CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Telemedicine / Telehealth and Telephone-only Services Coverage

Defines coverage, prerequisites, billing, documentation, reimbursement, limitations, exclusions, and permitted CPT/HCPCS codes for telemedicine/telehealth and telephone-only services for Neighborhood Health Plan of Rhode Island (Commercial, Medicaid excluding EFP, INTEGRITY).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine / Telehealth and Telephone-only Services Coverage

Policy CodePolicy N/A

Change TypeRevised / Added / Clarified (historical updates listed)

Effective Date

Next Review Date

Key ActionProvider must verify member eligibility, coverage and any authorization criteria; use Neighborhood's Prior Authorization Reference page and Clinical Medical Policies as applicable.

SourceLink

POLICY UPDATE CHANGES

05/01/22 Policy Update & Review: Combine Telemedicine and Temporary Telemedicine Policies and update language/coding to align with current CMS, EOHHS, QHIC guidance.

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

04/13/21 Formatting Updates No content changes.

04/13/20 Update: Add code Q3014.

03/03/20 Policy update_added Medicaid wording_Medicare coding_and format change.

100%Reimbursement of in-office allowable

3Codes approved for audio-only

1 per 14 daysNursing facility telehealth limit

1 per 3 days

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Hospital telehealth limit

~200Codes listed (approx)

ManyAudio-only denied entries

Coverage Summary & Scope

One-line summary: Neighborhood Health Plan of Rhode Island covers telemedicine/telehealth and telephone-only services with criteria for reimbursement for Commercial, Medicaid (excluding EFP), and INTEGRITY products. Scope: Defines coverage, prerequisites, billing, documentation, reimbursement, limitations, exclusions, and permitted CPT/HCPCS codes for telemedicine/telehealth and telephone-only services for Neighborhood Health Plan of Rhode Island (Commercial, Medicaid excluding EFP, INTEGRITY).

Policy-level summary

Reimbursement rate100% of in-office allowable

Nursing facility telehealth limit1 per 14 days

Hospital telehealth limit1 per 3 days

Audio-only approved codes (count)3 (CPT 99441-99443)

Total codes listed (approx.)~200 codes listed in tables

ScopeCovers telemedicine/telehealth and telephone-only for Commercial, Medicaid (excl. EFP), INTEGRITY

Coverage Criteria (Medical Necessity & Limits)

General Coverage Criteria

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

ALL of the following

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/requirements of the same service when rendered face-to-face.
Treatment must meet the same standard of care as, and be an appropriate substitute for, a face-to-face encounter.

CPT / HCPCS Codes and Audio-only Approval

Telemedicine / Telehealth Services (Table 1) - Approved for TelemedicineCPT|HCPCSCovered

90785	Interactive complexity (List separately in addition to the code for primary procedure). Approved for Audio Only Visit = Yes
90951	ESRD related services monthly, patients <2 years; Approved for Audio Only Visit = No
90952	ESRD related services monthly, patients <2 yrs; Approved for Audio Only Visit = No
90954	ESRD related services monthly, patients 2-11 yrs; Approved for Audio Only Visit = No
90955	ESRD related services monthly, patients 2-11 yrs; Approved for Audio Only Visit = No
90957	ESRD related services monthly, patients 12-19 yrs; Approved for Audio Only Visit = No
90958	ESRD related services monthly, patients 12-19 yrs; Approved for Audio Only Visit = No
90960	ESRD related services monthly, patients 20+ yrs; Approved for Audio Only Visit = No
90961	ESRD related services monthly, patients 20+ yrs; Approved for Audio Only Visit = No
90963	ESRD home dialysis per month, patients <2 yrs; Approved for Audio Only Visit = No

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Table 1: Telemedicine Services - Approved for Audio Only Visit = YesCPT|HCPCSCovered

99393	Periodic comprehensive preventive medicine reevaluation and management established patient; late childhood (age 5 through 11 years)
99394	Periodic comprehensive preventive medicine reevaluation and management established patient; adolescent (age 12 through 17 years)
99395	Periodic comprehensive preventive medicine reevaluation and management established patient; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation and management established patient; 40-64 years
99397	Periodic comprehensive preventive medicine reevaluation and management established patient; 65 years and older
99406	Smoking and tobacco use cessation counseling visit; intermediate, >3 minutes up to 10 minutes
99407	Smoking and tobacco use cessation counseling visit; intensive; >10 minutes
99408	Alcohol/substance abuse structured screening and brief intervention (SBI); 15-30 minutes
99409	Alcohol/substance abuse structured screening and brief intervention (SBI); >30 minutes
99497	Advance care planning; first 30 minutes, face-to-face with patient/family/surrogate

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Table 1: Telemedicine Services - Approved for Audio Only Visit = NoCPT|HCPCSNot Covered

99483	Assessment of and care planning for patient with cognitive impairment; requires independent historian; typically 50 minutes (Approved for Audio Only Visit = No)
99495	Transitional Care Management; communication within 2 business days of discharge, MDM of at least moderate complexity, face-to-face within 14 days (Approved for Audio Only Visit = No)
99496	Transitional Care Management; communication within 2 business days of discharge, MDM high complexity, face-to-face within 7 days (Approved for Audio Only Visit = No)
G0444	Annual depression screening; 15 minutes (Approved for Audio Only Visit = No)
G0508	Telehealth consultation, critical care, initial (~60 minutes) (Approved for Audio Only Visit = No)
G0513	Prolonged preventive service - note: G0513 listed as Approved = Yes elsewhere; G0508 and others explicitly No

Table 2: Temporary Telemedicine Services - Approved for Audio Only Visit = YesCPT|HCPCSCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group
92521	Evaluation of speech fluency (e.g., stuttering, cluttering)
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)
92523	Evaluation of speech sound production with evaluation of language comprehension and expression
92524	Behavioral and qualitative analysis of voice and resonance
96127	Brief emotional/behavioral assessment with scoring and documentation
96130	Psychological evaluation services; first hour
96131	Psychological testing; each additional hour (add-on)
96132	Neuropsychological evaluation services; first hour

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Table 2: Temporary Telemedicine Services - Approved for Audio Only Visit = NoCPT|HCPCSNot Covered

77427	Radiation treatment management; 5 treatments
90953	ESRD related services monthly for patients <2 years; includes 1 face-to-face visit per month
90956	ESRD related services monthly for patients 2-11 years; includes 1 face-to-face visit per month
90959	ESRD related services monthly for patients 12-19 years; includes 1 face-to-face visit per month
90962	ESRD related services monthly for patients >=20 years; includes 1 face-to-face visit per month
92002	Ophthalmological exam/evaluation with initiation of diagnostic and treatment program; intermediate, new patient
92004	Ophthalmological exam/evaluation; comprehensive, new patient
92012	Ophthalmological exam/evaluation; intermediate, established patient
92014	Ophthalmological exam/evaluation; comprehensive, established patient
92526	Treatment of swallowing dysfunction and/or oral function for feeding

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Telemedicine services (codes listed) - Approved for Audio Only Visit = NoCPT

97153	Adaptive behavior treatment by protocol, technician under direction, face-to-face with one patient; each 15 minutes.
97154	Group adaptive behavior treatment by protocol, technician under direction, face-to-face with two or more patients; each 15 minutes.
97155	Adaptive behavior treatment with protocol modification, physician/QHP, may include simultaneous direction of technician, face-to-face with one patient; each 15 minutes.
97156	Family adaptive behavior treatment guidance, physician/QHP, with or without patient present, face-to-face with guardian(s)/caregiver(s), each 15 minutes.
97157	Multiple-family group adaptive behavior treatment guidance, physician/QHP, without the patient present, face-to-face with multiple sets of guardians/caregivers, each 15 minutes.
97158	Group adaptive behavior treatment with protocol modification, physician/QHP, face-to-face with multiple patients, each 15 minutes.
97161	Physical therapy evaluation: low complexity; typically 20 minutes face-to-face.
97162	Physical therapy evaluation: moderate complexity; typically 30 minutes face-to-face.
97163	Physical therapy evaluation: high complexity; typically 45 minutes face-to-face.
97164	Re-evaluation of physical therapy established plan of care; typically 20 minutes face-to-face.

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Billing, Documentation, and Operational Requirements

Prior Authorization

Verify eligibility, coverage, and authorization

Provider must verify member eligibility, coverage, and any prior authorization requirements before rendering telemedicine/telephone services. Use Neighborhood's Prior Authorization Reference page and Clinical Medical Policies and contact Provider Services for questions.

Verify member eligibility and coverage
Check authorization criteria per Neighborhood's Prior Authorization Reference page
Consult Neighborhood Clinical Medical Policies as applicable
Contact Provider Services at 1-800-963-1001 for questions

Billing Rule

Place of Service and Modifiers for Telemedicine

Definitions

Background: For purposes of this policy, telemedicine and telehealth are used interchangeably. The policy outlines use of synchronous two-way real-time communications including audio/video, telephone-audio-only, electronic media and other telecommunications technologies to provide assessment, diagnosis, counseling, prescribing, and care management when the patient is at an originating site and the provider at a distant site. The policy lists covered modalities and specifies per-code approval for audio-only visits (codes explicitly marked Approved for Audio Only Visit = Yes or No).

Policy Update Changes

05/01/22revisedLatest

Policy Update & Review: Combine Telemedicine and Temporary Telemedicine Policies and update language/coding to align with current CMS, EOHHS, QHIC guidance.

01/20/22added

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

04/13/21clarified

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTelemedicine / Telehealth and Telephone-only Services Coverage

Policy CodePolicy N/A

Change TypeRevised / Added / Clarified (historical updates listed)

Effective Date

Next Review Date

Key ActionProvider must verify member eligibility, coverage and any authorization criteria; use Neighborhood's Prior Authorization Reference page and Clinical Medical Policies as applicable.

SourceLink

On This Page

Services must be within the scope of the provider's license.

Preventive Medicine via Telemedicine/Telephone

Neighborhood will reimburse preventive medicine visits via telemedicine/telephone only when ALL of the following are met:

ALL of the following

Adult Annual Preventive Exams, Pediatric Preventive Exams, and Medicare Annual Wellness Visit (AWV) may be provided via telemedicine/telephone.
For children ≤ 24 months and those over 24 months needing vaccination, AAP recommends continuation of in-person well child visits to ensure immunizations and screenings; telemedicine is not preferred.
For children >24 months (or <24 months unable to be seen in person), well child visits may be conducted via telemedicine/telephone consistent with the policy; remaining elements should be completed in person as soon as feasible.
The preventive visit may be split into two parts: (1) telemedicine/telephone portion for components appropriate to remote delivery (report E&M/AWV CPT on date of telemedicine/telephone service); (2) in-person portion for physical components (immunizations, vitals, screenings) billed separately on the in-person date using appropriate procedure codes but NOT the preventive E&M or AWV code again.
If additional sick issues are addressed during the second in-person visit, the provider may bill an appropriate sick E&M as a separately identifiable encounter with required documentation; commercial cost-sharing applies to the separately billed sick E&M.
The preventive E&M or AWV CPT/HCPCS code must be submitted only once on the initial telemedicine/telephone date of service.
Documentation in the medical record must reflect both encounters and reference the date of the initial telemedicine/telephone encounter.
For Medicaid and INTEGRITY, the second in-person visit should be billed directly to Rhode Island EOHHS for Medicaid FFS reimbursement per EOHHS guidance.

Coverage Limits for Subsequent Visits

Limits on frequency of telehealth visits for certain settings:

ALL of the following

Subsequent nursing facility care services: limited to 1 telehealth visit every 14 days.1 per 14 days
Subsequent hospital services: limited to 1 telehealth visit every 3 days.1 per 3 days

Exclusions (Not Covered)

Telemedicine/Telephone services are NOT covered for the following (any of):

ANY of the following

Services rendered via e-mail or facsimile (fax).
Services delivered via Facebook or social networking platforms (including Twitch, TikTok).
Telemedicine/Telephone services delivered on the same day as a face-to-face visit by the same provider for the same condition.
Reporting of test results.
Patient communication incidental to an office visit, including educational materials, follow-up calls / check-ins, scheduling.
Administrative services such as appointment reminders, ordering of diagnostic/lab tests, medication refills.
Telemedicine/Telephone services conducted by office staff (RNs, LPNs) rather than qualified providers.
Automated computer programs used to diagnose/treat ocular or refractive conditions.

Excluded Provider Types

It is not medically appropriate for the following provider types to provide Telephone and/or Telemedicine services (any of):

ANY of the following

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

Claims for telemedicine must be billed on a professional claim. Use place of service (POS) 10 when the patient is at home or POS 02 when patient is not at home, and report modifier 95. Telephone-only claims must be filed with POS 02 or POS 10.

Bill on a professional claim
Use POS 10 when patient is at home
Use POS 02 when patient is not at home
Append modifier 95 for telemedicine services
Telephone-only claims: file with POS 02 or POS 10

Billing Rule

COVID-19 Temporary Guidance Billing

For services temporarily allowed due to COVID-19, telemedicine claims require POS 10 (home) or POS 02 (not home) with modifier 95 and modifier CR. Telephone-only claims require POS 02 or POS 10 with modifier CR.

Telemedicine during COVID-19: POS 10 or POS 02 + modifier 95 + modifier CR
Telephone-only during COVID-19: POS 02 or POS 10 + modifier CR

Documentation Required

Medical record documentation

Neighborhood may request medical records for any billed service. Documentation must support the services billed, demonstrate medical necessity, follow CMS standards, and—for split preventive visits—each encounter note must reference the other and include dates.

Maintain records supporting billed services and medical necessity per CMS standards
For split preventive visits, progress notes for the in-person encounter must reference the initial telemedicine/telephone date
Ensure documentation ties both encounters in the medical record/EMR

Billing Rule

Billing for Preventive Visits Split Between Telemedicine and In-person

The preventive E&M or AWV CPT/HCPCS code must be submitted only once on the initial telemedicine/telephone date of service. The later in-person visit may only bill separate services provided that are distinct from the preventive E&M/AWV (do not bill the preventive E&M/AWV again). Documentation must reflect both encounters.

Bill the preventive E&M or AWV CPT/HCPCS code once on the initial telemedicine/telephone date
On the in-person date, bill only separate, distinct services (not the preventive E&M/AWV code)
Document both encounters and reference dates in the medical record

Billing Rule

Professional claim requirement

All claims for telemedicine services must be billed on a professional claim.

Billing Rule

Use audio-only telehealth indicator per code

Report the CPT/HCPCS codes with the audio-only modality only for codes explicitly marked Approved for Audio Only Visit = Yes in the policy tables; the tables list which codes are approved or not approved for audio-only visits.

Billing Rule

Audio-only approval

Codes explicitly marked Approved for Audio Only Visit = Yes (99441-99443) may be billed for audio-only visits.

99441
99442
99443

Billing Rule

Use code-specific service descriptions

When billing telemedicine services, use the listed CPT/HCPCS procedure codes and their corresponding service descriptions (time/complexity) as documented in the policy tables.

Billing Rule

Report audio-only approval status per code

Providers must bill using the listed CPT/HCPCS codes and be aware which codes the plan approves for audio-only visits. The policy explicitly lists codes approved for audio-only (including 99441-99443) and many codes that are not approved for audio-only.

Codes include: 99441, 99442, 99443, 99468, 99469, 99471, 99472, 99473, 99475, 99476, 99477, 99478, 99479, 99480, 0362T, 0373T, G0156, G0299, G0422, G0423, G0424, G9685, S5125, S9152, S9446, T1001, T1002, T1003, T1013, T1016, T1019, T1023, T1024, T1027
Be aware which of these are approved for audio-only per the tables

Documentation Required

Claims subject to audit and eligibility rules

All services billed are subject to audit and contingent on member eligibility, claims edits, documentation guidelines, authorization policies, provider contracts, and state/federal regulations.

Formatting Updates No content changes.

04/13/20revised

Update: Add code Q3014.

03/03/20revised

Policy update_added Medicaid wording_Medicare coding_and format change.