Neighborhood Health Plan RI Telemedicine Coverage Update

Coverage Criteria for Telemedicine / Telephone Services

Covered Telemedicine/Telephone Services

Telemedicine/Telephone Services are covered when ALL of the following criteria are met:

Telemedicine Coverage Criteria: Services must be medically necessary and clinically appropriate to be provided through telemedicine; the patient must be present at the time of service; the communication exchanged must be sufficient to meet the components and/or requirements of the same service when rendered face-to-face; treatment must meet the same standard of care and be an appropriate substitute for a face-to-face encounter; services must be within the provider's scope of license.

Coverage Limitations

Limits on subsequent telehealth visits:

Facility and Hospital Visit Limits: Subsequent facility care services are limited to 1 telehealth visit every 14 days; subsequent hospital services are limited to 1 telehealth visit every 3 days.

Telemedicine modality approval per code

Codes are approved for telemedicine modalities as indicated; approval is specified per code for Audio/Visual and Audio Only visits.

Approval per code: Each CPT code entry includes two boolean-style approvals: 'Approved for Audio / Visual Visit' and 'Approved for Audio Only Visit' indicating coverage for that modality.

Providers must select codes compatible with the delivered modality.

Telehealth modality-based coverage

Covered when billed with the listed CPT/HCPCS codes and delivered via an approved modality as indicated for each code.

Telehealth modality requirement: The service must be billed with the specific CPT/HCPCS code listed and delivered via the modality approved for that code (audio/visual and/or audio-only).

Modality approvals are explicit per code in the document.

Modality approval per code

Per-code approvals for telemedicine modality

modality_flags: Each listed code includes fields indicating whether approved for Audio/Visual Visit and Audio Only Visit and the Line of Business

Examples: S9485: AV=Yes, AudioOnly=Yes; T1001: AV=Yes, AudioOnly=No; T1013: AV=Yes, AudioOnly=Yes

Services delivered via non-interactive or insecure channels are excluded from telemedicine coverage. Specifically, Neighborhood does not cover services rendered via e-mail or facsimile (fax), nor services delivered on social networking platforms (examples listed include Facebook, Twitch, and TikTok).

Administrative or incidental communications are not billable telemedicine services. Examples listed as exclusions include appointment reminders, scheduling, ordering of tests, provision of educational materials, patient follow-up calls or check-ins, and medication refills. Telemedicine services conducted by office staff, RNs, or LPNs are also excluded, as are automated computer programs used to diagnose or treat ocular or refractive conditions.

The policy identifies specific CPT codes that are not approved for audio-only visits. Representative examples include ESRD/home dialysis codes such as 90966 and 90967, numerous audiology diagnostic codes (see chunk 22), and device interrogation/programming codes such as neurostimulator analysis (95970) which are all flagged Approved for Audio Only Visit = No.

These per-code restrictions mean that when a code is listed with Approved for Audio Only Visit = No, that procedure is only permitted via audio/visual (two-way synchronous video) or in-person delivery; billing the code as an audio-only encounter may be denied or not reimbursed.

Multiple therapy and assessment CPT codes are explicitly marked Approved for Audio Only Visit = No. Examples include physical/occupational therapy procedures and higher-complexity occupational evaluations such as 97110 (therapeutic exercises) and 97167 (occupational evaluation, high complexity), where the entry shows Approved for Audio Only Visit = No.

The effect of these restrictions is that therapy and many assessment services require either in-person or audio/visual (synchronous video) encounters to meet the policy’s modality requirements; audio-only delivery is not authorized for these listed codes.

Several high-acuity E/M, neonatal/pediatric critical care, and ancillary service codes are also listed as Approved for Audio Only Visit = No. Representative codes include hospital initial care 99223, observation/admission codes like 99234–99236 (see hospital/observation group), pediatric critical care codes 99471–99478, and multiple T‑codes such as T1019 which show Audio Only = No.

In practice, when a code appears in the grid with Approved for Audio Only Visit = No, that code is not permitted to be billed for telephone-audio-only encounters. Providers must select a modality consistent with the per-code approval (typically Audio/Visual = Yes) or provide the service in person.

The policy uses the per-code flag 'Approved for Audio Only Visit = No' as an explicit delivery-mode exclusion. Examples in the pediatric/critical care group (99471–99478) and hospital E/M group (99223) are listed with Audio/Visual = Yes and Audio Only = No, which operationally prohibits audio-only delivery for those services.

This modality-based exclusion approach means that coverage is determined by the code-level modality approvals: if a code’s entry disallows audio-only, the audio-only delivery mode is not an authorized billing modality for that code.

T1019 (Personal care services, per 15 minutes) is listed with modality approvals showing Approved for Audio / Visual Visit = Yes and Approved for Audio Only Visit = No. This is a clear example of a service that may be provided via synchronous two-way audio/visual telemedicine but is not authorized when delivered as an audio-only (telephone) encounter.

When a code like T1019 is billed, providers must ensure the claim reflects an approved modality; billing it as audio-only when the grid lists Audio Only = No creates risk for denial.

The policy lists provider types considered inappropriate to deliver telemedicine/telephone services. Examples include acupuncturists, ambulance services, ambulatory surgical facilities, and audiologists, among others such as chiropractors, DME suppliers, laboratories, pharmacies, radiologists, and skilled nursing facilities.

Services provided by these excluded provider types are identified as not medically appropriate or reasonable for telemedicine/telephone delivery under the policy, and therefore are not covered when submitted as telemedicine services.

Several chunks that list modality approvals and code grids do not include explicit statements declaring services "not medically necessary." The document instead applies coverage determinations through modality flags (e.g., Approved for Audio Only Visit = No) and by listing excluded provider types, rather than using a blanket "not medically necessary" phrase in those entries.

Providers should therefore interpret absence of the phrase as the policy relying on per-code modality approvals and provider-type exclusions to define coverage rather than explicit 'not medically necessary' wording in these sections.

Similarly, other sections of the coding grid and E/M listings omit explicit 'not medically necessary' language. Instead, the policy documents modality-based coverage decisions (Audio/Visual = Yes/No; Audio Only = Yes/No) and administrative exclusions to determine whether a service is payable when delivered via telemedicine.

As a result, the operational guidance is driven by the per-code modality approvals and exclusions rather than explicit NMN (not medically necessary) statements in these chunks.

CPT/HCPCS Codes and Modality Approvals

Telemedicine Applicable CPT CodesCPT

77427	Radiation treatment management; 5 treatments.
90785	Interactive complexity (List separately in addition to the code for primary procedure).
90791	Psychiatric diagnostic evaluation.
90792	Psychiatric diagnostic evaluation with medical services.
90832	Psychotherapy, 30 minutes with patient.
90833	Psychotherapy, 30 minutes with patient when performed with an evaluation and management service.
90834	Psychotherapy, 45 minutes with patient.
90836	Psychotherapy, 45 minutes with patient when performed with an evaluation and management service.
90837	Psychotherapy, 60 minutes with patient.
90838	Psychotherapy, 60 minutes with patient when performed with evaluation and management service.

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Telemedicine — selected codes (examples)CPT

90966	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
90967	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
90968	ESRD services for dialysis less than a full month for patients 2-11 years. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
90969	ESRD services for dialysis less than a full month for patients 12-19 years. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
90970	ESRD services for dialysis less than a full month for patients 20+ years. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92002	Ophthalmological services: intermediate new patient. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92004	Ophthalmological comprehensive new patient. Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Speech-language/audiology codesCPT

92012	Ophthalmological intermediate established patient. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92014	Ophthalmological comprehensive established patient. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
92508	Treatment of speech... group. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
92521	Evaluation of speech fluency. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
92523	Evaluation of speech sound production with language evaluation. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
92524	Behavioral and qualitative analysis of voice and resonance. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
92526	Treatment of swallowing dysfunction and/or oral function for feeding. Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Audiology diagnostic codesCPT

92550	Tympanometry and reflex threshold measurements. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92552	Pure tone audiometry (air only). Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92553	Pure tone audiometry (air and bone). Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92557	Comprehensive audiometry threshold evaluation and speech recognition. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92587	Distortion product evoked otoacoustic emissions; limited evaluation. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92588	Distortion product evoked otoacoustic emissions; comprehensive evaluation. Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Cochlear/AAC and swallowing codesCPT

92601	Diagnostic analysis of cochlear implant; patient <7; with programming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92602	Diagnostic analysis of cochlear implant; patient <7; reprogramming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92603	Diagnostic analysis of cochlear implant; age 7+; with programming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92604	Diagnostic analysis of cochlear implant; age 7+; reprogramming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92607	Evaluation for prescription for speech-generating AAC device, face-to-face; first hour. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92608	Evaluation for prescription for AAC device; each additional 30 minutes. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92609	Therapeutic services for use of speech-generating device, including programming and modification. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92610	Evaluation of oral and pharyngeal swallowing function. Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Cardiac/VAD/rehab codesCPT

92625	Assessment of tinnitus. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
92626	Evaluation of auditory function for implant candidacy or postop; first hour. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
93750	Interrogation of ventricular assist device (VAD), in person, with analysis and programming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
93797	Outpatient cardiac rehabilitation without continuous ECG monitoring (per session). Approved for Audio/Visual: Yes. Approved for Audio Only: No.
93798	Outpatient cardiac rehabilitation with continuous ECG monitoring (per session). Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Pulmonary/ventilation codesCPT

94002	Ventilation assist and management; initiation for hospital inpatient/observation initial day. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
94003	Ventilation assist and management; each subsequent day. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
94004	Ventilation assist and management; nursing. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
94005	Home ventilator management care plan oversight (patient not present) within a calendar month, 30 minutes or more. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
94625	Outpatient pulmonary rehabilitation without continuous oximetry monitoring (per session). Approved for Audio/Visual: Yes. Approved for Audio Only: No.
94626	Outpatient pulmonary rehabilitation with continuous oximetry monitoring (per session). Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Neurostimulator programming/analysis codesCPT

95970	Electronic analysis of implanted neurostimulator generator/transmitter without programming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
95971	Electronic analysis with simple spinal cord or peripheral nerve neurostimulator programming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
95972	Electronic analysis with complex cord or peripheral nerve neurostimulator programming. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
95983	Electronic analysis with brain neurostimulator programming, first 15 minutes face-to-face. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
95984	Electronic analysis with brain neurostimulator programming, each additional 15 minutes. Approved for Audio/Visual: Yes. Approved for Audio Only: No.

Behavioral, cognitive, and therapy codesCPT

96105	Assessment of aphasia per hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96110	Developmental screening with scoring and documentation. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96112	Developmental test administration, first hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96113	Each additional 30 minutes developmental test administration. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96116	Neurobehavioral status exam, first hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96121	Neurobehavioral status exam, each additional hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96125	Standardized cognitive performance per hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96127	Brief emotional/behavioral assessment per standardized instrument. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96130	Psychological testing evaluation services, first hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.
96131	Psychological evaluation each additional hour. Approved for Audio/Visual: Yes. Approved for Audio Only: Yes.

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Physical/occupational therapy codes (partial)CPT

97110	Therapeutic procedure; therapeutic exercises, per 15 minutes. Approved for Audio/Visual: Yes. Approved for Audio Only: No.
97112	Therapeutic procedure; neuromuscular reeducation. Approved for Audio/Visual: Yes.

Behavioral and assessment CPT codesCPTCovered

96139	Psychological or neuropsychological test administration and scoring by technician; two or more tests, any method; each additional 30 minutes
96156	Health behavior assessment; Or re-assessment
96158	Health behavior intervention; individual, face-to-face; initial 30 minutes
96159	Health behavior intervention; individual, face-to-face; each additional 15 minutes
96160	Administration of patient-focused health risk assessment instrument with scoring and documentation
96161	Administration of caregiver-focused health risk assessment instrument
96164	Health behavior intervention, group; initial 30 minutes

Therapy and behavior intervention codesCPTCovered

97110	Therapeutic procedure, therapeutic exercises; each 15 minutes
97112	Therapeutic procedure, neuromuscular reeducation; each 15 minutes
97116	Therapeutic procedure, gait training; each 15 minutes
97129	Therapeutic interventions focusing on cognitive function; initial 15 minutes
97130	Therapeutic interventions focusing on cognitive function; each additional 15 minutes
97150	Therapeutic procedures group (2 or more individuals)
97151	Behavior identification assessment by QHP, each 15 minutes
97152	Behavior identification-supporting assessment by technician, each unit

ABA/adaptive behavior codesCPTCovered

97153	Adaptive behavior treatment by protocol, technician-administered, each 15 minutes
97154	Group adaptive behavior treatment by protocol, each 15 minutes
97155	Adaptive behavior treatment with protocol modification by physician/QHP, each 15 minutes
97156	Family adaptive behavior treatment guidance, each 15 minutes
97157	Multiple-family group adaptive behavior treatment guidance, each 15 minutes
97158	Adaptive behavior treatment with protocol modification, group, each 15 minutes

Physical therapy evaluation/re-evaluation codesCPTCovered

97161	Physical therapy evaluation: low complexity, typically 20 minutes
97162	Physical therapy evaluation: moderate complexity, typically 30 minutes
97163	Physical therapy evaluation: high complexity, typically 45 minutes
97164	Re-evaluation of physical therapy established plan of care, typically 20 minutes

Occupational therapy and therapeutic activitiesCPTCovered

97165	Occupational therapy evaluation, low complexity, typically 30 minutes
97166	Occupational therapy evaluation, moderate complexity, typically 45 minutes
97167	Occupational therapy evaluation, high complexity, typically 60 minutes
97168	Re-evaluation of occupational therapy established plan of care, typically 30 minutes
97530	Therapeutic activities, each 15 minutes
97535	Self-care/home management training, each 15 minutes

Assistive/orthotic/prosthetic and performance testing codesCPTCovered

97542	Wheelchair management assessment, each 15 minutes
97750	Physical performance test or measurement with written report, each 15 minutes
97755	Assistive technology assessment, each 15 minutes
97760	Orthotic management and training, initial encounter, each 15 minutes
97761	Prosthetic training, initial encounter, each 15 minutes
97763	Orthotic/prosthetic management and/or training, subsequent encounter, each 15 minutes

Nutrition and patient education codesCPTCovered

97802	Medical nutrition therapy initial assessment and intervention, each 15 minutes
97803	Medical nutrition therapy re-assessment and intervention, each 15 minutes
97804	Medical nutrition group, each 30 minutes
98960	Education and training for patient self-management by qualified nonphysician, each 30 minutes (individual)
98961	Education and training for patient self-management, 2-4 patients, each 30 minutes
98962	Education and training for patient self-management, 5-8 patients, each 30 minutes
99199	Unlisted service; procedure or report (Doula services only)

Evaluation & Management (E/M) and inpatient codesCPTCovered

99202	Office/outpatient visit for new patient, expanded problem focused history/exam, straightforward MDM, typically 20 minutes
99203	Office/outpatient visit for new patient, detailed exam, low complexity MDM, typically 30 minutes
99204	Office/outpatient visit for new patient, comprehensive history/exam, moderate complexity MDM, typically 45 minutes
99205	Office/outpatient visit for new patient, comprehensive history/exam, high complexity MDM, typically 60 minutes
99211	Office/outpatient visit for established patient, may not require physician presence, typically 5 minutes
99212	Office/outpatient visit for established patient, problem focused history/exam, straightforward MDM, typically 10 minutes
99213	Office/outpatient visit for established patient, expanded problem focused history/exam, low complexity MDM, typically 15 minutes
99214	Office/outpatient visit for established patient, detailed history/exam, moderate complexity MDM, typically 25 minutes
99215	Office/outpatient visit for established patient, comprehensive history/exam, high complexity MDM, typically 40 minutes
99221	Initial hospital care, detailed/comprehensive history and exam, straightforward/low complexity MDM, typically 30 minutes

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Hospital/Observation E/M CodesCPTCovered

99223	Initial hospital care; comprehensive history/exam; high complexity MDM
99231	Subsequent hospital care; problem focused; straightforward/low complexity MDM
99232	Subsequent hospital care; expanded problem focused; moderate complexity MDM
99233	Subsequent hospital care; detailed history/exam; high complexity MDM
99234	Observation/inpatient care including admission/discharge same date; detailed/comprehensive; straightforward MDM
99235	Observation/inpatient care including admission/discharge same date; comprehensive; moderate MDM
99236	Observation/inpatient care including admission/discharge same date; comprehensive; high complexity MDM
99238	Hospital discharge management; 30 minutes or less
99239	Hospital discharge management; more than 30 minutes

Emergency Department E/M CodesCPTCovered

99281	Emergency department visit; problem focused; straightforward MDM
99282	Emergency department visit; expanded problem focused; low complexity MDM
99283	Emergency department visit; expanded problem focused; moderate complexity MDM
99284	Emergency department visit; detailed history/exam; moderate complexity MDM
99285	Emergency department visit; comprehensive history/exam; high complexity MDM

Critical Care and Nursing Facility E/M CodesCPTCovered

99291	Critical care, first 30-74 minutes
99292	Critical care, each additional 30 minutes
99304	Initial nursing facility care; detailed/comprehensive; straightforward/low complexity MDM
99305	Initial nursing facility care; comprehensive; moderate complexity MDM
99306	Initial nursing facility care; comprehensive; high complexity MDM
99307	Subsequent nursing facility care; problem focused; straightforward MDM
99308	Subsequent nursing facility care; expanded problem focused; low complexity MDM
99309	Subsequent nursing facility care; detailed; moderate complexity MDM
99310	Subsequent nursing facility care; comprehensive; high complexity MDM
99315	Nursing facility discharge management; 30 minutes or less

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Home Visit E/M CodesCPTCovered

99341	Home visit new patient; problem focused; straightforward MDM
99342	Home visit new patient; expanded problem focused; low complexity MDM
99344	Home visit new patient; comprehensive; moderate complexity MDM
99345	Home visit new patient; comprehensive; high complexity MDM
99347	Home visit established patient; problem focused; straightforward MDM
99348	Home visit established patient; expanded problem focused; low complexity MDM
99349	Home visit established patient; detailed; moderate complexity MDM
99350	Home visit established patient; comprehensive; moderate to high complexity MDM

Behavioral, Neonatal/Pediatric Critical Care, Remote Monitoring, Cognitive AssessmentCPTCovered

99406	Smoking/tobacco cessation counseling; intermediate >3 to 10 minutes
99407	Smoking/tobacco cessation counseling; intensive >10 minutes
99468	Initial inpatient neonatal critical care, neonate 28 days or younger
99469	Subsequent inpatient neonatal critical care
99471	Initial inpatient pediatric critical care, 29 days through 24 months
99472	Subsequent inpatient pediatric critical care
99473	Self-measured blood pressure device validated for clinical accuracy; patient education/training and device calibration
99475	Initial inpatient pediatric critical care, 2 through 5 years
99476	Subsequent inpatient pediatric critical care
99477	Initial hospital care of the neonate requiring intensive observation/interventions

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Telemedicine CPT Codes (selected)CPT

99471	Initial inpatient pediatric critical care, 29 days through 24 months — Approved for Audio/Visual Visit: Yes; Audio Only: No
99472	Subsequent inpatient pediatric critical care, 29 days through 24 months — Approved for Audio/Visual Visit: Yes; Audio Only: No
99473	Self-measured blood pressure device education/calibration — Approved for Audio/Visual Visit: Yes; Audio Only: No
99475	Initial inpatient pediatric critical care, 2 through 5 years — Approved for Audio/Visual Visit: Yes; Audio Only: No
99476	Subsequent inpatient pediatric critical care — Approved for Audio/Visual Visit: Yes; Audio Only: No
99477	Initial hospital care for neonate (28 days or younger) requiring intensive services — Approved for Audio/Visual Visit: Yes; Audio Only: No
99478	Subsequent intensive care for very low birth weight infant (<1500 g) — Approved for Audio/Visual Visit: Yes; Audio Only: No

Telemedicine CPT Codes (continued)CPT

99479	Subsequent intensive care recovering low birth weight infant (1500-2500 g) — Approved for Audio/Visual Visit: Yes; Audio Only: No
99480	Subsequent intensive care recovering infant (2501-5000 g) — Approved for Audio/Visual Visit: Yes; Audio Only: No
99483	Assessment and care planning for patient with cognitive impairment (dementia) — Approved for Audio/Visual Visit: Yes; Audio Only: No

Telemedicine CPT/HCPCS/Temp Codesmixed

99495	Transitional Care Management (moderate complexity) — Approved for Audio/Visual Visit: Yes; Audio Only: No; Line of Business: INTEGRITY
99496	Transitional Care Management (high complexity) — Approved for Audio/Visual Visit: Yes; Audio Only: No; Line of Business: INTEGRITY
99497	Advance care planning, first 30 minutes — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
99498	Advance care planning, additional 30 minutes — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
99502	Home visit for newborn care and assessment — Approved for Audio/Visual Visit: Yes; Audio Only: No
0362T	Behavior identification supporting assessment, 15 minutes technicians' time — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
0373T	Adaptive behavior treatment with protocol modification, per 15 minutes technicians' time — Approved for Audio/Visual Visit: Yes; Audio Only: Yes

Telemedicine G-codesHCPCS

G0011	Individual counseling for PrEP — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0108	Diabetes outpatient self-management training, individual per 30 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0109	Diabetes outpatient self-management training, group per 30 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0155	Services of clinical social worker in home health/hospice, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: No
G0156	Home health/hospice aide services, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: No
G0270	Medical nutrition reassessment and intervention, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0296	Counseling visit for LDCT lung cancer screening shared decision making — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0299	Direct skilled nursing services in home health/hospice, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: No
G0316	Prolonged hospital inpatient/observation E/M beyond primary service, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0317	Prolonged nursing facility E/M beyond primary service, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes

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Telehealth consultation and education G-codesHCPCS

G0396	Alcohol/substance misuse structured assessment & brief intervention 15-30 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0397	Alcohol/substance misuse assessment & intervention >30 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0406	Follow-up inpatient consultation, limited (~15 min) via telehealth — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0407	Follow-up inpatient consultation, intermediate (~25 min) via telehealth — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0408	Follow-up inpatient consultation, complex (~35 min) via telehealth — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0420	Face-to-face educational services for chronic kidney disease, individual per 1 hour — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0421	Face-to-face educational services for chronic kidney disease, group — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0422	Intensive cardiac rehabilitation with/without continuous ECG monitoring with exercise — Approved for Audio/Visual Visit: Yes; Audio Only: No
G0425	Telehealth consultation; emergency dept or initial inpatient ~30 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0426	Telehealth consultation; emergency dept or initial inpatient ~50 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes

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Preventive and FQHC G-codesHCPCS

G0438	Annual wellness visit, initial — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0439	Annual wellness visit, subsequent — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0442	Annual alcohol misuse screening, 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0443	Brief behavioral counseling for alcohol misuse, 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0444	Annual depression screening, 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0445	High intensity behavioral counseling to prevent STIs, semiannual, individual, 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0446	Intensive behavioral counseling for cardiovascular disease, 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0447	Behavioral counseling for obesity, 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0459	Inpatient telehealth pharmacologic management — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0466	FQHC visit, new patient — Approved for Audio/Visual Visit: Yes; Audio Only: Yes; Line of Business: INTEGRITY & Commercial

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Additional G-codes and add-onsHCPCS

G0513	Prolonged preventive service, first 30 minutes — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G0514	Prolonged preventive service, each additional 30 minutes — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G2211	Visit complexity inherent to E/M add-on — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G2212	Prolonged office/outpatient E/M beyond maximum time, each additional 15 minutes — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
G9685	Evaluation and management of acute change in condition in nursing facility (demonstration) — Approved for Audio/Visual Visit: Yes; Audio Only: No

Behavioral health, therapy, T-codes, S-codes, and other servicesmixed

H0004	Behavioral health counseling per 15 minutes — Line of Business: Medicaid; Approved for Audio/Visual Visit: Yes; Audio Only: Yes
H0019	Behavioral health long-term residential, per diem — Line of Business: Medicaid & INTEGRITY; Approved for Audio/Visual Visit: Yes; Audio Only: No
H0020	Alcohol/drug services; methadone administration — Approved for Audio/Visual Visit: Yes; Audio Only: Yes
H0031	Mental health assessment by nonphysician — Line of Business: Medicaid & INTEGRITY; Approved for Audio/Visual Visit: Yes; Audio Only: Yes
H0036	Community psychiatric supportive treatment, face-to-face, per 15 min — Approved for Audio/Visual Visit: Yes; Audio Only: No
H0037	Community psychiatric supportive treatment program, per diem — Line of Business: Medicaid & INTEGRITY; Approved for Audio/Visual Visit: Yes; Audio Only: No
H0038	Self-help/peer services per 15 min — Line of Business: Medicaid & INTEGRITY; Approved for Audio/Visual Visit: Yes; Audio Only: Yes
H0040	Assertive community treatment program, per diem — Line of Business: Medicaid & INTEGRITY; Approved for Audio/Visual Visit: Yes; Audio Only: No
H0046	Early intervention supervision — Approved for Audio/Visual Visit: Yes; Audio Only: No
H2000	Comprehensive multidisciplinary evaluation — Approved for Audio/Visual Visit: Yes; Audio Only: No

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Telemedicine Services (codes and descriptions)HCPCS

S9485	Private /independent nursing service(s), licensed, up to 15 minutes duty
T1001	Nursing assessment/ evaluation
T1002	RN services, up to 15 minutes
T1003	LPN/LVN services, up to 15 minutes
T1013	Sign language Or oral interpretive services, per 15 minutes
T1016	Case management, each 15 minutes
T1017	Targeted case management; each 15 minutes

Telemedicine Services (additional codes)HCPCS

T1019	Personal care services, per 15 minutes
T1023	Screening to determine appropriateness for participation in specified program per encounter
T1024	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter
T1027	Family training and counseling for child development, per 15 minutes
T1031	Nursing care, in the home, by licensed practical nurse, per diem
T2017	Habilitation, residential, waiver; 15 minutes
T2021	Habilitation, waiver; per 15 minutes Day

Audio-only vs Audio/Visual allowance flags

Examples of codes approved only for Audio/Visual

Provider Responsibilities, Billing and Documentation

Prior Authorization

Verify Authorization Requirements

It is the provider's responsibility to verify member eligibility, coverage and whether prior authorization is required before rendering services. Refer to Neighborhood's Prior Authorization Reference and applicable Clinical Medical Policies for details.

Verify member eligibility and coverage prior to service.
Confirm if prior authorization (PA) is required via Neighborhood's PA Reference.
Contact Provider Services at 1-800-963-1001 with questions.

Note

Modality approvals noted (PA not specified in excerpt)

This policy lists CPT/HCPCS codes with modality approvals (Audio/Visual and Audio-Only). Some codes are approved for audio-visual visits only while others allow audio-only. The excerpt does not consistently state prior authorization requirements for those services — providers must check authorization rules separately.

Modality approvals are shown per code (Approved for Audio/Visual Visit = Yes/No; Approved for Audio Only Visit = Yes/No).

Background and Scope

For this policy, Telemedicine/Telehealth refers to the use of real-time, two-way synchronous audio and video communications as well as telephone (audio-only) communications and other telecommunications technology to provide healthcare services — including assessment, diagnosis, counseling, prescribing, and care management when patient and provider are at different locations.

The policy treats telemedicine and telehealth interchangeably and requires that services delivered via telemedicine meet the same standard of care as face-to-face visits; modality-specific approvals in the code grid determine whether a given CPT/HCPCS code is permissible via Audio/Visual and/or Audio Only delivery.

Definitions and Code Timeframes

Telemedicine / Telehealth definition

Telemedicine / Telehealth (definition)Use of real time, two-way synchronous audio, video, telephone-audio-only communications or electronic media or other telecommunications technology to provide healthcare delivery including assessment, diagnosis, counseling, prescribing treatment, and care management.

Terminology noteThe terms telemedicine and telehealth are used interchangeably in this policy.

Modality examplesIncludes secure video conferencing, telephone-audio-only communications, online adaptive interviews, and remote patient monitoring devices.

97161-97163 PT evaluation complexity definitions

97161 — Low complexity PT evaluationComponents: history with no impacting personal factors/comorbidities; exam addressing 1–2 elements; stable clinical presentation; low complexity clinical decision making. Typically 20 minutes face-to-face.

OpenPayer

Telemedicine / Telehealth Services Coverage Criteria

Coverage Criteria for Telemedicine / Telephone Services

CPT/HCPCS Codes and Modality Approvals

Provider Responsibilities, Billing and Documentation

Background and Scope

Definitions and Code Timeframes