Description
Telemedicine is the use of medical information about a patient that is exchanged from one eligible referring provider ("Referring Physician") site to another eligible consulting provider site ("Consulting Physician") via two-way, real-time, interactive, secured and HIPAA-compliant, electronic audio and video telecommunications systems to provide medical care to a patient in circumstances in which in-person, face-to-face contact with the Consulting Physician is not necessary.

Telemedicine includes consultation, diagnostic and treatment services. Telemedicine is not an expansion of covered services but an option for delivery of certain covered services. Such a service delivery option can, in some cases, provide increased access to specialists, better continuity of care and elimination of the hardship of traveling extended distances. Quality of health care delivery must be maintained, regardless of the mode of delivery. A Referring Physician must have determined that medical care can be provided via electronic communication with no loss in the quality or efficacy of the care.

Policy:
Referring Sites: 
A referring site is the location of an eligible Referring Physician site in which a Plan's beneficiary/member is personally presented by the Referring Physician to a Consulting Physician at the time the service is being furnished as defined above. Plan members/beneficiaries are eligible for telemedicine services only if the member/beneficiary access to appropriate specialty care is difficult, inaccessible or unavailable by the member or in an urgent situation such that access to the specialty care is needed immediately without requiring the patient to travel. Referring Physician sites are required to facilitate the delivery of this service. The referring site presenter should be a physician or other clinician provider knowledgeable in how the equipment works and who can provide the clinical support needed during a session.

Covered referring sites, unless otherwise specified, include but are not limited to:

• The office of a physician or practitioner.
• Hospital inpatient.
• Hospital outpatient.
• Hospital emergency departments.
• Rural health clinics.
• Federally qualified health centers.
• South Carolina Department of Mental Health community mental health centers.

Consultant Sites: A consultant site means the site or location at which the specialty Consulting Physician providing the medical care is located at the time the service is provided via telemedicine. The Consulting Physician providing the medical care must be currently and appropriately licensed as required by the appropriate state’s Board of Medical Examiners.

Eligible Telemedicine Providers: Providers who meet the Plan's contracting requirements and are currently contracted are eligible to submit claims for telemedicine and telepsychiatry when the service is within the scope of their practice. The Eligible Referring Physician is the practitioner who has evaluated the member/beneficiary, determined the need for a consultation and has arranged the services of the Eligible Consulting Physician for the purpose of consultation, diagnosis and/or treatment. The Eligible Consulting Physician is the practitioner who evaluates the beneficiary via the telemedicine mode of delivery upon the recommendation of the Referring Physician. Eligible Consulting Physicians at the consulting/distant site who may furnish and receive payment of covered telemedicine services are limited to allopathic and osteopathic physicians.

Covered Services: Services that are eligible for reimbursement, when delivered via an appropriately secure telecommunications system, include:

• Consultation for high-risk pregnancy.
• Consultation for acute stroke treatment.
• Pharmacologic management; psychiatric diagnostic interview examinations and testing.
• Emergency room-to-emergency room consultations.
• Specialty consultations provided to hospitalized inpatients.

A South Carolina licensed physician with completed specialty training appropriate to the condition of referral is the only provider that may provide consulting care via telemedicine.

As a condition of reimbursement, a real-time audio and video telecommunication system must be used that is HIPAA compliant and that permits interactive communication between the Consulting Physician and the member/beneficiary at the consultant site and the Referring Physician at the referring site.

Office and outpatient visits that are conducted via telemedicine are counted toward any applicable benefit limits for these services. Telemedicine services will be covered by the Plan when they are covered services under the terms of the member’s/beneficiary’s policy, medically necessary and under the following circumstances:

• The medical care is individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's need.
• The medical care can be safely furnished, and there is no equally effective, more conservative and less costly treatment available.

The lists of services that may be covered under telemedicine include:

• Office or other outpatient consultations (CPT 99241 – 99245).
• Inpatient consultation (CPT 99251 – 99255).
• Psychiatric diagnostic interview examination (CPT 90791,90792).
• Pyschotherapy (90832, 90834, 90837).
• Neurobehavioral status examination (CPT96116).
• Inpatient consultation, initial and follow up (G0406 – G0408, G0425 – G0427).

The following interactions are not reimbursable telemedicine or telepsychiatry services and will not be reimbursed:

• Telephone conversations
• Email messages
• Video cellphone interactions
• Facsimile transmissions
• Services provided by allied health professionals that are neither allopathic or osteopathic physicians
• Internet-based audio-video communication that is not secure and HIPAA compliant (e.g., Skype)

The following conditions and guidelines apply to all services rendered via telemedicine:

• The member/beneficiary must be present and participating in the telemedicine visit.
• The Referring Physician must provide pertinent medical information and/or records to the Consulting Physician via a secure transmission as defined above.
• Real-time, interactive audio and video telecommunications must be used, permitting encrypted communication between the consulting/distant site physician or practitioner and the Plan's member/beneficiary. The telecommunication service must be secure and adequate to protect the confidentiality and integrity of the telemedicine information transmitted.
• The telemedicine equipment and transmission speed and image resolution must be technically sufficient to support the service billed. Staff involved in the telemedicine visit must be trained in the use of the telemedicine equipment and competent in its operation.
• The Referring Physician or his or her qualified clinician staff member at the referring site is required to present the member/beneficiary to the Consulting Physician at the consulting site and remain available as clinically appropriate.
• If the member/beneficiary is a minor child, a parent and/or guardian must present the minor child for telemedicine service unless otherwise exempted by state or federal law. The parent and/or guardian need not attend the telemedicine session unless attendance is therapeutically appropriate.
• The member/beneficiary retains the right to withdraw at any time.
• All telemedicine activities must comply with the requirements of the Health Insurance Portability and Accountability Act of 1996: Standards for Privacy of individually identifiable health information and all other applicable state and federal laws and regulations.
• The member/beneficiary has access to all transmitted medical information, with the exception of live interactive video, as there is often no stored data in such encounters.
• There will be no dissemination of any member's/beneficiary’s images or information to the other entities without written consent from the member/beneficiary.
• The provider at the distant/consulting site must obtain prior approval for service when services require prior approval, based on service type or diagnosis.

Reimbursement to the Consulting Physician delivering the medical service is the same as the current fee schedule amount for the service provided. Consulting Physicians will submit claims for telemedicine or telepsychiatry services using the appropriate CPTcode for the professional service along with the telemedicine modifier GT, via interactive audio and video telecommunications systems (e.g., 99243 GT). By coding and billing the "GT" modifier with a covered telemedicine procedure code, the Consulting Physician is certifying that the member/beneficiary was present at the Referring Physician site when the telemedicine service was furnished. Telemedicine services are subject to any coinsurance or copayment requirements.

The Referring Physician site is only eligible to receive a facility fee for telemedicine services. Claims must be submitted with HCPCS code Q3014 "telemedicine origination site facility fee." If a provider from the Referring Physician site performs a separately identifiable service for the beneficiary on the same day as telemedicine, documentation for both services must be clearly and separately identified in the member's/beneficiary’s medical record, and both services are eligible for reimbursement. 

References:

1. American Telemedicine Association. Telemedicine/Telehealth Terminology (http://www.americantelemed.org/files/public/abouttelemedicine/Terminology.pdf0), American Telemedicine Association website, Washington, D.C. Retrieved November 11, 2012.
2. HJ Rogove, D McArthur, BM Demaerschalk, and PM Vespa. Barriers to Telemedicine: Survey of Current Users in Acute Care Units. Telemedicine and e-Health. January/February 2012, 18(1): 48-53. Doi:10.1089/tmj.2011.0071.
3. EM Strehle and N Shabde. One hundred years of telemedicine: does this new technology have a place in paediatrics? Archives of Disease in Childhood. December 2006, 91(12): 956-959.
4. American Telemedicine Association. What is Telemedicine? (http://www.americantelemed.org/files/public/abouttelemedicine/What_Is_Telemedicine.pdf). American Telemedicine Association website, Washing, D.C. Retrieved November 11, 2012.
5. DM Angaran. Telemedicine and Telepharmacy: Current status and future implications. American Journal of Health-System Pharmacy, July 15 1999, 56: 1405-26.
6. GD Clifton, H Byer, K Heaton, DJ Haberman and H Gill. Provision of pharmacy services to underserved populations via remote dispensing and two-way videoconferencing. American Journal of Health-System Pharmacy. December 15 2003, 60: 2577-82.
7. EJ Ludman, GE Sinom, LC Grothaus, C Luce, DK Markley, J Schaefer. A pilot study of telephone care management and structured disease self-management groups for chronic depression. Psychiatric Services, August 2007, 58(8): 1065-1072.
8. R O’Reilly, J Bishop, L Hutchinson, M Fisman, J Takhar. Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatric Services, June 2007, 58(6): 836-843.
9. CMS Manual System (Pub 100-04 Medicare Claims Processing).Transmittal 1716. April 24, 2009.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology^© American Medical Association. All Rights Reserved" 

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