QUEST Integration - Telemedicine

HMSA’s plans recognize telemedicine (where an individual receives medical services from a healthcare provider without face-to-face contact) for benefit payment in accordance with Medicare guidelines for payment of this service.

Telemedicine is the practice of healthcare delivery, diagnosis, consultation, treatment, and transfer of medical data, using interactive audio, video or data communications.  This technology enables healthcare practitioners to deliver care to patients separated by distance.  Standard telephone calls, fax transmissions and email, in the absence of other integrated information and data, do not qualify for benefit payment under HMSA plans.

Covered Services

The following services will be covered under this benefit if the criteria are met:

• Consultations (99241-99275)
• Office visits (99201-99215)
• Individual psychotherapy (90804-90809)
• Pharmacologic management (90862)

HMSA also will cover “store and forward technology” in single or multimedia formats, when used as a substitute for an interactive telecommunications system.

Consultations

An interactive video consultation allows a practitioner to consult with a specialist when they are separated by distance.  This type of consultation generally involves a local “presenting” or referring practitioner, who presents and examines the patient while communicating with a distant specialist concerning the patient’s condition and course of treatment.  In some cases, the presenting party may not be a medical professional.  In such cases, the presenting party may not bill for his or her services.

To be eligible for benefit payment, a teleconsultation must meet the following criteria:

• The patient must be present during the examination.
• The examination must be performed using multimedia communications that include, at a minimum, audio-video equipment permitting two-way, real-time communications.
• The examination must be an interactive medical examination and clinical assessment directed by the specialist/consultant.
• The examination must include the participation of the presenting party, who provides information to, and at the direction of, the specialist and who is available to receive the specialist’s immediate feedback or assessment.
• If a medical examination is performed by a practitioner at the originating site during the teleconsultation, the practitioner must be an eligible provider to receive payment for the service.
• The specialist/consultant must be an eligible provider and the services performed must be eligible services.

Coding and Payment:

Consultations

The consulting specialist may bill the appropriate consultation code as referenced above followed by modifier code -GT (by interactive audio and visual communication systems).  Plan benefits will be paid based on the fee schedule for the consultation.

Presenting practitioners may bill for the appropriate level office visit code if a medical examination is carried out at the time of the telemedicine consultation.  No modifier code is required.  Plan benefits will be paid based on the fee schedule for the office visit.

No additional payment will be made for “special services” (e.g., after hours) codes.

Procedural services 

If procedural services are performed under the direction of the specialist/consultant, the physician who actually performs the service should bill using standard procedure codes.  It is not necessary to use a -GT modifier.  Benefits will be paid based on the fee schedule for the procedural service.

The specialist/consultant physician (who monitors the procedure and advises the attending physician via video) should bill for a consultation, not for the procedure.  The consultation should be billed using modifier code -GT.  Plan benefits will be paid based on the fee schedule for the consultation.

Emergency room services

An emergency room physician may bill for a consultation if a physician in an outlying area requests a telemedicine consultation.  The consultation should be billed using modifier code -GT.  Plan benefits will be paid based on the fee schedule for the consultation.

If the patient eventually is taken to the consulting physician’s emergency room for treatment, the physician may only bill for the resulting emergency room visit.  The physician should not bill both a telemedicine consultation and an emergency room visit for the same patient on the same date.

"Store and Forward" Technology

“Store and forward ” technology is defined as the transmission of medical information via telecommunications media to be reviewed at a later time by a practitioner at the distant site.  The information is then available at the new location for viewing and interpretation.  The patient does not need to be present.  The medical information may include, but is not limited to, video clips, still images, X-rays, MRIs, EKGs, and EEGs, laboratory results, audio clips and text.  Photographs must be specific to the patient’s condition and adequate for rendering or confirming a diagnosis and/or treatment plan.

The interpretation only of stored diagnostic tests or images may be billed using standard CPT codes followed by modifier code -26.

If the receiving specialist interprets the data and writes a consultation report, the service can be billed using modifier code -GQ.

Special Considerations

All plan provisions, exclusions, payment guidelines and negotiated agreements apply to services delivered through telemedicine.

Revision History