Telehealth Clinical Policy Number: 18.02.01 Effective Date: Initial Review Date: Most Recent Review Date: Next Review Date: Dec. 1, 2013 June 19, 2013 June 18, 2014 June 2015 Policy contains: • Telemedicine; • Telehealth. ABOUT THIS POLICY: Keystone VIP Choice has developed clinical policies to assist with making coverage determinations. Keystone VIP Choice 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 Keystone VIP Choice 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. Keystone VIP Choice 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. Keystone VIP Choice clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Keystone VIP Choice will update its clinical policies as necessary. Keystone VIP Choice clinical policies are not guarantees of payment. Coverage Policy: Keystone VIP Choice 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. Keystone VIP Choice does not consider telemedicine to be a substitute for direct member-provider encounters AND • For Keystone VIP Choice 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) 1 • NOTE: Services provided by the Medicare Claims Processing Manual, Chapter 12 Physician, Nonphysician Practitioners Section 190 http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf (last accessed Aug. 11,2014) 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. Keystone VIP Choice 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. 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 Hampshire, Georgia, and other rural sites. The use of transmission of imaging data has improved 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 2 • 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: Keystone VIP Choice 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”. • • • Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. 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. 3 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. 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 Hilty et al 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 allcause 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 of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous or “store and forward” applications would not be considered telemedicine but may be utilized to deliver services 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 4 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: Keystone VIP Choice 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 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 5 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):45567. 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):45567. 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: Searches of Medicare and Medicaid coverage databases yielded no relevant coverage decision documents. Telehealth services: Rural health fact sheet series. Department of Health and Humana Services, http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/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 6 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 3 days CY 2013 list of Medicare telehealth services 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 CY 2013 list of Medicare telehealth services 7 initial year training period to ensure effective injection training 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 semiannually, 30 minutes CY 2013 list of Medicare telehealth services G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes CY 2013 list of Medicare 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) 8 Q3014 Originating site (not covered by Medicare) ICD-9 Code Description Comment ICD-10 Code Description Comment HCPCS Level II Description Comment 9