RetiredCapital BluecrossPolicy MP 4.044

TELESTROKE

Defines medical necessity and operational requirements for clinician-interactive telestroke services (hub-and-spoke model) including applicable provider qualifications, permitted service types, imaging transmission requirements, and associated ICD-10 and HCPCS/G codes. Indicates policy retirement date.

Policy Summary

PayerCapital Bluecross

PolicyTELESTROKE

Policy CodePolicy MP 4.044

Change TypeRetirement; prior consensus reviews

Effective Date

Next Review Date

Key ActionEnsure telestroke professionals and imaging interpreters are fully licensed and credentialed in the hub and service jurisdictions, document credentials, meet imaging transmission and technical requirements, and provide/document patient/family notification about the telestroke program.

POLICY UPDATE CHANGES

Policy retired (retirement entries noted in policy history and header).

Multiple consensus reviews with coding and reference updates; no changes to policy statements.

1Primary coverage statement

8+ICD-10 codes listed

8HCPCS/G/Q codes listed

Coverage Summary & Scope

This policy (MP 4.044) defines that clinician-interactive telestroke services delivered in a hub-and-spoke model are covered with criteria — clinician interactive telemedicine services may be considered medically necessary when telestroke services are reported. Status: RETIRED (policy history notes retirement 11/14/2024; header indicates RETIRED effective 6/1/2025).

Relevant Billing and Diagnosis Codes

Covered HCPCS/G/Q codes (when medically necessary)HCPCSCovered

G0406
G0407
G0408
G0425
G0427
G0508
G0509
Q3014	Telehealth originating site facility fee

Associated ICD-10-CM diagnosis codes (cerebral infarction / ischemic stroke)ICD-10Covered

I63.00	Cerebral infarction due to thrombosis of unspecified precerebral artery.
I63.011	Cerebral infarction due to thrombosis of right vertebral artery.
I63.012	Cerebral infarction due to thrombosis of left vertebral artery.
I63.013	Cerebral infarction due to thrombosis of bilateral vertebral arteries.
I63.02	Cerebral infarction due to thrombosis of basilar artery.
I63.031	Cerebral infarction due to thrombosis of right carotid artery.
I63.032	Cerebral infarction due to thrombosis of left carotid artery.
I63.033	Cerebral infarction due to thrombosis of bilateral carotid arteries.
I63.09	Cerebral infarction due to thrombosis of other precerebral artery
I63.10	Cerebral infarction due to embolism of unspecified precerebral artery.

1–10 of 66

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Documentation & Operational Requirements for Providers

Documentation Required

Provider licensing and credentialing

Telestroke clinicians and the professionals who interpret imaging must be fully licensed, registered, and credentialed both where the hub facility is physically located and where services are rendered to the patient. Maintain and record licensing, registration, and credentialing documentation for hub-based telestroke providers and imaging interpreters.

Document credentials

Documentation Required

Technical imaging requirements

Maintain and document that CT imaging and the supporting systems meet the policy's minimum technical requirements: CT images must be transmitted in real-time or near real-time (less than two minutes) to allow collaboration between telestroke specialists and the spoke site. Ensure connectivity via broadband or sufficient bandwidth for real-time image acquisition and display, that hub and spoke facilities have a PACS, and that hub monitors meet the specified resolution and pixel depth.

CT transmission in <2 minutes (real-time or near real-time)
Connection via broadband or necessary bandwidth for real-time image acquisition/display
Hub and spoke facilities must have a PACS (picture archiving and communications system)
Hub monitor resolution: 512 x 512 matrix at 8-bit pixel depth

Documentation Required

Patient/family notification

Provide patients and their families with information about the telestroke program, the role of the program in patient management, how the technology will be used, and assurances about confidentiality as time permits in the emergent setting. If this communication cannot occur before treatment, document that it occurred after stabilization or document that information was provided when feasible.

Background and Definitions

Telestroke uses interactive audiovisual technologies in a hub-and-spoke network where a distant hub (typically a comprehensive tertiary care center) provides remote stroke expertise to originating spoke sites to improve acute ischemic stroke management, including timely administration of IV alteplase and triage for endovascular thrombectomy. It is intended to extend specialist access to settings without onsite stroke physicians (for example rural emergency departments) and to address geographic access gaps.

Term	Definition
Hub	Typically a comprehensive tertiary care center where vascular neurologists and other acute stroke specialists deliver telestroke services to spoke sites; if a patient requires transfer to a higher level of care, a hub is usually the destination.
Spoke / Originating site	Affiliate or partner site where the patient is located and receives telestroke services; often underserviced or underserved by onsite neurologists (also referred to as Originating Site or Spoke Site).
Telestroke	A network of audio-visual communication and computer systems for collaborative, inter-professional care of acute stroke patients by remote stroke specialists; used to augment local services and facilitate treatment such as timely administration of IV alteplase and triage for thrombectomy.
Distant Site	The telestroke provider location; sometimes used interchangeably with 'Hub Site.'

Evidence summary

References count6+ cited sources including ATA Telestroke Guidelines (2017) and AAN position statement