Remote Access Technologies/Telehealth Services Medicare Effective January 1, 2016

Transcription

1 Remote Access Technologies/Telehealth Services Medicare Effective January 1, 2016 Prior Authorization Requirement Yes No Not Applicable * Not covered by Medicare but is covered by HealthPartners Freedom (Cost) evisits, Scheduled Telephone Visits and Real-time Interactive Audio and Video Technologies Use Source Reference/Website Link National Coverage Determination NA (NCD) National Coverage Manual NA Citation Local Coverage Determination NA (LCD) Coverage Article (Local) Other Medicare Benefit Policy Manual. Chapter 15 Guidance/Guidance/Manuals/downloads/bp102c15.pdf Medicare Learning Network Telehealth Services Learning-Network- MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf Administrative Process Prior authorization is not required for remote access technologies/telehealth services. Coverage (Indications, Limitations, and/or Medical Necessity) HealthPartners provides coverage for Medicare-covered telehealth services. In addition, HealthPartners also covers e-visits, scheduled telephone visits, and real-time interactive audio and video technologies, which include telehealth services without the Medicare geographic limitation. HealthPartners pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. Eligible practitioners include: Physicians; Nurse practitioners (NP); Physician assistants (PA); Nurse-midwives; Clinical nurse specialists (CNS); Certified registered nurse anesthetists; Clinical psychologists (CP) and clinical social workers (CSW). and Registered dietitians or nutrition professionals. Pharmacists Indications that are covered 1. Electronic visits (e-visit) and scheduled telephone visits are covered when: a. The e-visit occurs over a secure encrypted web site Page 1 of 6

2 b. The visit is between an established patient and a provider. For behavioral health services an established patient means the psychiatrist has had a previous assessment face-to-face with the patient. 2. Medicare-covered Telehealth consultations include consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system. The patient must be present and participating in the visit. HealthPartners does not consider Skype or similar applications to be secure. a. For interactive video services an interactive audio and video telecommunications system that permits real-time communication between the provider, at the distant site, and the beneficiary, at the originating site must be used. b. HealthPartnerrs does not require the originating site geographic limitation for covered telehealth services 3. Real-time interactive audio and video technologies include the following: a. Online video consultations between a patient and a provider using secure online video technology. (HealthPartners does not consider Skype or similar applications to be secure.) b. Covered telehealth services with no geographic limitation 4. Covered interactive audio and video services include: Telehealth consultations, emergency HCPCS codes G0425 G0427 department or initial inpatient Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs HCPCS codes G0406-G0408 Office or other outpatient visits CPT codes Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days Individual and group kidney disease education services Individual and group diabetes self-management training services, with a minimum of 1 hour of inperson instruction to be furnished in the initial year training period to ensure effective injection training Individual and group health and behavior assessment and intervention CPT codes CPT codes HCPCS codes G0420 and G0421 HCPCS codes G0108 and G0109 CPT codes Individual psychotherapy CPT codes and Telehealth Pharmacologic Management HCPCS code G0459 Psychiatric diagnostic interview examination CPT codes and End-Stage Renal Disease (ESRD)-related services included in the monthly capitation payment at least one hands on visit (not telehealth) must be furnished each month to examine the vascular access site by a physician, NP, PA or CNS CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and Individual and group medical nutrition therapy HCPCS code G0270 and CPT codes Neurobehavioral status examination CPT code Smoking cessation services HCPCS codes G0436 and G0437 and CPT codes and Alcohol and/or substance (other than tobacco) HCPCS codes G0396 and G0397 Page 2 of 6

3 abuse structured assessment and intervention services 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 HCPCS code G0442 HCPCS code G0443 HCPCS code G0444 HCPCS code G0445 HCPCS code G0446 Face-to-face behavioral counseling for obesity, 15 minutes HCPCS code G0447 Transitional care management services with moderate medical decision complexity (face-toface visit within 14 days of discharge) Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) CPT code CPT code Psychoanalysis CPT codes Family psychotherapy (without the patient present) Family psychotherapy (conjoint psychotherapy) (with patient present) Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit Remote real-time interactive videoconferenced critical care, evaluation and management of the critically ill or critically injured patient; first minutes Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) CPT code CPT code CPT code CPT code HCPCS code G0438 HCPCS code G T 0189T 5. Covered e-visits and Scheduled Telephone visits include: Telephone assessment and management service provided by a Telephone Page 3 of 6

4 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 of medical discussion Telephone 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; minutes of medical discussion Telephone 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; minutes of medical discussion 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 Telephone 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 of medical discussion Telephone 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; minutes of medical discussion Telephone 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; minutes of medical discussion 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 Telephone Telephone e-visit Telephone Telephone Telephone e-visit Indications that are not covered [Limitations] 1. The physician of record or the attending physician cannot furnish the emergency department or initial inpatient consultation via an interactive video service. 2. Follow-up inpatient (hospital, SNF) cannot be furnished by the physician of record or the attending physician via interactive video service. Page 4 of 6

5 3. Interactive video service that doesn t use an interactive telecommunications system with real-time communication. 4. Asynchronous store and forward technology (except as permitted by CMS only in Federal telemedicine demonstration programs conducted in Alaska or Hawaii) 5. 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) 6. Prescription renewals 7. Scheduling a test or appointment 8. Psychotherapy via Scheduled telephone visits 9. Call to nurse line for questions or standing orders, e.g. sinusitis or conjunctivitis 10. Clarification of issues from previous visit 11. Other non-clinical communication 12. Updating patient demographic information 13. Reporting test results 14. Requesting a referral 15. Any consultation with another physician in reference to the patient 16. Phone calls or s 17. Interactive video visits not initiated by the member 18. Reminders 19. Providing educational materials General Information: Definitions Originating sites: An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunications system occurs. The originating sites authorized by law are: The offices of physicians or practitioners; Hospitals; Critical Access Hospitals (CAH); Rural Health Clinics; Federally Qualified Health Centers; Hospital-based or CAH-based Renal Dialysis Centers (including satellites); Skilled Nursing Facilities (SNF); and Community Mental Health Centers (CMHC). Note: Independent Renal Dialysis Facilities are not eligible originating sites. Distant site: means the site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system. 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 Real-time Interactive Audio and Video Technologies secure, real-time consultations between a patient and a network provider to diagnose and treat some conditions. Scheduled Telephone Visit: a telephone encounter between a provider and an established patient conducted over the phone. Telehealth Consultation: a secure, real time consultation between a patient at an originating site and a consulting provider (distant site provider) via a secure two-way interactive video connection. CPT/HCPCS Codes If available, Current Procedural Terminology (CPT ) and Healthcare Common Procedure Coding System (HCPCS) codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive. Page 5 of 6

6 The appropriate CPT or HCPCS code should be submitted for the professional service along with the telehealth modifier GT. The originating site should bill with code Q3014 See applicable codes under Indications that are Covered section above. CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Products These coverage criteria apply to HealthPartners Freedom (Cost) plans. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at or Policy Limitations: Medicare and Medicaid Policies specifically developed to assist HealthPartners in administering Medicare or Medicaid plan benefits and determining coverage for a specific procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to other HealthPartners plans and members. Number T005MC References: Page 6 of 6