Clinical Policy Title: Telehealth - amerihealthcaritasnh.com · afforded superior results than...

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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: April 10, 2018

Next Review Date: April 2020

Related policies:

CP# 04.01.03 Ambulatory blood pressure monitoring

CP# 09.01.05 Ambulatory and video electroencephalogram (AEEG, VEEG)

CP# 11.02.00 Apnea monitors for infants — in-home use

CP# 09.01.01 Autonomic nervous system monitoring for neuropathy

CP# 03.03.06 Biofeedback for chronic pain

CP# 12.01.01 Home uterine activity monitoring

CP# 17.01.02 Medical alert devices

CP# 06.02.02 Outpatient diabetes self-management training

CP# 04.01.01 Real-time outpatient cardiac monitoring

CP# 05.01.02 Prothrombin international normalized ratio — self-testing

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’

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 AmeriHealth Caritas 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. AmeriHealth Caritas’ 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. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers telemedicine to be a covered service for members who meet the following

criteria (Lee 2018, Heitkemper 2017, Hayes 2015, American Diabetes Association [ADA] 2014, Hilty 2013,

Bender 2010):

• A member for whom access to specific necessary medical services is not readily available.

• A member's healthcare provider must document that the in-service risk for a life-threatening

Policy contains:

Asynchronous transfer.

Distant or hub site.

Distant site practitioner.

Originating or spoke site.

Synchronous transfer.

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event is low (e.g., cardiac arrest during outpatient cardiac telemetry).

• The results of the telehealth intervention will provide diagnostic information and/or treatment

useful in the ongoing management of the patient.

AmeriHealth Caritas does not consider telemedicine to be a substitute for direct member-provider

encounters.

For AmeriHealth Caritas 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:

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. AmeriHealth Caritas 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.

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Advances in communications technology now afford the patient and physician greater opportunities for

interaction. Physicians have traditionally engaged in telephonic communication to extend the physician-

patient 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:

AmeriHealth Caritas searched PubMed and the databases of:

• UK National Health Services Centre for Reviews and Dissemination.

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• 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 February 13, 2018. 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.

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:

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

5

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.

During the past twelve months there has been further information published regarding telehealth

management of medical conditions (i.e., for oral anticoagulation management).

A systematic review and meta-analysis (Lee 2018) studied the benefits and harms of telehealth

interventions (n = 6955) compared to usual care for oral anticoagulation management. Telehealth

interventions mainly consisted of telephone visits by clinicians, pharmacists and specialists. Meta-analysis

of 3 studies showed significant improvements in the telehealth group for major thromboembolic events (RR

0.43, 95 percent CI 0.25-0.74, p = 0.002), but no significant difference for major bleeding events (RR 0.83,

95 percent CI 0.52-1.33, p = 0.44). There was no significant difference in any of the secondary outcomes.

The overall quality of evidence was rated very low due to high risk of bias and low precision. Based on very

low quality evidence, telehealth interventions may lower the risk of major thromboembolic events, but not

other clinically important outcomes.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Lee (2018) Do telehealth interventions improve oral anticoagulation management? A systematic review and meta-analysis.

Key points:

Systematic review and meta-analysis studied the benefits and harms of telehealth interventions compared to usual care for oral anticoagulation management.

Telehealth interventions mainly consisted of telephone visits by clinicians, pharmacists and specialists.

Meta-analysis of 3 studies (n = 6955) showed significant improvements in the telehealth group for major thromboembolic events (RR 0.43, 95% CI 0.25-0.74, p = 0.002), but no significant difference for major bleeding events (RR 0.83, 95% CI 0.52-1.33, p = 0.44).

There was no significant difference in any of the secondary outcomes.

The overall quality of evidence was rated very low due to high risk of bias and low precision.

Based on very low quality evidence, telehealth interventions may lower the risk of major thromboembolic events, but not other clinically important outcomes.

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Citation Content, Methods, Recommendations

Heitkemper (2017)

Do health information

technology self-

management

interventions improve

glycemic control in

medically

underserved adults

with diabetes?

Key points:

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.

Hayes (2015)

Teledermatology for

Diagnosis and

Management of Skin

Neoplasms

Key points:

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

encounter.

It is premature to indicate whether there is cost-effectiveness of telemedicine.

ADA (2014)

Standards of medical

care in diabetes—

2014

Key points:

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.

Hilty (2013)

The effectiveness of

telemental health: a

2013 review

Key points:

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.

Bender (2010)

Test of an interactive

voice response

intervention to

improve adherence to

controller medications

in adults with asthma

Key points:

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.

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References

Professional society guidelines/other:

American Academy of Family Practice. Telehealth Discussion. AAFP website. http://www.aafp.org.

Accessed February 13, 2018.

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/providers-

professionals/implementation-resources/communicating-patients-electronically-telephone Accessed

February 13, 2018.

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

February 13, 2018.

American Heart Association. Recommendations for the Implementation of Telemedicine Within Stroke

Systems of Care. Stroke 2009; 40: 2635-2660.

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&sectionSelector=indexView.

Accessed February 13, 2018.

Peer-reviewed references:

Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, Westfall JM. Test of an interactive voice

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.

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.

http://www.aafp.org/

https://www.healthit.gov/providers-professionals/implementation-resources/communicating-patients-electronically-telephone

https://www.healthit.gov/providers-professionals/implementation-resources/communicating-patients-electronically-telephone

http://care.diabetesjournals.org/content/37/Supplement_1/S14.full

https://www.hayesinc.com/subscribers/displaySubscriberArticle.do?articleId=12451&searchStore=%24search_type%3Dall%24icd%3D%24keywords%3Dteledermatology%24status%3Dall%24page%3D1%24from_date%3D%24to_date%3D%24report_type_options%3D%24technology_type_options%3D%24organ_system_options%3D%24specialty_options%3D%24order%3DasearchRelevance&sectionSelector=indexView




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Lee M, Wang M, Liu J, Holbrook A. Do telehealth interventions improve oral anticoagulation management?

A systematic review and meta-analysis. J Thromb Thrombolysis. 2018 Jan 19. doi: 10.1007/s11239-018-

1609-2. [Epub ahead of print] Review. PubMed PMID: 29350322.

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.

Wootton R. Twenty years of telemedicine in chronic disease management—an evidence synthesis. J

Telemed Telecare. 2012;18(4):211-20.

CMS National Coverage Determination (NCDs):

160.21 Telephone Transmission of EEGs. CMS Medicare Coverage Database website.

https://www.cms.gov/medicare-coverage-database/details/ncd-

details.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 February 13, 2018.

Local Coverage Determinations (LCDs)

L34997 Real-Time Outpatient Cardiac Telemetry. CMS Medicare Coverage Database website.

https://www.cms.gov/medicare-coverage-database/details/lcd-

details.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 February 13, 2018.

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

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=214&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=Tele&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAACAAAAAAAA%3d%3d&




https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34997&ver=10&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=Tele&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAACAAAAAAAA%3d%3d&




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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

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-to-

face 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



development, and counseling of parents; with 2-3 face-to-face visits by a


90957



development, and counseling of parents; with 4 or more face-to-face visits by a


90958



development, and counseling of parents; with 2-3 face-to-face visits by a


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


patients 2-11 years of age to include monitoring for adequacy of nutrition,

assessment of growth and development, and counseling of parents

90965


patients 12-19 years of age to include monitoring for adequacy of nutrition,

assessment of growth and development, and counseling of parents

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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 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, 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

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


patient; expanded problem focused


patient; medical decision making low complexity


patient; medical decision making moderate complexity


patient; medical decision making high complexity

99211 Office or other outpatient visit for evaluation and management of an

established patient


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established patient; problem focused


established patient; medical decision making low complexity


established patient; medical decision making moderate complexity


established patient; medical decision making high complexity

99231 Subsequent hospital care, low complexity with the limitation of 1 telehealth visit

every 3 days

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

Description Comments

G0108

Diabetes outpatient self-management training services, individual per 30

minutes

CY 2017/2018 list of

Medicare telehealth

services

G0109 Diabetes outpatient self-management training services, group session per 30

minutes

G0270 Medical nutrition therapy; reassessment and subsequent intervention(s)

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HCPCS Level II Code

Description Comments

following second referral in same year for change in diagnosis, medical

condition or treatment regimen

G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment

and brief intervention 15 to 30 minutes

G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment

and intervention greater than 30 minutes

G0406 Follow-up inpatient telehealth consultation, limited, typically 15 minutes

communicating with the patient.





G0420 Face-to-face educational services related to the care of chronic kidney

disease; individual, per session, per one hour

G0421 Face-to-face educational services related to the care of chronic kidney

disease; group, per session, per one hour

G0425 Telehealth consultations, emergency department or initial inpatient, typically

30 minutes


50 minutes


70 minutes

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;

intensive greater than 10 minutes

G0438 Annual wellness visit; includes a personalized prevention plan of service, initial

visit

G0439 Annual wellness visit; includes a personalized prevention plan of service,

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

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

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

G0508 Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth

G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth

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