Policy No: 132
Date of Origin: 01/01/2023
Section: Administrative
Last Reviewed: 04/01/2024
Last Revised: 08/21/2024
Approved: 09/12/2024
Effective: 06/01/2024
Policy applies to: Medicare Advantage

This policy applies to Providers. All terms described in this policy are subject to federal laws. In the event of any discrepancy between the terms of this policy and the requirements of federal law, the law governs.

Asynchronous Interaction
Asynchronous Interaction –Transmission of a Member’s health care information over secure connection enabling a Member-to-Provider or Provider-to-Provider interaction that is not simultaneous or concurrent in time and where the participants are separated by distance. The interaction must result in medical diagnosis or management of the Member and the technology cannot include the use of audio-only telephone, fax or standard email.

Covered Services
Medically Necessary health care services and supplies rendered or furnished by a Provider that are eligible for benefit consideration under a Member Agreement.

Digital Health Products
Technologies, platforms, and systems that engage consumers for lifestyle, wellness, and health-related purposes. Digital therapeutic products differ from digital health products in that they are practitioner-prescribed software that delivers evidence-based therapeutic interventions to prevent, manage, or treat a medical disorder or disease.

Distant Site – Site at which the Provider delivering the Virtual Care is located at the time of the service.

• Providers location must be listed on the provider’s enrollment file

• Provider must be licensed and enrolled in the state(s) the Provider and Member are physically located

Established Relationship
The member has had at least one in-person or real-time interactive appointment within 6 months of the initial telehealth service, and at least once for every 12 months afterward with the physician or other provider rendering the services, with a provider employed at the same medical group as the provider rendering services or with a provider that referred the member to the rendering provider.

In-Person
Face-to-face interaction when a Member and a Provider are physically in the same location.

Modifier 93
Used to indicate services furnished real-time (synchronous) using telephone or other interactive audio-only telecommunications system.

Modifier FQ
Used to indicate services furnished using audio-only communication technology. This must be appended to any procedure using Audio-only Technology even if the provider has the capability of Audio/Video Technology.

Modifier FR
The Supervising Practitioner Was Present Through Two-Way, Audio/Video Communication Technology

Modifier GT
While the Centers for Medicare & Medicaid (CMS) no longer requires modifier GT for professional services, please continue to use this with POS 02 or POS 10 when submitting claims to our health plan for distant site services performed using audio and video technology. Professional providers should submit claims using modifier 26 (instead of GT) for radiology services.

Modifier GQ
This modifier must be submitted with ' Store and Forward' services. Generally, asynchronous telecommunications must be used to permit non-real-time communication between the distant site Provider and the member.

Member
A person eligible to receive health care benefits for Covered Services under a Member Agreement.

Member Agreement
A contract or plan underwritten or administered in whole or in part, by payer, which sets forth the terms and conditions under which a Member is entitled to receive benefits for Covered Services.

Originating Site
Physical location of the Member at the time the service is provided.

Provider
A physician (person who is legally qualified to practice medicine in the state where he or she practices) or other qualified health care professional.

Store and Forward Technology
Use of an Asynchronous Interaction to transmit a Member’s medical information from an Originating Site to a Provider at a Distant Site, which results in medical diagnosis and management of the Member and does not include the use of audio-only telephone, fax, or email.

Store and Forward Services
The Provider’s professional services of diagnosis and medical management of the Member that result from the use of Store and Forward Technology.

Synchronous Interaction
Live real-time communication through interactive technology that enables a Member and a Provider who are separated by distance to interact simultaneously.

Telemedicine/Telehealth - Use of medical or behavioral health information to diagnose and treat a Member exchanged from one site to another via a Synchronous Interaction audio-only or audio/video telecommunication system.

• The services for both types of encounters are evaluation and management focused. Only services specifically defined by CMS, our health plan’s published policies and member benefits or applicable state authorities as suitable for delivery via Telehealth/Telemedicine are eligible for reimbursement. When specified in this policy, other types of services may be applicable.

• Please note that there is not yet industry consensus on the use of the terms "Telemedicine" and "Telehealth." In light of this, we continue to include our own definition of these two terms in our policies. For example, where a state law defines "Telemedicine" in a manner that we would define as "Telehealth," we ensure that the federal requirements are met within our Virtual Care policy.

Virtual Care
Services provided by Synchronous Interaction audio (telephonic), Synchronous Interaction audio/video communications, or Store and Forward Technology. The Provider and Member, or the Providers, participating are separated by distance. The service provided is evaluation and management focused. When specified in this policy, other types of services may be applicable. Requirements concerning the establishment of the Provider-Member relationship are subject to applicable state laws.

For example: Member receives Virtual Care from Provider for an immediate health concern. Provider diagnoses a low-level condition, gives Member medical advice and calls in a prescription. Provider can bill for the service.

This policy describes reimbursement requirements for Virtual Care services. Virtual Care includes all Telehealth, Telemedicine, Store and Forward, Remote Physiologic Monitoring (RPM), and Remote Therapeutic Monitoring (RTM) services between health care professionals and patients or authorized caregiver that are furnished for the purposes of diagnosis, evaluation, or treatment of an illness or injury.

Virtual Health services occur when the physician or other Qualified Health Care Professional and the member are not at the same site.

The plan pays for Virtual Care services such as basic office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management, nutrition therapy, Wellness exams, and end stage renal disease related services.

Telehealth/Telemedicine:
Telehealth/Telemedicine services are synchronous, real-time services performed via interactive audio/video or audio-only technology received at an Originating Site where the Member is physically located and the provider is located at a separate, distant site.

Services must be initiated at the request of the member or authorized caregiver seeking access to a provider.

Services must replace the need for an in-person visit. The member must be present and able to participate.

Professional claims billed with place of service 10 will be reimbursed using the non-facility rate. Professional claims billed with place of service 02 will continue to be reimbursed using the facility rate.

The plan will consider reimbursement for telehealth/telemedicine services when the following criteria are met:

• Services must be included in the Eligible Telehealth Services list in the Policy Requirements section at the bottom of this policy.
• Services performed via audio-only technology must be included in the Eligible Audio-Only Services list in the Policy requirements section at the bottom of this policy.
• The place of service (POS) must reflect the location of the patient when receiving the Telehealth/Telemedicine services. If POS 02 or 10 is not submitted on the claim line, the claim may be returned to the provider to resubmit with the correct POS
  • POS 02: Services Provided other than in patient’s home. Use this POS when the originating site is a health care facility.
  • POS 10 (effective 1/1/2022): Services Provided in patient’s home. Use this POS when the originating site is not a healthcare facility.
• Modifier GT or 93 must be used to reflect the technology used to deliver the service. If one of these modifiers are not submitted on the claim line, the claim will be denied as not reimbursable for the provider to resubmit with the correct modifier. Claims will not be reimbursed if both audio/video and audio-only modifier is billed.
  • Modifier GT: This modifier must be used when services are performed with audio/video technology.
  • Modifier 93 (effective 1/1/2023): This modifier must be used when services are performed using audio-only technology.
• Distant Site provider type must be included in Eligible Providers list in the Policy Requirements section at the bottom of this policy
• Provider must have documented an established relationship with the member seeking services whether performed Audio/Video or Audio-only.
  • Relationship can be established if the member has had at least one in-person appointment or real-time interactive appointment using both audio and video within 6 months of the initial telehealth services, and at least once for every 12 months afterward with the provider rendering the services or with a provider employed at the same medical group as the provider rendering services or with a provider that referred the member to the rendering provider.
• Virtual Services using Audio Only technology must have an established relationship between member and provider follow CMS Guidelines for what services can be performed via Audio-Only.

• Virtual Services using Audio Only technology must have consent obtained prior to first audio-only encounter with a provider and may cover such encounters for a period of up to 12 months. If audio-only encounters continue beyond an initial 12-month period, consent must be obtained from the covered person for each prospective 12-month period. Consent must be documented in the member’s medical record and available for a minimum of five years.

Telehealth Services are not reimbursed for the following:

• Service performed via audio only or Virtual Check-in that originate from a related E/M service provided within the previous 7 days. Service is considered reimbursed as part of the E/M the service originated from and is not separately payable.
• Service performed via audio only or Virtual Check-in that lead to an E/M service or procedure within the next 24 hours or soonest available appointment. Service is considered reimbursed as part of the E/M service and not separately payable.
• Services delivered within the post-operative/global period of a procedure is considered part of the global payment for the procedure and not reimbursed separately.

• Services billed with audio-only and audio/video modifiers will not be reimbursable.

The following services are not covered as services under this scenario:

• E-mail; fax transmission; secure messaging
• Installation or maintenance of any telecommunication devices or systems
• Home health monitoring
• Reporting of test results only
• Request for medication refill
• Follow-up care that does not require shared medical decision making
• Provider-to-Provider interactions
• Asynchronous or "Store and Forward" telecommunication (including transferring data from one site to another through the use of a scanning, camera or similar devices that record (stores) an image that is sent (forwarded) via telecommunication to another site for consultation).
• Radiology interpretations. Claims should be billed with modifier 26.
• Service covering monitoring the Member’s clinical status.
• "Health line" type services provided by nurses and other non-physician, non-nurse practitioner providers.
• Triage to assess the appropriate place of service and/or appropriate provider type.
• Administrative services including but not limited to, follow-up care that does not require shared medical decision making, or follow-up phone calls that do not replace what would have been a follow-up visit, scheduling, registration, updating billing information, reminders, requests for medication refills or referrals, pre-authorizations, prior authorizations, ordering of diagnostic studies, and medical history intake completed by the Member.
• Follow-up phone calls that do not replace what would have been a follow-up visit.

• Any communications that are used to convey results of test(s).

Originating Site/Facility Fee Requirements
The originating site is where the member is located during a telemedicine visit. For the originating site Facility Fee to be considered for reimbursement, the following must be met:

• Member must be physically located in the Health Care Facility billing as the originating site
• Claims should be submitted using the same date of service for the originating and distant site.
• Service must include audio and video in order for an originating site facility fee to be reimbursed (facility fee billings for audio-only are not reimbursable)
• The originating site must be providing health services to the Member
• Originating Site provider must be included in the Eligible Originating Site Health Care Facilities list in the Policy Requirements section at the bottom of this policy.
• Providers billing on ANSI 837P must submit with appropriate place of service, HCPCS Q3014 with no modifier. It is not appropriate for place of service 02 or 10 to be used when billing facility fee.

• Providers billing on ANSI 837I must submit with revenue code 0780 range with HCPCS Q3014 with no modifier.

Store and Forward:
Store and Forward services are asynchronous services performed through a patient portal, healthcare application or other HIPAA-compliant platform. There is no interactive real-time audio/video or audio-only services performed using Store and Forward services. The service must be initiated by the member or authorized caregiver seeking diagnosis and treatment for the member. These services must replace the need for an in-person visit.

The following are billing requirements for Store and Forward services:

• List of Store and Forward Services located in the Policy Requirements section at the bottom of this policy.
• The place of service (POS) must reflect the location of the patient when receiving Store and Forward services. If place of service 02 or 10 is not submitted on the claim line, the claim may be returned to the provider to resubmit with the correct POS
  • POS 02: Services Provided other than in patient’s home. Use this POS when the originating site is a health care facility.
  • POS 10 (effective 1/1/2022): Services Provided in patient’s home. Use this POS when the originating site is not a healthcare facility.
• Modifier GQ must be used to reflect services performed as asynchronous. If modifier GQ is not submitted on the claim line, the claim may be returned to the provider to correct the modifier.
• Distant Site provider must be those included in the eligible providers list in the Policy Requirements section at the bottom of this policy
• Provider must have documented an established relationship with the member seeking services.
  • Relationship can be established if the member has had at least one in-person appointment with 6 months of the initial telehealth services, and at least once for every 12 months afterward with the provider rendering the services or with a provider employed at the same medical group as the provider rendering services or with a provider that referred the member to the rendering provider.

Store and Forward Services are not reimbursed for the following:

• Store and Forward service that originate from a related E/M service provided within the previous 7 days. Service is considered reimbursed as part of the E/M the service originated from and is not separately payable.
• Store and Forward service that lead to an E/M service or procedure within the next 24 hours or soonest available appointment. Service is considered reimbursed as part of the E/M service and not separately payable.

• Services delivered within the post-operative/global period of a procedure is considered part of the global payment for the procedure and not reimbursed separately.

Remote Monitoring
Remote monitoring is a digital service where a physician or qualified health care professional uses software or device to monitor the member’s vital signs or response to the therapeutic treatment. The plan considers most Remote Monitoring services non-reimbursable.

• Remote Physiologic Monitoring (RPM) is used by providers to access data remotely in order to appropriately manage a disease. Examples of RPM include but are not limited to glucose monitoring, oximetry, Blood pressure, or cardiac monitoring.

• Remote Therapeutic Monitoring (RTM) is used by providers to monitor data related to signs, symptoms and functions of a therapeutic response. These monitoring services measure responses to therapy delivered via a device or software.
  RTM performed using a Digital Therapeutic Device that monitors and provides direct responses to the member has to meet requirements under Digital Therapeutics Medical Policy

Providers are responsible for ensuring the security and privacy of information, including, but not limited to, HIPAA, community standards, and best practices for security and privacy, recording consent, Protected Health Information (PHI) storage and storage disclosure.

Providers must ensure access to Virtual Care services is inclusive for those patients who may have disabilities or limited-English proficiency and for whom the use of telemedicine technology may be more challenging.

Reimbursement for billable services is determined by the Provider’s contract and the Member Agreement.

Provider is responsible for authenticating the member’s identity and verifying the member is eligible for Virtual Care Benefits prior to the service. Benefits can be verified using Availity Essentials.

Service delivered to a Member must be within the scope of the performing (distant site) provider’s license and in compliance with applicable state laws in the state(s) where the Member is physically located and where the distant site Provider is physically located. This requirement includes satisfaction of the elements of the Member-Provider relationship as determined by the relevant healthcare regulatory board and all applicable law. Please refer to your state licensing board to determine care guidelines when the provider and/or member are in different states, as these requirements vary by state, provider type, and service type. In most, if not all instances, the provider must be licensed in the state the member is physically located at the time of the visit.

A permanent record of relevant evaluation, management, and follow-up instructions are maintained as part of the Member’s medical record. The record must be available for review or audit by the Member’s health plan at any time.

• The record-keeping standards that apply to in person visits also apply to virtual care visits.

Following the Virtual Care session, if the rendering Provider is not the Member’s primary care provider (PCP), the rendering Provider should communicate a summary of the Virtual Care encounter to the Member’s PCP using secure methods (e.g., email/fax, secure email, transmit to EMR), as well as to the Member, unless the Member has requested a limitation on such communication.

Annual Wellness – G0438, G0439

Evaluation and Management Codes (E&M Codes):

• 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G2211
• Audio Only: 99441, 99442, 99443, 98966, 98967, 98968
• Home visit: 99347, 99348

• Prolonged Visit: G2212

Behavioral Health:

• 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90853, G0017, G0018

Care Planning – 99483, 99495, 99496

Chemical Dependency – G0396, G0397, G0442, G0443, G2086, G2087, G2088

Chronic Pain Management – G3002, G3003

CKD Educational Services – G0420, G0421

Critical Care Consult – G0508, G0509

Diabetes Management – G0108, G0109

ESRD-Related Services – 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970

Home Health – G0320, G0321

Inpatient Services – G0406, G0407, G0408, G0425, G0426, G0427, G0459

Neurobehavioral Status Examination – 96116, 96121

Nutrition Counseling/Therapy – 97802, 97803, 97804, G0270

Palliative Care – 99497, 99498

Preventive Services:

• including G0513, G0514

• Preventive and similar services are eligible for reimbursement only as services specifically defined by CMS, our health plan’s published policies and member benefits or applicable state and federal law as suitable for delivery via Virtual Care and as consistent with all other requirements of this policy.

Psychological/Behavioral Testing & Evaluation – 96127, 96131, 96138, 96139

Smoking and Tobacco use Cessation – 99406, 99407

Virtual Check-in – G2012, G2251, G2252

Other Services – 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96160, 96161, G0136, G0296, G0444, G0445, G0446, G0447

Eligible Audio-Only Services: 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90839, 90840, 90846, 90847, 90853, 96116, 96121, 96127, 96131, 96138, 96139, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 97802, 97803, 97804, 98966, 98967, 98968, 99406, 99407, 99441, 99442, 99443, 99497, 99498, G0108, G0109, G0270, G0296, G0396, G0397, G0406, G0407, G0408, G0420, G0421, G0425, G0426, G0427, G0438, G0439, G0442, G0443, G0444, G0445, G0446, G0447, G0459, G0513, G0514, G2086, G2087, G2088, G2211, G2212

• Remote Monitoring (other) - 0733T 0734T

• G0136

• RPM non-reimbursable - 99453, 99454, 99457, 99458, G0322 (home health)

• RTM 98978, 0740T, 0741T

• RTM non-reimbursable - 98975, 98976, 98977, 98980, 98981

• Physicians (MD, DO)
• Nurse practitioners
• Physician assistants/physician associates
• Nurse midwives
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Clinical psychologists
• Clinical social workers
• Registered dietitians or nutrition professionals
• Marriage and Family Therapist

• Mental Health Counselor

• The office of a Provider
• A hospital
• Critical access hospital (CAH)
• A rural health clinic
• A renal dialysis center, except an independent renal dialysis center
• A federally qualified health center
• A hospital-based or critical access hospital- based renal dialysis center (including satellites)
• A skilled nursing facility; or

• A community mental health center

• E-Consultation (provider-to-Provider) 99446, 99447, 99448, 99449, 99451, 99452: Both providers must be at a health care facility
• Greater than 50% of the time must be devoted to medical consultative verbal/secure online discussion. (Does not apply to 99451, 99452)
• Member is aware that the consult occurred. This can be achieved through making the results of the consult available to the Member.
• If more than one telephone/internet contact is required to complete the consultation request (e.g., discussion of test results), the entirety of the service and the cumulative discussion and information review time should be reported with a single code.
• E-Visits – G0071
• Online Diabetes Prevention Program – 0488T

American Telemedicine Association, Telemedicine Practice Guidelines

Centers for Medicare & Medicaid Services (CMS) List of Telehealth Services

CMS Medicare Benefit Policy Manual:

• Chapter 12 270: Telehealth:

• Chapter 12 190: CMS Physician/Non-physician practitioners

CMS Manual System. Publication 100-04 Medicare Claims Processing. Transmittal 3586. New Place of Service (POS) Code for Telehealth and Distant Site Payment Policy

Noridian Healthcare Solutions Jurisdiction F – Medicare Part B, Telehealth, Distant Site

CMS MLN New Place of service codes telehealth

CMS Calendar Year 2024 Medicare Physician Fee Schedule Final Rule

Telehealth Services Medicare Learning Network MLN90175 - Telehealth Services (cms.gov)

CMS MLN New FR Modifier, MM12549 - CY2022 Telehealth Update Medicare Physician Fee Schedule (cms.gov)

Federal Register: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program

Care Management Services

Digital Therapeutic Products, Medical Policy Manual, M-MED175

Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder, Medical Policy Manual, M-MED175.01

Digital Therapeutic Products for Substance Use Disorders, Medical Policy Manual, M-MED175.02