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Medical Policy: 02.01.41
Original Effective Date: October 2010
Reviewed: January 2012
Revised: January 2012
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Telemedicine is defined as the use of interactive audio-visual technologies to exchange medical information for diagnostic, monitoring, and therapeutic purposes to improve health care when clinicians and patients are separated by distance.
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Prior Approval:
Not applicable
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Policy:
Benefits for telemedicine services will be allowed when the service provided is considered medically necessary and is not readily available for the patient through a direct patient-provider encounter.
The originating site of the telemedicine service must be one of the following:
- The office of a physician or practitioner
- A hospital
- A federally qualified health center (FQHC)
- A rural health clinic (RHC)
- A hospital-based renal dialysis center (including satellite)
- A skilled nursing facility (SNF)
- A community mental health center (CMHC)
Telemedicine services may be provided by:
- A physician
- A nurse practitioner
- A physician’s assistant
- A nurse midwife
- A clinical nurse specialist
- A clinical psychologist
- A clinical social worker
- A registered dietitian or nutrition professional
- A licensed mental health counselor
- A licensed marriage and family therapist
Services provided by telemedicine may include the following:
- Inpatient visits for consultations
- Office or other outpatient visits
- Individual psychotherapy
- Pharmacologic management
- Psychiatric diagnostic interview examination
- End stage renal disease related services
- Neurobehavioral status exam
- Individual medical nutrition therapy when performed by a dietetic professional under the supervision of a primary care provider
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- Q3014 Telehealth originating site facility fee
- 96150 Health and behavior assessment (eg, 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 (eg, 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
- GT modifier; Via interactive audio and video telecommunication systems
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Selected References:
- American Psychiatric Association. APA Telepsychiatry Via Videoconferencing Resource Document. Reference no. 980021. Approved 7/98. Archived. Accessed April 27, 2010. Available at: http://archive.psych.org/edu/other_res/lib_archives/archives/199821.pdf
- American Academy of Dermatology and AAD Association. (2004, May). Position Statement on telemedicine. Retrieved April 26, 2010 from: http://www.aad.org/forms/policies/Uploads/PS/PS-Telemedicine%206-15-07.pdf
- Taylor P. Evaluating telemedicine systems and services. J Telemed Telecare. 2005;11(4):167-77.
- Hersh WR, Hickam DH, Severance SM et al. Diagnosis, access and outcomes: Update of a systematic review of telemedicine services. J Telemed Telecare. 2006;12 Suppl 2:S3-31.
- Hersh WR, Hickam DH, Severance SM, Dana TL, Krages KP, Helfand M. Telemedicine for the Medicare Population: Update. Evidence Report/Technology Assessment No. 131 (Prepared by the Oregon Evidence-based Practice Center under Contract No. 290-02-0024.) AHRQ Publication No. 06-E007. Rockville, MD: Agency for Healthcare Research and Quality. February 2006.
- Garcia-Lizana F, Munoz-Mayorga. Telemedicine for depression: a systematic review. Perspect Psychiatr Care. 2010 Apr;46(2):119-26.
- Whitten P, Holz B, Nguyen L. Keys to a successful and sustainable telemedicine program. Int J Technol Assess Health Care. 2010 Apr;26(2):211-6.
- American Telemedicine Association. Telemedicine defined. Accessed April 27, 2010. Available at: http://www.americantelemed.org/i4a/pages/index.cfm?pageid=1
- Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Chapter 15, Sections 270-270.4.
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Policy History:
Date Reason Action
January 2012 Annual review Policy revised
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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