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MP 3.01.98 Psychiatric Telemedicine Program

Medical Policy    
Mental Health
Original Policy Date
Last Review Status/Date
Created local policy/5:2012
  Return to Medical Policy Index


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


The Mental Health Telemedicine is available for limited psychiatric services provided via telemedicine technology if the telecommunications permit real-time communication between the Blue Cross of Idaho psychiatric provider and the member. Reimbursement is not available for a telephone conversation, electronic mail message (email), or facsimile transmission (fax) between a psychiatrist and a member. Service will not be reimbursed when provided via a videophone or webcam. This psychiatric telemedicine is available only to the following provider type:

  • Psychiatrist 



  • Telemedicine - the exchange of medical information between sites via electronic communication, and limited to live, interactive real-time transmissions.  The terms Telemedicine and Telehealth are used interchangeably; however Telehealth is intended to offer broader services like video conferences and transmission of images.
  • Originating site - the site from which the member originates
  • Distant site -  the site where the psychiatrist is located

Policy Guidelines 

The following are the CPT codes associated with these services and billing requirements for reimbursement.


CPT code

CPT Description


Psychiatric Diagnostic Evaluation


Psychiatric diagnostic evaluation (no medical services)

GT modifier required
(requires prior authorization after 10 visits)

Medication Management


Appropriate E/M code (99xxx series)

GT modifier required

Medication Management with Psychotherapy

99xxx, and 90833

Appropriate E/M code (99xxx series), and 90833, 30-minute psychotherapy, add-on code

GT modifier required
(requires prior authorization after 10 visits)

Originating Site Transmission


Telehealth Originating Site Transmission

1 Unit = 1 Originating Site Transmission. No modifier required

Facility Transmission Code

Revenue code 780

Facility transmission code

Requires corresponding HCPC code Q3014

Blue Cross of Idaho Telemedicine Technology Requirements



For Blue Cross of Idaho reimbursement to occur, interactive audio and video telecommunications must be used permitting real-time communication between the originating site where the member is located and the distant site where the psychiatrist is located. This communication must have sufficient quality to assure the accuracy of the assessment, diagnosis, and visible evaluation of symptoms and potential medication side effects. As a condition of reimbursement, the member must be present and participating in the telemedicine visit. All interactive video telecommunication must comply with HIPAA patient privacy regulations at the distant site where the psychiatrist is located, the originating site where the member is located, and in the transmission process. If distortions in the transmission make adequate diagnosis and assessment improbable and a presenter at the originating site where the member is located is unavailable to assist, the visit must be halted and rescheduled. It is not appropriate to bill for portions of the evaluation unless the exam was actually performed by the billing provider. 

Required Standards for the Practice of Telemedicine

In order to receive reimbursement from Blue Cross of Idaho for services delivered through telehealth technology the following standards must be observed:

  • The telemedicine originating and distant sites are responsible to ensure that policies and procedures that address all aspects of administrative, clinical, and technical components regarding the provision of telemedicine are in place prior to providing telemedicine services.
  • The telemedicine originating and distant sites are responsible to ensure that appropriate staff is available to meet the patient and provider needs before, during and after the telemedicine encounter.
  • If an operator who is not an employee of the involved agency is needed to operate the teleconferencing equipment or is present during the session, they should sign a confidentiality agreement. This statement should be filed with other documentation of the teleconference, such as a post-conference evaluation form.
  • The provider is required to maintain standards of care within their scope of practice.
  • The provider needs to be able to provide documentation to support that they have completed education; training/orientation and ongoing continuing education/professional development to ensure they possess the competencies to perform telemedicine.
  • Providers are required to maintain current Idaho licensure.
  • The same procedure codes and rates apply as for services delivered in person.
  • The same prior authorization protocols apply whether the services are delivered in person or through telemedicine.
  • Member consent and other releases should be developed and maintained in the member’s medical record.
  • The services must be medically necessary and follow generally accepted standards of care.
  • Before the initial visit using telemedicine, the provider conducting the telemedicine is responsible to ensure that written information is provided to the member in a form and manner which the member can understand informing them about telemedicine-what to expect and what will occur.
  • If the member indicates at any time they want to stop using telemedicine, the service should cease immediately and an alternative appointment scheduled.
  • Quality assurance/improvement activities relative to telemedicine delivered services need to be identified, documented and monitored.
  • Providers need to develop and document evaluation processes and member outcomes related to the telemedicine program, visits, provider access, and member satisfaction.
  • Providers are required to develop and maintain documentation as required by PAP 107 Medical Records Standards. The notes should be the same as those completed during an in-person visit, with the exception that the mode of communication (i.e. teleconference) should be noted. 

As part of the contracting process to be eligible to provide telemedicine services the originating and distant sites will be required to attest to compliance with these standards by signing a Telemedicine Attestation which will be affixed to the Facility or Provider Contract. 

Policy History


Date Action Reason
05/01/12 Add to Mental Health section New policy- local policy
2/04/13 coding update only new HCPCS/CPT codes added

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