CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine/Telephone Services Payment Policy – Archive 2

Defines Neighborhood Health Plan of Rhode Island coverage, billing, documentation, and reimbursement requirements for telemedicine and telephone-only services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines; includes permanent and temporary (COVID-19) allowed CPT/HCPCS codes and coding/billing rules through specified dates.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine/Telephone Services Payment Policy – Archive 2

Policy CodePolicy N/A

Change TypeCoding & temporary audio-only allowances

Effective DateN/A

Next Review DateN/A

Key ActionDocument medical necessity and link the in-person follow-up note to the initial telemedicine/telephone encounter; bill with required POS and modifiers and follow code-level audio-only allowance flags.

SourceLink

POLICY UPDATE CHANGES

1/27/2023 Policy Revision: Updated coding section to clarify requirements, added Doula service CPTs to Coding Grid and allowed Established E/M codes for Audio Only for PCPs effective 7/1/22.

07/01/2022 Action: Policy updates from 5/01/22 revision effectuated.

05/01/2022 Policy Update & Review: Combined Telemedicine and Temporary Telemedicine policies and updated language/coding to align with CMS, EOHHS, OHIC guidance.

01/20/2022 Policy update to include new POS 10 per CMS effective 4/1/22.

04/13/2021 Formatting Updates. No content changes.

05/07/2020 Formatting Updates.

04/13/2020 Update: Add code Q3014.

03/03/2020 Policy update, added Medicaid wording, Medicare coding, and format change.

100%Reimbursement relative to in-office allowable

1 per 3 days

Coverage Summary

Policy defines telemedicine/telehealth/telephone services as real-time, two-way synchronous audio/video, telephone-audio-only communications, electronic media and remote monitoring; the terms telemedicine and telehealth are used interchangeably. This policy applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. Telemedicine/telephone-only services meeting policy criteria will be reimbursed at 100% of the in-office allowable amount. The policy includes both permanent allowances (codes marked Permanent = X) and temporary allowances for additional codes tied to the COVID-19 period; temporary allowances require specific billing modifiers/place of service and are documented as allowed through 2023-12-31.

Operational summary

Reimbursement relative to in-office allowable100%

Temporary allowances expire2023-12-31

Hospital telehealth visit limit1 per 3 days

Nursing facility telehealth visit limit1 per 14 days

Lines of businessMedicaid (excl. EFP), INTEGRITY, Commercial

Medical Necessity Criteria

General Coverage Criteria / Telemedicine Services

ALL of the following

The patient must be present at the time of service.
Services must be medically necessary and clinically appropriate to be provided through telemedicine/telephone.
The communication exchanged must be sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
Treatment must meet the same standard of care as, and be an appropriate substitute for, a face-to-face encounter.
Services must be within the provider's scope of license.

Temporary Audio-only & Code-level Approval

Temporary Audio-only Telemedicine Approval

Neighborhood temporarily allowed audio-only (telephone) services for specific CPT codes through 12/31/2023 as indicated below; permanent approval status shown per code.

Temporary audio-only approvals (grouped examples)

Psychological/neuropsych testing and administration: 96131, 96132, 96133, 96136, 96137, 96138, 96139 — Approved for Audio Only Visit = Yes; Temporarily allowed through 12/31/2023 = X (per code entries)
Health behavior interventions: 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 96170, 96171 — Approved for Audio Only Visit = Yes; Permanent = X for many (96156/58/59/60/61/64/65/67/68); 96170/71 marked temporarily allowed X
Therapy and rehab codes (temporary): 97110, 97112, 97116, 97129, 97130, 97150, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 97161-97168, 97530, 97535, 97542, 97750, 97755, 97760, 97761, 97763 — Many marked Temporarily allowed through 12/31/2023 = X; Approved for Audio Only Visit generally = No (exceptions noted in grid)

Coding

Temporarily allowed via Telemedicine/Telephone through 2023-12-31 (Neighborhood guidance)CPTCovered

77427	Radiation treatment management, 5 treatments
99442	Telephone evaluation and management service, 11-20 minutes of medical discussion
99480	Transitional care management, moderate complexity (example temporary)

Permanent Telemedicine Services (examples noted as Permanent in grid)mixedCovered

90785	Interactive complexity (add-on)
99335	Domiciliary or rest home visit for established patient, 15 minutes
99336	Domiciliary or rest home visit for established patient, 25 minutes
99342	Prolonged evaluation and management, office or other outpatient, new patient (example)
99343	Prolonged E/M, office, new patient additional time
99344	Prolonged E/M, office, established patient initial
99345	Prolonged E/M, office, established patient extended
99347	Home visit for established patient, 15 minutes
99348	Home visit for established patient, 25 minutes
99349	Home visit for established patient, 40 minutes

1–10 of 18

1/2

Codes listed with Audio-only approval and temporary allowance through 12/31/2023CPT

99442	Telephone E/M 11-20 minutes (approved for audio-only)
99480	Transitional care management (audio-only where allowed temporarily)
99407	Smoking and tobacco use cessation counseling, intensive, >10 minutes
99408	Alcohol and/or substance abuse screening and brief intervention

Codes listed in this partCPT

90951	ESRD related services monthly (partial listing)
90785	Interactive complexity (listed here as example)

Codes Approved for Audio Only Visit (Permanent = X)HCPCS/CPTCovered

90785	Interactive complexity (Approved for audio-only)
99442	Telephone E/M 11-20 minutes (Audio-only approval)
99407	Smoking cessation intensive counseling (Audio-only allowed)
99408	Alcohol/substance abuse screening intervention (Audio-only allowed)

Codes Temporarily Allowed for Audio-Only through 12/31/2023 (marked X)HCPCS/CPTCovered

77427	Radiation treatment management, 5 treatments (Temporary allowance; Not approved for audio-only)
99480	Transitional care management (Temporary allowance through 12/31/2023)

Codes Not Approved for Audio Only Visit (No) and No Temporary AllowanceHCPCS/CPTNot Covered

77427	Radiation treatment management, 5 treatments (Not approved for audio-only)
90951	ESRD related services monthly (Not approved for audio-only unless specified)

Provider Actions & Billing Requirements

Documentation Required

Medical record documentation

Documentation must support services billed and medical necessity. Neighborhood may request medical records and follows CMS documentation standards. For split preventive visits, the progress note for the in-person (second) visit must reference the date of the initial telemedicine/telephone encounter and tie the records together.

Billing Rule

Place of service and modifier requirements

When patient is at home bill with POS 10 and modifier 95; when patient is not at home use POS 02 and modifier 95. For services temporarily allowed through 12/31/2023, include modifier CR in addition to modifier 95 and the POS specified for temporary services. Telephone-only claims must be filed with POS 02 or 10 as specified and follow the Approved for Audio Only Visit guidance.

Background

Telemedicine/telehealth/telephone are defined as real-time, two-way synchronous audio and video communications, telephone-audio-only communications, electronic media, and other telecommunications technology used to provide or support healthcare delivery; the policy states that telemedicine and telehealth are used interchangeably. The policy applies to the following lines of business: Medicaid (excluding Extended Family Planning), INTEGRITY, and Commercial. The policy definition (Telemedicine/Telehealth) specifies real-time synchronous audio/video, telephone-audio-only, electronic media, and remote monitoring as included modalities.

Revision History

1/27/2023revisedLatest

1/27/2023 Policy Revision: Updated coding section to clarify requirements, added Doula service CPTs to Coding Grid and allowed Established E/M codes for Audio Only for PCPs effective 7/1/22.

07/01/2022revised

07/01/2022 Action: Policy updates from 5/01/22 revision effectuated.

05/01/2022revised

05/01/2022 Policy Update & Review: Combined Telemedicine and Temporary Telemedicine policies and updated language/coding to align with CMS, EOHHS, OHIC guidance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine/Telephone Services Payment Policy – Archive 2

Policy CodePolicy N/A

Change TypeCoding & temporary audio-only allowances

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Preventive Medicine Services via Telemedicine/Telephone

ALL of the following

Neighborhood will reimburse Adult Annual Preventive Exams, Pediatric Preventive Exams, and Medicare Annual Wellness Visit (AWV) provided via telemedicine/telephone only.
For children age 24 months and under, and those over 24 months in need of vaccination, the AAP recommends continuation of in-person well child visits to ensure critical immunizations and screenings; telemedicine may not substitute for required immunizations.
For children over 24 months (or under 24 months unable to be seen in person), well child visits may be conducted via telemedicine/telephone consistent with this policy; remaining elements should be completed in person as soon as feasible.
The preventive encounter may be split: the first portion (telemedicine/telephone) documents the preventive E&M or AWV components appropriate for remote delivery. Submit the appropriate preventive E&M or AWV CPT/HCPCS code on the date of the telemedicine/telephone service (only once).
The second portion (in-person) is intended to perform face-to-face components (immunizations, vitals, vision/hearing screening). Only services provided on the second date that are separate from the preventive E&M/AWV should be billed on that second date using appropriate procedure codes; do NOT bill the preventive E&M/AWV code again on the second date.
If additional sick concerns are addressed during the in-person second visit, providers may bill an appropriate sick E&M for a separately identifiable encounter with usual documentation; for Commercial members standard cost share applies to that sick visit.
Documentation must reflect both encounters; the face-to-face progress note must reference the date of the initial telemedicine/telephone encounter and link to that encounter in the medical record/EMR.
For Medicaid and INTEGRITY members, the second (in-person) visit should be billed directly to EOHHS for reimbursement by Medicaid FFS per EOHHS guidance.

Coverage Limitations

ALL of the following

Subsequent hospital services: limited to 1 telehealth visit every 3 days.
Subsequent nursing facility care services: limited to 1 telehealth visit every 14 days.
Telemedicine/Telephone services delivered on the same day as a face-to-face visit by the same provider for the same condition are not covered (see exclusions).
Claims for services temporarily allowed due to COVID-19 must follow modifier CR and POS rules per policy when indicated; refer to coding grid for temporary vs permanent status of specific codes.
All billable services are subject to contractual agreements and timely filing; providers must submit complete claims within contractual timely filing guidelines.

Coverage Exclusions

ANY of the following

Services rendered via e-mail or facsimile (fax).
Services rendered on social networking platforms (e.g., Facebook, Twitch, TikTok).
Telemedicine/Telephone services delivered on the same day as a face-to-face visit by the same provider and for the same condition.
Patient communication incidental to an office visit (reporting test results, provision of educational materials, patient follow-up calls or 'check-ins').
Administrative services (scheduling, appointment reminders, medication refills, ordering of diagnostic or laboratory tests).
Telemedicine/Telephone services conducted by office staff, RNs, LPNs (not reimbursable provider-performed services).
Automated computer programs used to diagnose and/or treat ocular or refractive conditions.

Excluded Provider Types

ANY of the following

Acupuncture.
Ambulance service.
Ambulatory surgical facility.
Audiologist.
Certified registered nurse first assist.
Chiropractors.
Dental specialties.
Durable medical equipment supplier.
General hospital.
Home infusion.
Laboratory.
Pathology.
Pharmacy.
Psychiatric hospital.
Radiologists.
Rehabilitation hospital.
Renal/Dialysis facility.
Retail based clinic.
Skilled nursing facility.

Code-level Telemedicine Approval Conditions (temporal and permanent flags)

Each listed CPT code includes fields: Approved for Audio Only Visit (Yes/No), Temporarily allowed through 12/31/2023 (X if allowed), Permanent (X if permanent).

Code-level conditions — grouped examples

Hospital/Observation E/M codes: 99233 — Approved Audio Only = Yes; Permanent = X; 99234/99235/99236 — Approved Audio Only = No; Temporarily allowed through 12/31/2023 = X
ED and Critical Care codes: 99281-99285, 99291-99292 — Generally Approved Audio Only = No; Temporarily allowed through 12/31/2023 = X for ED and critical care codes listed
Nursing facility codes: 99304-99306 — Temporarily allowed through 12/31/2023 = X (Approved Audio Only = No); 99307-99310 — Approved Audio Only = Yes; Permanent = X
Home/Domiciliary visit codes: 99324-99328, 99334-99337, 99341-99350 — Many codes marked Temporarily allowed through 12/31/2023 = X or Permanent = X as specified in the grid (see policy table for each code)
Prolonged and preventive series: 99354-99357, 99381-99397 — Many codes Approved for Audio Only Visit = Yes and Permanent = X (permanent allowances shown in grid)
Telephone E/M and counseling: 99441-99443 — Telephone E/M codes Approved for Audio Only Visit = Yes and Temporarily allowed through 12/31/2023 = X; 99406-99409 and preventive counseling codes have Approved Audio Only = Yes and Permanent = X
Advance care planning and other HCPCS: 99497-99498, G-codes, S9445, G0406-0408, G0425-0427, G0438-0439, etc. — Codes listed with Approved for Audio Only and Permanent flags as shown in the grid (many marked Permanent = X and Approved Audio Only = Yes)
Temporary-only (Approved = No but X temporary): Many procedure codes (eg, ophthalmology 92002/92004/92012/92014; numerous audiology, implant, device interrogation, rehab codes) are marked Approved for Audio Only = No but Temporarily allowed through 12/31/2023 = X

Billing Rule

Temporary allowance for audio-only services

Report audio-only (telephone) visits using the CPT codes explicitly listed as 'Approved for Audio Only Visit = Yes' when audio-only is approved during the temporary allowance period through 2023-12-31, and follow permanent approval status where indicated. Examples of listed codes are included in the policy coding grid.

Codes listed in provider_actions: 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 96170, 96171, 97802, 97803, 97804, 99199, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233

Billing Rule

Do not bill audio-only for codes marked No

Do not report audio-only visits for CPT codes where 'Approved for Audio Only Visit = No' unless the code is explicitly shown as temporarily allowed through 12/31/2023 with an 'X'. Follow the temporary allowance indicator in the coding grid.

Examples listed in provider_actions include: 97110, 97112, 97116, 97129, 97130, 97150, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97535, 97542, 97750, 97755, 97760, 97761, 97763, 98960, 98961, 98962, 99202, 99203, 99204, 99205, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226, 99234, 99235