2015) Content, Methods, Recommendations Systematic review and meta-analysis to examine glycemic control in over 3,000 remote, medically underserved patients. Hemoglobin A1c pre- and post-intervention or its change at six or 12 months were the endpoints. Mean age 55 years; 66% female; 74% racial/ethnic minorities). Interventions varied: computer software without internet (n = 2), cellular/automated telephone (n = 4), internet-based (n = 4), and telemedicine/telehealth (n = 3). Pooled A1c decreases were found at six months (-0.36 (95% CI, -0.53 and -0.19]; I 2 = 35.1%, Q = 5.0), with diminishing effect at 12 months (-0.27 [95% CI, -0.49 and -0.04]; I 2 = 42.4%, Q = 10.4). Findings suggest that medically underserved patients with diabetes achieve glycemic benefit following telehealth interventions, with dissipating but significant effects at 12 months. Telemedicine/telehealth interventions were the most successful intervention type because they incorporated interaction with educators similar to in-person encounters. Studies on teledermatology have methodologic flaws that prevent conclusive findings of benefit in patient care. Accuracy and concordance among teledermatologists is inconsistent compared to in-person 5
Citation ADA (2014) Hilty (2013) Bender (2010?) Zimmer-Galler (2006) Fransen (2002) Whited (2002) Whited (1999) Content, Methods, Recommendations encounter. It is premature to indicate whether there is cost-effectiveness of telemedicine. High-quality fundus photographs can detect most clinically significant diabetic retinopathy. If diabetic retinopathy is present, subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight threatening, then examinations will be required more frequently. While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. Tele-mental health care (TMHC) is effective for diagnosis and assessment. TMHC is pertinent across disparate populations and appears to be comparable to in-person care. Electronic collaborative care, asynchronous care, and mobile care seem to have equivalent outcomes with traditional care models. TMHC improves access to care. A study of self-reported asthmatic medication compliance with software app intervention. The number of inhaler puffs taken each day divided by the number of puffs prescribed to be taken each day was higher in the intervention than in the control group by a margin of 64.5% to 49.1% (p=0.03). Current lack of large, robust studies prevents recommendation for routine use of these apps. Retinal telescreening is practical and improves access to care. Telescreening allows screening of patients with diabetes who are otherwise not receiving recommended eye examinations. Digital imaging of the retina is satisfactorily sensitive and specific to permit to detect incipient diabetic eye events. Thresholds for referral included: EDTRS severity level greater than or equal to 53. Questionable or definite clinically significant macular edema in either eye. Ungradable images. Teledermatology reduces derm appointment wait times. Average wait in a VA clinic dropped from 127 days to 41 days. 18.5% of telederm patients were treated without need of face-to-face encounter. Diagnostic reliability and accuracy is comparable between telederm and in-person provider 6
Citation Content, Methods, Recommendations encounters. Digital image and clinic-based consultants displayed similar diagnostic accuracy. Agreement on management recommendations was variable. References Professional society guidelines/other: American Academy of Dermatology. Position Statement on Telemedicine May 2004. AAD website. http://www.aad.org/forms/policies/uploads/ps/ps-telemedicine%206-15-07.pdf. Accessed April 12, 2017. American Academy of Family Practice. Telehealth Discussion. AAFP website. http://www.aafp.org. Accessed April 12, 2017. American College of Physicians.HealthIT.gov. Communicating with Patients Electronically (via Telephone, Email and Web Sites) August 2008. ACP HealthIT.gov Web site. https://www.healthit.gov/providersprofessionals/implementation-resources/communicating-patients-electronicallytelephonehttp://www.acponline.org/running_practice/technology/comm_electronic.pdf Accessed April 12, 2017June 1, 2016. American Diabetes Association. Standards of medical care in diabetes 2014. Diabetes Care. 2014; 37 Suppl 1:S14-S80. ADA website. http://care.diabetesjournals.org/content/37/supplement_1/s14.full. Accessed on April 12, 2017. American Heart Association. Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care. Stroke 2009; 40: 2635-2660. American Telemedicine Association. Core Standards for Telemedicine Operations. Nov. 2007. ATA website. http://www.ncbhs.org/sites/default/files/corestandards.pdf. Accessed April 12, 2017. Hayes Inc., Hayes Medical Technology Report. Teledermatology for Diagnosis and Management of Skin Neoplasms. Lansdale, Pa. Hayes Inc.; August 2013. https://www.hayesinc.com/subscribers/displaysubscriberarticle.do?articleid=12451&searchstore=%24sear ch_type%3dall%24icd%3d%24keywords%3dteledermatology%24status%3dall%24page%3d1%24from_dat e%3d%24to_date%3d%24report_type_options%3d%24technology_type_options%3d%24organ_system_o ptions%3d%24specialty_options%3d%24order%3dasearchrelevance§ionselector=indexview. Accessed April 12, 2017. Peer-reviewed references: Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, Westfall JM. Test of an interactive voice 7
response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med. 2010 Mar-Apr; 23(2):159-65. Bove AA, Homko CJ, Santamore WP, Kashem M, Kerper M, Elliott DJ. Managing hypertension in urban underserved subjects using telemedicine a clinical trial. Am Heart J. 2013;165(4):615-21. Fransen SR, Leonard-Martin TC, Feuer WJ, et al. Clinical evaluation of patients with diabetic retinopathy: accuracy of the Inoveon diabetic retinopathy-3dt system. Ophthalmology. 2002; 109(3):595-601. Heitkemper EM, Mamykina L, Travers J, Smaldone A. Do health information technology self-management interventions improve glycemic control in medically underserved adults with diabetes? A systematic review and meta-analysis. J Am Med Inform Assoc. 2017;31. Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental health: a 2013 review. Telemed J E Health. 2013;19(6):444-54. Nelson EL, Duncan AB, Peacock G, Bui T. Telemedicine and adherence to national guidelines for ADHD evaluation: a case study. Psychol Serv. 2012;9(3):293-7. Omboni S, Gazzola T, Carabelli G, Parati G. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized controlled studies. J Hypertens. 2013;31(3):455-67. Rubin MN, Wellik KE, Channer DD, Demaerschalk BM. A systematic review of telestroke. Postgrad Med. 2013;125(1):45-50. Whited JD, Hall RP, Foy ME, et. al. Teledermatology's impact on time to intervention among referrals to a dermatology consult service. Telemed J E Health. 2002;8(3):313-21. Whited JD, Hall RP, Simel DL, et. al. Reliability and accuracy of dermatologists' clinic-based and digital image consultations. J Am Acad Dermatol. 1999;41(5 Pt 1):693-702. Whitten P, Kingsley C, Grigsby J. Results of a meta-analysis of cost-benefit research: is this a question worth asking? J Telemed Telecare 2000;6:suppl 1 4-6. Wootton R. Twenty years of telemedicine in chronic disease management an evidence synthesis. J Telemed Telecare. 2012;18(4):211-20. Zimmer-Galler I, Zeimer R. Results of implementation of the DigiScope for diabetic retinopathy assessment in the primary care environment. Telemed J E Health. 2006; 12(2):89-98. Zundel KM, Telemedicine: history, applications, and impact on librarianship. Bull Med Libr Assoc. 1996; 84(1): 71 79. 8
CMS National Coverage Determination (NCDs): 160.21 Telephone Transmission of EEGs. CMS Medicare Coverage Database website. https://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?ncdid=214&ncdver=1&coverageselection=both&articletype=all&policytype=final&s=all&ke yword=tele&keywordlookup=title&keywordsearchtype=and&list_type=ncd&bc=gaaaacaaaaaaaa%3 d%3d&. Accessed April 24, 2017. Local Coverage Determinations (LCDs) L33377 Implantable Miniature Telescope (IMT). CMS Medicare Coverage Database website. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=33377&ver=11&coverageselection=both&articletype=all&policytype=final&s=all&key Word=Tele&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAACAAAAAAAA%3d %3d&. Accessed April 24, 2017. L33584 Implantable Miniature Telescope (IMT). CMS Medicare Coverage Database website. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=33584&ver=17&coverageselection=both&articletype=all&policytype=final&s=all&key Word=Tele&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAACAAAAAAAA%3d %3d&. Accessed April 24, 2017. L34997 Real-Time Outpatient Cardiac Telemetry. CMS Medicare Coverage Database website. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?lcdid=34997&ver=10&coverageselection=both&articletype=all&policytype=final&s=all&key Word=Tele&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAACAAAAAAAA%3d %3d&. Accessed April 24, 2017. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments 90791 Psychiatric diagnostic examination CY 2017 list of Medicare telehealth services 90792 Psychiatric diagnostic examination with medical services 90832 Psychotherapy, 30 minutes with patient and/or family member 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 & management service 90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation & management service 9
CPT Code Description Comments 90951 End-Stage Renal Disease-related services monthly for patients younger than 2 years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-toface visits by a physician or other qualified health care professional each month 90952 End-Stage Renal Disease-related services monthly for patients younger than 2 years of age to include monitoring for 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 each month 90954 End-Stage Renal Disease-related services monthly for patients 2-11 years of age to include monitoring for 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 each month 90955 End-Stage Renal Disease-related services monthly for patients 2-11 years of age to include monitoring for 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 each month 90957 End-Stage Renal Disease-related services monthly for patients 12-19 years of age to include monitoring for 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 each month 90958 End-Stage Renal Disease-related services monthly for patients 12-19 years of age to include monitoring for 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 each month 90960 End-Stage Renal Disease-related services monthly for patients 20 years of age or older; with 4 or more face-to-face visits by a physician or other qualified health care professional each month 90961 End-Stage Renal Disease-related services monthly for patients 20 years of age or older; with 2-3 face-to-face visits by a physician or other qualified health care professional each month 90963 End-Stage Renal Disease-related services for home dialysis per full month for patients younger than 2 years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents 90964 End-Stage Renal Disease-related services for home dialysis per full month for patients 2-11 years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents 90965 End-Stage Renal Disease-related services for home dialysis per full month for patients 12-19 years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents 90966 End-Stage Renal Disease-related services for home dialysis per full month for patients 20 years of age or older 90967 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day for patients younger than 2 years of age 90968 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day: for patients 2-11 years of age 90969 End-stage renal disease (ESRD) related services for home dialysis per less than a full month of service, per day; for patients 12-19 years of age 90970 End-stage renal disease (ESRD) related services for home dialysis per less 10
CPT Code Description Comments than a full month of service, per day: for patients 20 years of age and older 90845 Psychoanalysis 90846 Family psychotherapy (without the patient present) 90847 Family psychotherapy (conjoint psychotherapy)(with patient present) 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of psychologist s or physician s time, both face-to-face time with the patient and time interpreting test results and preparing the report 96150 Health and behavior assessment (e.g., 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 (e.g., 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 patient present) 97802 Medical nutrition therapy; initial assessment and intervention, individual, faceto-face with the patient, each 15 minutes 97803 Medical nutrition therapy; re-assessment and intervention, individual, face-toface with the patient, each 15 minutes 97804 Medical nutrition therapy; group (2 or more), each 30 minutes 99201 Office or other outpatient visit for evaluation and management of a new patient; problem focused 99202 Office or other outpatient visit for evaluation and management of a new patient; expanded problem focused 99203 Office or other outpatient visit for evaluation and management of a new patient; medical decision making low complexity 99204 Office or other outpatient visit for evaluation and management of a new patient; medical decision making moderate complexity 99205 Office or other outpatient visit for evaluation and management of a new patient; medical decision making high complexity 99211 Office or other outpatient visit for evaluation and management of an established patient 99212 Office or other outpatient visit for evaluation and management of an established patient; problem focused 99213 Office or other outpatient visit for evaluation and management of an established patient; medical decision making low complexity 99214 Office or other outpatient visit for evaluation and management of an established patient; medical decision making moderate complexity 99215 Office or other outpatient visit for evaluation and management of an established patient; medical decision making high complexity 99231 Subsequent hospital care, low complexity with the limitation of 1 telehealth visit every 3 days 11
CPT Code Description Comments 99232 Subsequent hospital care, moderate complexity 99233 Subsequent hospital care, high complexity 99307 Subsequent nursing facility care, straightforward medical decision making, with the limitation of 1 telehealth visit every 30 days 99308 Subsequent nursing facility care, low complexity 99309 Subsequent nursing facility care, moderate complexity 99310 Subsequent nursing facility care, high complexity +99354 Prolonged evaluation and management or psychotherapy service(s) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour +99355 Prolonged evaluation and management or psychotherapy service(s) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes +99356 Prolonged service in the inpatient or observation setting, requiring unit or floor time beyond the usual service; first hour +99357 Prolonged service in the inpatient or observation setting, requiring unit or floor time beyond the usual service; each additional 30 minutes 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 99495 Transitional care management services with medical decision making of at least moderate complexity 99496 Transitional care management services with medical decision making of high complexity ICD-10 Code Description Comments Non-specific HCPCS Level II Code G0108 G0109 G0270 G0396 G0397 G0406 G0407 G0408 Description Diabetes outpatient self-management training services, individual per 30 minutes Diabetes outpatient self-management training services, group session 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 Alcohol and/or substance (other than tobacco) abuse structured assessment and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention greater than 30 minutes Follow-up inpatient telehealth consultation, limited, typically 15 minutes communicating with the patient. Follow-up inpatient telehealth consultation, limited, typically 25 minutes communicating with the patient. Follow-up inpatient telehealth consultation, limited, typically 35 minutes Comments CY 2016 list of Medicare telehealth services 12
HCPCS Level II Code G0420 G0421 G0425 G0426 G0427 G0436 G0437 G0438 G0439 G0442 G0443 G0444 G0445 G0446 G0447 G0459 Description communicating with the patient. 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 consultations, emergency department or initial inpatient, typically 30 minutes Telehealth consultations, emergency department or initial inpatient, typically 50 minutes Telehealth consultations, emergency department or initial inpatient, typically 70 minutes Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive greater than 10 minutes Annual wellness visit; includes a personalized prevention plan of service, initial visit Annual wellness visit; includes a personalized prevention plan of service, subsequent visit Annual alcohol misuse screening, 15 minutes Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Annual depression screening, 15 minutes High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Face-to-face behavioral counseling for obesity, 15 minutes Inpatient telehealth pharmacologic management Comments 13