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Telehealth

Clinical Policy Number: 18.02.01

Effective Date: Dec. 1, 2013

Initial Review Date: June 19, 2013

Most Recent Review Date: June 18, 2014

Next Review Date: June 2015

ABOUT THIS POLICY: AmeriHealth Caritas Louisiana has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Louisiana 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 Louisiana 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 Louisiana 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 Louisiana clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Louisiana will update its clinical policies as necessary. AmeriHealth Caritas Louisiana clinical policies are not guarantees of payment.

Coverage Policy:

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

• The originating site is located in geographically remote areas and for whom access to necessary medical services is not available. AmeriHealth Caritas Louisiana does not consider telemedicine to be a substitute for direct member-provider encounters

AND

• For AmeriHealth Caritas Louisiana Medicaid members the Service is listed among one of the following:

o Provider office visit (CPT 99201-99215)

o Is a follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs (HCPCS codes G0406 – G0408, CPT 99231-99233, or 99307-99310)

o Mental health diagnostic visits and psychotherapy based upon coverage requirements o End-stage renal disease service applicable to telemedicine (CPT codes 90951, 90952,

90954, 90955, 90957, 90958, 90960, and 90961)

o Individual and group medical nutritional counseling within benefits limits (HCPCS code G0270 and CPT codes 97802 – 97804)

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Limitations:

Telemedicine and telehealth services for which there is no evidence of improved outcomes or for which there is not a defined benefit in state or federal policy are not covered. AmeriHealth Caritas Louisiana 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.

NOTE the following codes are not on the Louisiana Medicaid Fee Schedule:

• 90791 - Psychiatric diagnostic evaluation;

• 90792 - Psychiatric diagnostic evaluation with medical services;

• 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) ADD-ON CODE;

• 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) ADD-ON CODE;

• 90637 - Psychotherapy, 60 minutes with patient and/or family member;

• 90638 - 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) ADD-ON CODE;

• 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-to-face with the patient, each 15 minutes;

• 99307 - Subsequent nursing facility care per day; • 99308 - Subsequent nursing facility care per day; • 99309 - Subsequent nursing facility care per day; • 99310 - Subsequent nursing facility care per day;

• 99406 - Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 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 minute; • 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;

• G0396 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes;

• G0397 - Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes;

• G0406 - Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via Telehealth;

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3 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; 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 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;

• 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-to-face, 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 pharmacologic management;

• T1014 - Telehealth transmission, per minute, professional services bill separately; Q3014 - Telehealth originating site facility fee.

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 only in direct face-to-face settings has been

altered as greater technology has afforded the patient and physician greater opportunities for

communication. For decades now, physicians have engaged in telephonic communication to

extend the relationship between doctor and patient beyond office hours or the hospital setting.

After-hours call coverage engaged doctors who did not know the patient in making clinical

decisions. Those earlier telephonic clinical encounters between doctors and patients where there

was no prior relationship, forged the way for contemporary digital formats for evaluation and

treatment of patients.

Telemedicine in its more modern sense grew from the needs for access to care in more rural areas

of the country. In the 1960s through the 1980s, the use of telemedicine was developed in

demonstration projects by NASA for space flights, and in remote areas in Nebraska, New

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with digital technology over analogue. Telepsychiatry and teledermatology were among the initial

applications of transmission of synchronous data.

Telemedicine is currently divided into several applications:

• Telephonic—which has defined CPT codes for potential coverage. Often the use of telephone

communications is an extension of an office, hospital or emergency room visit so is not

considered separately reimbursable. However telephonic consultation is a uni-modality

method of telemedicine

• Remote patient data transfer—there is no active participation by the patient in this activity.

The treating providers may upload and send imaging or pathology slides to a remote

consultant for interpretation. Such transmission generally is asynchronous.

• Remote patient monitoring—this use of data transmission does not involve verbalized

communication by the patient. It may include cardiac monitoring or other biophysical data

transmission to a physician or to a reception center for asynchronous interpretation. A variant

of this technology is the so-called “TeleICU” in which remotely monitored data from Intensive

Care Unit Patients is closely monitored synchronously with immediate orders for changes in

therapy communicated back to the ICU, based upon the data received.

• Video Consultation—In this setting the patient is in live video and audio communication with

the specialist

• Telehealth—while Telemedicine may be considered a part of the larger “telehealth” field, the

term is more commonly refers to the patient and professional teach capacity provided either

synchronously through immediate feedback or asynchronously in educational material.

While telemedicine has been perceived as a way to expand health care services to individuals who

reside remotely from the appropriate providers, early experience has not demonstrated any

positive clinical outcomes. More recent studies have applied the technology more selectively and

have begun to demonstrate improved outcomes. Hilty and others have defined the populations

for whom telepsychiatry or telemental health is most appropriate. Clark et al performed a

meta-analysis on the often contradictory results found in the cardiac literature to demonstrate

reduction of all-cause mortality for patients with advanced heart failure by telemonitoring with

telecommunications.

Methods Searches:

AmeriHealth Caritas Louisiana searched PubMed and the databases of: • UK National Health Services Centre for Reviews and Dissemination.

• Agency for Healthcare Research and Quality Guideline Clearinghouse and evidence-based practice centers. • The Centers for Medicare & Medicaid Services.

Search terms were: “telemedicine” and “telehealth”.

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5 • 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.

Overview of the literature: systematic reviews/guidelines and economic analyses for continuous passive motion: reverse chronological order and then alphabetically by first author

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 has not demonstrated any positive clinical outcomes.

• More recent studies have applied the technology more selectively and have begun to demonstrate improved outcomes. Hilty and others have defined the populations for whom telepsychiatry or telemental health is most appropriate.

• Clark et al performed a meta-analysis on the often contradictory results found in the cardiac literature to demonstrate reduction of all-cause mortality for patients with advanced heart failure by

telemonitoring with telecommunications.

Citation Content, Methods, Recommendations

Whitten Key Point :

• Studies on Telemedicine have had substantial methodologic flaws

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

Hilty et al Key Point:

• Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care.

• New models of telemental health (collaborative care, asynchronous, mobile) with equally positive outcomes) appear to have equivalent outcomes

• .Telementat health is improving access to care

Clark et al Key Points from Cochrane data base:

Based upon 25 studies and 5 abstracts with 5613 participants

• Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality for patients with heart failure

Quality of life is improved for heart failure patients

Glossary :

Asynchronous or “Store and Forward”: Transfer of data from one site to another through the use

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Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service

is located at the time the service is provided via telecommunications system.

Distant Site Practitioners: Practitioners at the distant site who may furnish and receive payment

for covered telehealth services (subject to State law) are:

• Physicians

• Nurse practitioners (NP)

• Physician assistants (PA)

• Nurse midwives

• Clinical nurse specialists (CNS)

• Clinical psychologists (CP) and clinical social workers (CSW)

Originating or Spoke site: Location of the Medicare or Medicaid patient at the time the service

being furnished via a telecommunications system occurs. Telepresenters may be needed to

facilitate the delivery of this service. According to CMS Medicare beneficiaries are eligible for

telehealth services only if they are presented from an originating site located in a rural Health

Professional Shortage Area or in a county outside of a Metropolitan Statistical Area. Entities that

participate in a Federal telemedicine demonstration project approved by (or receiving funding

from) the Secretary of the Department of Health and Human Services as of December 31, 2000,

qualify as originating sites regardless of geographic location.

The originating sites authorized by law are:

• The offices of physicians or practitioners

• Hospitals

• Critical Access Hospitals (CAH)

• Rural Health Clinics (RHC)

• Federally Qualified Health Centers (FQHC)

• Hospital-based or CAH-based Renal Dialysis Centers (including satellites)

• Skilled Nursing Facilities (SNF)

• Community Mental Health Centers (CMHC).

Synchronous: Interactive video connections that transmit information in both directions during

the same time period

Related Policies:

AmeriHealth Caritas Louisiana Utilization Management Program Description

REFERENCES

Professional Society Guidelines/Other

American Academy of Dermatology. Position Statement on Telemedicine May

2004 http://www.aad.org/forms/policies/Uploads/PS/PS-Telemedicine%206-15-07.pdf American Academy of Family Practice. Telehealth

Discushttp://www.aafp.org/online/en/home/membership/ruralcommunity/governmentandnongovernme ntresources/telemedicine/telehealth.printerview.html

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7 American College of Physicians. Communicating with Patients Electronically (via Telephone, Email and Web Sites) August 2008 http://www.acponline.org/running_practice/technology/comm_electronic.pdf 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

Peer-Reviewed References

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 Jun;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 Aug;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 Mar;31(3):455-67.

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 Mar;31(3):455-67.

Rubin MN, Wellik KE, Channer DD, Demaerschalk BM. A systematic review of telestroke. Postgrad Med. 2013 Jan;125(1):45-50

Whitten P, Kingsley C, Grigsby J. Results of a meta-analysis of cost-benefit research: is this a question worth asking? J Telemed Telecare February 10, 2000 vol. 6 no. suppl 1 4-6

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

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

Zundel KM, Telemedicine: history, applications, and impact on librarianship. Bull Med Libr Assoc. 1996 January; 84(1): 71–79.

Clinical Trials:

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 Apr;165(4):615-21.

Centers for Medicare and Medicaid Services (CMS) National Coverage Determination:

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8 Telehealth services: Rural health fact sheet series. Department of Health and Humana

Services,

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf ICN 901705 April 2014, Last accessed June 9, 2014

Local Coverage Determinations:

Searches of Medicare and Medicaid coverage databases yielded no relevant coverage decision documents.

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 in accordance with those manuals.

CPT Code Description Comment

90791 and

90792 Psychiatric diagnostic interview examination CY 2013 list of Medicare telehealth services

90832 – 90834 and 90836 – 90838

Individual psychotherapy CY 2013 list of Medicare

telehealth services 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961

End-Stage Renal Disease-related services included in the monthly capitation

payment CY 2013 list of Medicare telehealth services

96116 Neurobehavioral status examination CY 2013 list of Medicare telehealth services

96150 – 96154 Individual and group health and behavior assessment and intervention CY 2013 list of Medicare telehealth services

97802 – 97804

and G0270 Individual and group medical nutrition therapy CY 2013 list of Medicare telehealth services

99201 – 99215 Office or other outpatient visits CY 2013 list of Medicare telehealth services

99231 – 99233 Subsequent hospital care services, with the limitation of 1 telehealth visit every

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99307 – 99310 Subsequent nursing facility care services, with the limitation of 1 telehealth

visit every 30 days CY 2013 list of Medicare telehealth services

99406 and 99407 and G0436 and G0437

Smoking cessation services CY 2013 list of Medicare

telehealth services

99495 and

99496 Transitional care management services CY 2014 list of Medicare Telehealth services

G0108 and

G0109 Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training

CY 2013 list of Medicare telehealth services

G0396 and

G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services CY 2013 list of Medicare telehealth services

G0406 –

G0408 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs CY 2013 list of Medicare telehealth services

G0420 and

G0421 Individual and group kidney disease education services CY 2013 list of Medicare telehealth services

G0425 –

G0427 Telehealth consultations, emergency department or initial inpatient CY 2013 list of Medicare telehealth services

G0442 Annual alcohol misuse screening, 15 minutes CY 2013 list of Medicare telehealth services

G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes CY 2013 list of Medicare telehealth services

G0444 Annual depression screening, 15 minutes CY 2013 list of Medicare telehealth services

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

CY 2013 list of Medicare telehealth services

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individual, 15 minutes telehealth services

G0447 Face-to-face behavioral counseling for obesity, 15 minutes CY 2013 list of Medicare telehealth services

G0459 Inpatient pharmacologic management CY 2013 list of Medicare telehealth services

T1014 Telehealth transmission per minute (not covered by Medicare)

Q3014 Originating site (not covered by Medicare)

ICD-9 Code Description Comment

ICD-10 Code Description Comment

HCPCS Level

II Description Comment

Disclaimer: AmeriHealth Caritas Louisiana has developed clinical policies to assist with making

coverage determinations. AmeriHealth Caritas Louisiana clinical policies are based on guidelines

from established industry sources such as Centers for Medicare and Medicaid (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, are

References

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