Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 1

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

77427 Radiation treatment management, 5 treatments Extended

90791 Psychiatric diagnostic evaluation Existing

90792 Psychiatric diagnostic evaluation with medical services Existing

90832 Psychotherapy, 30 minutes with patient Existing

90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (add-on code) Existing

90834 Psychotherapy, 45 minutes with patient Existing

90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (add-on code) Existing

90837 Psychotherapy, 60 minutes with patient Existing

90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (add-on code) Existing

90839 Psychotherapy for crisis; first 60 minutes Existing

90845 Psychoanalysis Existing

90846 Family psychotherapy (without the patient present), 50 minutes Existing

90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes Existing

90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (add-on code) Existing

90951 Dialysis services (4 or more physician visits per month), patient younger than 2 years of age Existing

90952 Dialysis services (2-3 physician visits per month), patient younger than 2 years of age Existing

90954 Dialysis services (4 or more physician visits per month), patient 2-11 years of age Existing

90955 Dialysis services (2-3 physician visits per month), patient 2-11 years of age Existing

90957 Dialysis services (4 or more physician visits per month), patient 12-19 years of age Existing

90958 Dialysis services (2-3 physician visits per month), patient 12-19 years of age Existing

90960 Dialysis services (4 or more physician visits per month), patient 20 years of age and older Existing

90961 Dialysis services (2-3 physician visits per month), patient 20 years of age and older Existing

90963 Home dialysis services per month, patient younger than 2 years of age Existing

90964 Home dialysis services per month, patient 2-11 years of age Existing

90965 Home dialysis services per month, patient 12-19 years of age Existing

90966 Home dialysis services per month, patient 20 years of age or older Existing



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 2

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

90967 Dialysis services, per day (less than full month service), patient younger than 2 years of age Existing

90968 Dialysis services, per day (less than full month service), patient 2-11 years of age Existing

90969 Dialysis services, per day (less than full month service), patient 12-19 years of age Existing

90970 Dialysis services, per day (less than full month service), patient 20 years of age or older Existing

92507 Treatment Of Speech, Language, Voice, Communication, And/or Auditory Processing Disorder Extended

92520 Laryngeal function studies (ie, aerodynamic testing and acoustic testing) Extended

92521 Evaluation of speech fluency (eg, stuttering, cluttering) Extended

92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); Extended

92523 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Extended

92524 Behavioral and qualitative analysis of voice and resonance Extended

92526 Treatment of swallowing dysfunction and/or oral function for feeding Extended

92592 Hearing aid check; monaural Extended

92593 Hearing aid check; binaural Extended

92610 Evaluation of oral and pharyngeal swallowing function Extended

92625 Assessment of tinnitus (includes pitch, loudness matching, and masking) Extended

96105 Assessment of expressive and receptive speech with interpretation and report per hour Extended

96116 Neurobehavioral status examination by qualified health care professional with interpretation and report, first 60 minutes Existing

96130 Psychological testing evaluation by qualified health care professional, first 60 minutes Extended

96131 Psychological testing evaluation by qualified health care professional, additional 60 minutes Extended

96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, first 60 minutes Extended

96133 Neuropsychological testing evaluation services by physician or other qualified health care professional, additional 60 minutes Extended

96136 Psychological or neuropsychological testing; first 30 minutes Extended

96137 Psychological or neuropsychological testing; additional 30 minutes Extended

96138 Psychological or neuropsychological test administration; first 30 minutes Extended

96139 Psychological or neuropsychological test administration; additional 30 minutes Extended

96160 Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Existing



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 3

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument Existing

97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Extended

97112 Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes Extended

97116 Walking training to 1 or more areas, each 15 minutes Extended

97129 Therapeutic interventions that focus on cognitive function and compensatory strategies to manage the performance of an activity, direct (one-on-one) patient contact; initial 15 minutes Extended

97130
Therapeutic interventions that focus on cognitive function and compensatory strategies to manage
the performance of an activity, direct (one-on-one) patient contact; each additional 15 minutes
(add-on code)

Extended

97151
Behavior identification assessment, administered by a physician or other qualified health care
professional, each 15 minutes of the physician's or other qualified health care professional's time
face-to-face with patient and/or guardian(s)/caregiver(s)

Extended

97152
Behavior identification-supporting assessment, administered by one technician under the direction
of a physician or other qualified health care professional, face-to-face with the patient, each 15
minutes

Extended

97153
Adaptive behavior treatment by protocol, administered by technician under the direction of a
physician or other qualified health care professional, face-to-face with one patient, each 15
minutes

Extended

97154
Group adaptive behavior treatment by protocol, administered by technician under the direction of
a physician or other qualified health care professional, face-to-face with two or more patients, each
15 minutes

Extended

97155
Adaptive behavior treatment with protocol modification, administered by physician or other
qualified health care professional, which may include simultaneous direction of technician, face-to-
face with one patient, each 15 minutes

Extended

97156
Family adaptive behavior treatment guidance, administered by physician or other qualified health
care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s),
each 15 minutes

Extended

97157
Multiple-family group adaptive behavior treatment guidance, administered by physician or other
qualified health care professional (without the patient present), face-to-face with multiple sets of
guardians/caregivers, each 15 minutes

Extended

97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes Extended

97161 Evaluation of physical therapy, typically 20 minutes Extended

97162 Evaluation of physical therapy, typically 30 minutes Extended

97163 Evaluation of physical therapy, typically 45 minutes Extended

97164 Re-evaluation of physical therapy, typically 20 minutes Extended

97165 Evaluation of occupational therapy, typically 30 minutes Extended

97166 Evaluation of occupational therapy, typically 45 minutes Extended

97167 Evaluation of occupational therapy established plan of care, typically 60 minutes Extended

97168 Re-evaluation of occupational therapy established plan of care, typically 30 minutes Extended



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 4

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Extended

97535
Self-care/home management training and compensatory training, meal preparation, safety
procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-
on-one contact, each 15 minutes

Extended

97750 Physical performance test or measurement with report, each 15 minutes Extended

97755 Assistive technology assessment to enhance functional performance, each 15 minutes Extended

97760 Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes Extended

97761 Training in use of prosthesis for arms and/or legs, per 15 minutes Extended

97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Existing

97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Existing

97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes Existing

98960
Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient

Extended

98961
Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 2-4 patients

Extended

98962
Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 5-8 patients

Extended

98966 Telephone assessment and management service, 5-10 minutes of medical discussion Extended

98967 Telephone assessment and management service, 11-20 minutes of medical discussion Extended

98968 Telephone assessment and management service, 21-30 minutes of medical discussion Extended

98970 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes Extended

98971 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes Extended

98972 Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes Extended

99201 New patient office or other outpatient visit, typically 10 minutes Existing

99202 New patient office or other outpatient visit, typically 20 minutes Existing

99203 New patient office or other outpatient visit, typically 30 minutes Existing

99204 New patient office or other outpatient visit, typically 45 minutes Existing

99205 New patient office or other outpatient visit, typically 60 minutes Existing

99211 Established patient office or other outpatient visit, typically 5 minutes Existing



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 5

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

99212 Established patient office or other outpatient visit, typically 10 minutes Existing

99213 Established patient office or other outpatient visit, typically 15 minutes Existing

99214 Established patient office or other outpatient, visit typically 25 minutes Existing

99215 Established patient office or other outpatient, visit typically 40 minutes Existing

99217 Hospital observation care on day of discharge Extended

99218 Hospital observation care, typically 30 minutes Extended

99219 Hospital observation care, typically 50 minutes Extended

99220 Hospital observation care, typically 70 minutes Extended

99221 Initial hospital inpatient care, typically 30 minutes per day Extended

99222 Initial hospital inpatient care, typically 50 minutes per day Extended

99223 Initial hospital inpatient care, typically 70 minutes per day Extended

99224 Subsequent observation care, typically 15 minutes per day Extended

99225 Subsequent observation care, typically 25 minutes per day Extended

99226 Subsequent observation care, typically 35 minutes per day Extended

99231 Subsequent hospital inpatient care, typically 15 minutes per day Existing

99232 Subsequent hospital inpatient care, typically 25 minutes per day Existing

99233 Subsequent hospital inpatient care, typically 35 minutes per day Existing

99234 Hospital observation or inpatient care low severity, 40 minutes per day Extended

99235 Hospital observation or inpatient care moderate severity, 50 minutes per day' Extended

99236 Hospital observation or inpatient care high severity, 55 minutes per day Extended

99238 Hospital discharge day management, 30 minutes or less Extended

99239 Hospital discharge day management, more than 30 minutes Extended

99241 Patient office consultation, typically 15 minutes Existing

99242 Patient office consultation, typically 30 minutes Existing

99243 Patient office consultation, typically 40 minutes Existing

99244 Patient office consultation, typically 60 minutes Existing



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 6

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

99245 Patient office consultation, typically 80 minutes Existing

99251 Inpatient hospital consultation, typically 20 minutes Existing

99252 Inpatient hospital consultation, typically 40 minutes Existing

99253 Inpatient hospital consultation, typically 55 minutes Existing

99254 Inpatient hospital consultation, typically 80 minutes Existing

99255 Inpatient hospital consultation, typically 110 minutes Existing

99281 Emergency department visit, self limited or minor problem Extended

99282 Emergency department visit, low to moderately severe problem Extended

99283 Emergency department visit, moderately severe problem Extended

99284 Emergency department visit, problem of high severity Extended

99285 Emergency department visit, problem with significant threat to life or function Extended

99291 Critical care delivery critically ill or injured patient, first 30-74 minutes Extended

99292 Critical care delivery critically ill or injured patient Extended

99304 Initial nursing facility visit, typically 25 minutes per day Extended

99305 Initial nursing facility visit, typically 35 minutes per day Extended

99306 Initial nursing facility visit, typically 45 minutes per day Extended

99307 Subsequent nursing facility visit, typically 10 minutes per day Existing

99308 Subsequent nursing facility visit, typically 15 minutes per day Existing

99309 Subsequent nursing facility visit, typically 25 minutes per day Existing

99310 Subsequent nursing facility visit, typically 35 minutes per day Existing

99315 Nursing facility discharge day management, 30 minutes or less Extended

99316 Nursing facility discharge management, more than 30 minutes Extended

99327 New patient assisted living visit, typically 60 minutes Extended

99328 New patient assisted living visit, typically 75 minutes Extended

99334 Established patient assisted living visit, typically 15 minutes Extended

99335 Established patient assisted living visit, typically 25 minutes Extended



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 7

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

99336 Established patient assisted living visit, typically 40 minutes Extended

99337 Established patient assisted living visit, typically 60 minutes Extended

99341 New patient home visit, typically 20 minutes Extended

99342 New patient home visit, typically 30 minutes Extended

99343 New patient home visit, typically 45 minutes Extended

99344 New patient home visit, typically 60 minutes Extended

99345 New patient home visit, typically 75 minutes Extended

99347 Established patient home visit, typically 15 minutes Extended

99348 Established patient home visit, typically 25 minutes Extended

99349 Established patient home visit, typically 40 minutes Extended

99350 Established patient home visit, typically 60 minutes Extended

99354 Prolonged office or other outpatient service first hour Existing

99355 Prolonged office or other outpatient service each 30 minutes beyond first hour Existing

99356 Prolonged inpatient or observation hospital service first hour Existing

99357 Prolonged inpatient or observation hospital service each 30 minutes beyond first hour Existing

99381 Initial new patient preventive medicine evaluation infant younger than 1 year Extended

99382 Initial new patient preventive medicine evaluation, age 1 through 4 years Extended

99383 Initial new patient preventive medicine evaluation, age 5 through 11 years Extended

99384 Initial new patient preventive medicine evaluation, age 12 through 17 years Extended

99385 Initial new patient preventive medicine evaluation age 18-39 years Extended

99386 Initial new patient preventive medicine evaluation age 40-64 years Extended

99387 Initial new patient preventive medicine evaluation, age 65 years and older Extended

99391 Established patient periodic preventive medicine examination infant younger than 1 year Extended

99392 Established patient periodic preventive medicine examination, age 1 through 4 years Extended

99393 Established patient periodic preventive medicine examination, age 5 through 11 years Extended

99394 Established patient periodic preventive medicine examination, age 12 through 17 years Extended



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 8

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

99395 Established patient periodic preventive medicine examination age 18-39 years Extended

99396 Established patient periodic preventive medicine examination age 40-64 years Extended

99397 Established patient periodic preventive medicine examination, age 65 years and older Extended

99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Existing

99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Existing

99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Existing

99409 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Existing

99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes Extended

99422 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes Extended

99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes Extended

99441 Physician telephone patient service, 5-10 minutes of medical discussion Extended

99442 Physician telephone patient service, 11-20 minutes of medical discussion Extended

99443 Physician telephone patient service, 21-30 minutes of medical discussion Extended

99468 Initial inpatient hospital critical care of newborn, 28 days of age or younger, per day Extended

99469 Subsequent inpatient hospital critical care of newborn, 28 days of age or younger, per day Extended

99471 Initial inpatient hospital critical care of infant or young child, 29 days through 24 months of age, per day Extended

99472 Subsequent inpatient hospital critical care of infant or young child, 29 days through 24 months of age, per day Extended

99475 Initial inpatient hospital critical care of infant or young child, 2 through 5 years of age, per day Extended

99476 Subsequent inpatient hospital critical care of infant or young child, 2 through 5 years of age, per day Extended

99477 Initial intensive care of newborn, 28 days of age or younger, per day Extended

99478 Subsequent intensive care of recovering low birth weight infant, per day Extended

99479 Subsequent intensive care of recovering low birth weight infant, per day Extended

99480 Subsequent intensive care of recovering low birth weight infant, per day Extended

99483 Assessment of and care planning for patient with impaired thought processing, typically 50 minutes Extended

99495 Transitional care management services, moderately complexity, requiring face-to-face visits within 14 days of discharge Existing

99496 Transitional care management services, highly complexity, requiring face-to-face visits within 7 days of discharge Existing



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 9

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

99497 Advance care planning by the physician or other qualified health care professional Existing

99498 Advance care planning by the physician or other qualified health care professional (add-on code) Existing

0362T Behavior identification supporting assessment for patient exhibiting destructive behavior, each 15 minutes of technicians' face-to-face time Extended

0373T Adaptive behavior treatment with protocol modification for patient exhibiting destructive behavior, each 15 minutes of technicians' face-to-face time Extended

90887 HF Explanation of psychiatric, medical examinations, procedures, and data to other than patient; substance abuse program Extended

90887 UC Explanation of psychiatric, medical examinations, procedures, and data to other than patient; Medicaid level of care 12 Extended

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes Existing

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes Existing

G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen, each 15 minutes Existing

G0296 Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making) Existing

G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (eg, AUDIT, DAST). and brief intervention 15 to 30 minutes Existing

G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment (eg, AUDIT, DAST). and intervention, greater than 30 minutes Existing

G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth Existing

G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth Existing

G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth Existing

G0420 Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour Existing

G0421 Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour Existing

G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth Existing

G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth Existing

G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth Existing

G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Extended

G0445 High intensity behavioral counseling, 30 minutes Existing

G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Existing

G0506 Comprehensive assessment of and care planning for patients requiring chronic care management services (add-on code) Existing

G0508 Telehealth consultation, critical care, initial , physicians typically spend 60 minutes communicating with the patient and providers via telehealth Existing

G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth Existing



Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on April 8, 2020

Please note: Additional benefits may be available as codes are subject
to change frequently based on evolving guidance from Federal and State agencies.

CPT? is a registered mark of the American Medical Association. 10

An Independent Licensee of the
Blue Cross and Blue Shield Association.

Code Service Description
Telemedicine

Reimbursement Policy
Position for HNJH

G0513
Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the
office or other outpatient setting requiring direct patient contact beyond the usual service; first 30
minutes (add-on code)

Existing

G0514
Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the
office or other outpatient setting requiring direct patient contact beyond the usual service; each
additional 30 minutes (add-on code)

Existing

G2010 Remote evaluation of recorded video and/or images submitted by an established patient Extended

G2012 Brief communication technology-based service, e.g., virtual check-in, 5-10 minutes of medical discussion Extended

G2061 Qualified nonphysician health care professional online assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes Extended

G2062 Qualified nonphysician health care professional online assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes Extended

G2063 Qualified nonphysician qualified health care professional assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes Extended

H0001 Alcohol and drug assessment Extended

H0002 Behavioral health screening to determine eligibility for admission to treatment program Extended

H0004 Behavioral health counseling and therapy, per 15 minutes Extended

H0006 HF Navigator services (Maintenance) Extended

H0006 HF HG Navigator psychosocial assessment & patient-specific Treatment plan development (Initiation) Extended

H0006 HF SU Navigator services (Stabilization) Extended

H0014 Alcohol and/or drug services; ambulatory detoxification Extended

H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) Extended

H0020 HF Methadone (per diem) Extended

H0020 HF 26 Methadone (bundled) Extended

H0032 Mental Health service plan development by a non-physician, per 15 minutes Extended

H0033 HF non-Methadone (per diem) Extended

H0033 HF 26 non-Methadone (bundled) Extended

H0035 Mental health partial hospitalization, treatment, less than 24 hours Extended

H0047 Alcohol and/or other drug abuse services, not otherwise specified Extended

H2036 HF Alcohol and/or other drug treatment program, per diem; substance abuse program Extended





Page | 1

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

77427 Radiation treatment management, 5 treatments Extended during PHE

90791 Psychiatric diagnostic evaluation In Existing Policy

90792 Psychiatric diagnostic evaluation with medical services In Existing Policy

90832 Psychotherapy, 30 minutes with patient In Existing Policy

90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management
service (add-on code)

In Existing Policy

90834 Psychotherapy, 45 minutes with patient In Existing Policy

90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (add-on code) In Existing Policy

90837 Psychotherapy, 60 minutes with patient In Existing Policy

90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management
service (add-on code)

In Existing Policy

90839 Psychotherapy for crisis; first 60 minutes In Existing Policy

90840 Psychotherapy for crisis; each additional 30 minutes (add-on code) Extended during PHE

90846 Family psychotherapy (without the patient present), 50 minutes In Existing Policy

90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes In Existing Policy

90849 Multiple-family group psychotherapy Extended during PHE

90853 Group psychotherapy (other than of a multiple -family group) Extended during PHE

90863 Pharmacologic management, including prescription and review of medication, when
performed with psychotherapy services (add-on code)

In Existing Policy

90875 Psychophysiological therapy Extended during PHE

90951 Dialysis services (4 or more physician visits per month), patient younger than 2 years of age In Existing Policy

90952 Dialysis services (2-3 physician visits per month), patient younger than 2 years of age In Existing Policy

90953 Dialysis services (1 physician visit per month), patient younger than 2 years of age Extended during PHE

90954 Dialysis services (4 or more physician visits per month), patient 2-11 years of age In Existing Policy

90955 Dialysis services (2-3 physician visits per month), patient 2-11 years of age In Existing Policy

90956 Dialysis services (1 physician visit per month), patient 2-11 years of age Extended during PHE

90957 Dialysis services (4 or more physician visits per month), patient 12 -19 years of age In Existing Policy

90958 Dialysis services (2-3 physician visits per month), patient 12-19 years of age In Existing Policy

90959 Dialysis services (1 physician visit per month), patient 12-19 years of age Extended during PHE

90960 Dialysis services (4 or more physician visits per month), patient 20 years of age and older In Existing Policy

90961 Dialysis services (2-3 physician visits per month), patient 20 years of age and older In Existing Policy

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 2

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

90962 Dialysis services (1 physician visit per month), patient 20 years of age and older Extended during PHE

90963 Home dialysis services per month, patient younger than 2 years of age In Existing Policy

90964 Home dialysis services per month, patient 2-11 years of age In Existing Policy

90965 Home dialysis services per month, patient 12-19 years of age In Existing Policy

90966 Home dialysis services per month, patient 20 years of age or older In Existing Policy

90967 Dialysis services, per day (less than full month service), patient younger than 2 years of age In Existing Policy

90968 Dialysis services, per day (less than full month service), patient 2 -11 years of age In Existing Policy

90969 Dialysis services, per day (less than full month service), patient 12 -19 years of age In Existing Policy

90970 Dialysis services, per day (less than full month service), patient 20 years of age or older In Existing Policy

92002 Eye and medical examination for diagnosis and treatment, new patient Extended during PHE

92004 Eye and medical examination for diagnosis and treatment, new patient, 1 or more visits Extended during PHE

92012 Eye and medical examination for diagnosis and treatment, established patient Extended during PHE

92014 Eye and medical examination for diagnosis and treatment, established patient, 1 or more visits Extended during PHE

92227 Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes)
with analysis and report under physician supervision, unilateral or bilateral

Extended during PHE

92228 Remote imaging for monitoring and management of active retinal disease (eg, diabetic
retinopathy) with physician review, interpretation and report, unilateral or bilateral

Extended during PHE

92507 Treatment Of Speech, Language, Voice, Communication, And/or Auditory Processing Disorder Extended during PHE

92508
Treatment of speech, language, voice, communication, and/or auditory processing disorder;
group, 2 or more individuals Extended during PHE

92520 Laryngeal function studies (ie, aerodynamic testing and acoustic testing) Extended during PHE

92521 Evaluation of speech fluency (eg, stuttering, cluttering) Extended during PHE

92522
Evaluation of speech sound production (eg, articulation, phonological process, apraxia,
dysarthria); Extended during PHE

92523
Evaluation of speech sound production (eg, articulation, phonological process, apraxia,
dysarthria); with evaluation of language comprehension and expression (eg, receptive and
expressive language)

Extended during PHE

92524 Behavioral and qualitative analysis of voice and resonance Extended during PHE

92526 Treatment of swallowing dysfunction and/or oral function for feeding Extended during PHE

92592 Hearing aid check; monaural Extended during PHE

92593 Hearing aid check; binaural Extended during PHE

92601 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming Extended during PHE

92602
Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent
reprogramming Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 3

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

92603 Diagnostic analysis of cochlear implant, age 7 years or older; with programming Extended during PHE

92604 Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming Extended during PHE

92610 Evaluation of oral and pharyngeal swallowing function Extended during PHE

92625 Assessment of tinnitus (includes pitch, loudness matching, and masking) Extended during PHE

93228 Heart rhythm tracing, computer analysis, and interpretation of patient-triggered events greater
than 24-hour EKG up to 30 days

Extended during PHE

93229 Heart rhythm tracing, computer analysis, physician prescribed transmission of patient-
triggered events greater than 24-hour EKG up to 30 days

Extended during PHE

93268
Heart rhythm symptom-related tracing and interpretation of 24-hour EKG monitoring up to 30
days Extended during PHE

93270 Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days Extended during PHE

93271 Heart rhythm symptom-related transmission and analysis of 24-hour EKG monitoring up to 30
days

Extended during PHE

93272 Heart rhythm symptom-related interpretation of 24-hour EKG monitoring up to 30 days Extended during PHE

93750 Evaluation of lower heart chamber assist device with physician analysis Extended during PHE

93797 Physician services for outpatient heart cardiac rehabilitation per session Extended during PHE

93798
Physician services for outpatient heart rehabilitation with continuous EKG monitoring per
session Extended during PHE

94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for
assisted or controlled breathing; hospital inpatient/observation, initial day

Extended during PHE

94003 Ventilation assist and management, initiation of pressure or volume preset ventilators for
assisted or controlled breathing; hospital inpatient/observation, each subsequent day

Extended during PHE

94004 Ventilation assist and management, initiation of pressure or volume preset ventilators for
assisted or controlled breathing; nursing facility, per day

Extended during PHE

94005

Home ventilator management care plan oversight of a patient (patient not present) in home,
domiciliary or rest home (eg, assisted living) requiring review of status, review of laboratories
and other studies and revision of orders and respiratory care plan (as appropriate), within a
calendar month, 30 minutes or more

Extended during PHE

94664

Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer,
metered dose inhaler or IPPB device 96105 Assessment of aphasia (includes assessment of
expressive and receptive speech and language function, language comprehension , speech
production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination)
with interpretation and report, per hour Private Payor Plan

Extended during PHE

95970 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device Extended during PHE

95971 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with simple spinal cord or peripheral nerve stimulator programming Extended during PHE

95972 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with
complex spinal cord or peripheral nerve stimulator programming

Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 4

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

95983 Electronic analysis of implanted neurostimulator pulse generator/transmitter, first 15 minutes face-to-face time with physician or other qualified health care professional Extended during PHE

95984
Electronic analysis of implanted neurostimulator pulse generator/transmitter, each additional
15 minutes face-to-face time with physician or other qualified health care professional Extended during PHE

96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with
patient/family CPT

Extended during PHE

96105 Assessment of expressive and receptive speech with interpretation and report per hour Extended during PHE

96110 Developmental screening (eg, developmental milestone survey, speech and language delay
screen), with scoring and documentation, per standardized instrument

Extended during PHE

96112
Developmental test administration by qualified health care professional with interpretation
and report, first 60 minutes Extended during PHE

96113
Developmental test administration by qualified health care professional with interpretation
and report, additional 30 minutes Extended during PHE

96116 Neurobehavioral status examination by qualified health care professional with interpretation and report, first 60 minutes In Existing Policy

96121 Neurobehavioral status examination by qualified health care professional with interpretation and report, additional 60 minutes Extended during PHE

96127
Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/
hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized
instrument

Extended during PHE

96130 Psychological testing evaluation by qualified health care professional, first 60 minutes Extended during PHE

96131 Psychological testing evaluation by qualified health care professional, additional 60 minutes Extended during PHE

96132 Neuropsychological testing evaluation services by physician or other qualified health care
professional, first 60 minutes

Extended during PHE

96133 Neuropsychological testing evaluation services by physician or other qualified health care
professional, additional 60 minutes

Extended during PHE

96136 Psychological or neuropsychological testing; first 30 minutes Extended during PHE

96137 Psychological or neuropsychological testing; additional 30 minutes Extended during PHE

96138 Psychological or neuropsychological test administration; first 30 minutes Extended during PHE

96139 Psychological or neuropsychological test administration; additional 30 minutes Extended during PHE

96156 Health behavior assessment, or re-assessment Extended during PHE

96158 Health behavior intervention, individual, face-to-face; initial 30 minutes Extended during PHE

96159 Health behavior intervention, individual, face-to-face; each additional 15 minutes (add-on
code)

Extended during PHE

96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard
appraisal) with scoring and documentation, per standardized instrument

In Existing Policy

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 5

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

96161
Administration of caregiver-focused health risk assessment instrument (eg, depression
inventory) for the benefit of the patient, with scoring and documentation, per standardized
instrument

In Existing Policy

96164 Health behavior intervention, group (2 or more patients), face -to-face; initial 30 minutes Extended during PHE

96165 Health behavior intervention, group (2 or more patients), face -to-face; each additional 15
minutes (List separately in addition to code for primary service)

Extended during PHE

96167 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes Extended during PHE

96168 Health behavior intervention, family (with the patient present), face -to-face; each additional
15 minutes (List separately in addition to code for primary service)

Extended during PHE

96170 Health behavior intervention, family (without the patient present), face -to-face; initial 30
minutes

Extended during PHE

96171 Health behavior intervention, family (without the patient present), face -to-face; each
additional 15 minutes (List separately in addition to code for primary service)

Extended during PHE

97110
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop
strength and endurance, range of motion and flexibility Extended during PHE

97112 Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes Extended during PHE

97116 Walking training to 1 or more areas, each 15 minutes Extended during PHE

97129
Therapeutic interventions that focus on cognitive function and compensatory strategies to
manage the performance of an activity, direct (one-on-one) patient contact; initial 15 minutes Extended during PHE

97130
Therapeutic interventions that focus on cognitive function and compensatory strategies to
manage the performance of an activity, direct (one-on-one) patient contact; each additional 15
minutes (add-on code)

Extended during PHE

97150 Therapeutic procedure(s), group (2 or more individuals) Extended during PHE

97151
Behavior identification assessment, administered by a physician or other qualified health care
professional, each 15 minutes of the physician's or other qualified health care professional's
time face-to-face with patient and/or guardian(s)/caregiver(s)

Extended during PHE

97152
Behavior identification-supporting assessment, administered by one technician under the
direction of a physician or other qualified health care professional, face-to-face with the
patient, each 15 minutes

Extended during PHE

97153
Adaptive behavior treatment by protocol, administered by technician under the direction of a
physician or other qualified health care professional, face -to-face with one patient, each 15
minutes

Extended during PHE

97154
Group adaptive behavior treatment by protocol, administered by technician under the
direction of a physician or other qualified health care professional, face-to-face with two or
more patients, each 15 minutes

Extended during PHE

97155
Adaptive behavior treatment with protocol modification, administered by physician or other
qualified health care professional, which may include simultaneous direction of technician,
face-to-face with one patient, each 15 minutes

Extended during PHE

97156
Family adaptive behavior treatment guidance, administered by physician or other qualified
health care professional (with or without the patient present), face -to-face with
guardian(s)/caregiver(s), each 15 minutes

Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 6

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

97157
Multiple-family group adaptive behavior treatment guidance, administered by physician or
other qualified health care professional (without the patient present), face -to-face with
multiple sets of guardians/caregivers, each 15 minutes

Extended during PHE

97158
Group adaptive behavior treatment with protocol modification, administered by physician or
other qualified health care professional, face-to-face with multiple patients, each 15 minutes Extended during PHE

97161 Evaluation of physical therapy, typically 20 minutes Extended during PHE

97162 Evaluation of physical therapy, typically 30 minutes Extended during PHE

97163 Evaluation of physical therapy, typically 45 minutes Extended during PHE

97164 Re-evaluation of physical therapy, typically 20 minutes Extended during PHE

97165 Evaluation of occupational therapy, typically 30 minutes Extended during PHE

97166 Evaluation of occupational therapy, typically 45 minutes Extended during PHE

97167 Evaluation of occupational therapy established plan of care, typically 60 minutes Extended during PHE

97168 Re-evaluation of occupational therapy established plan of care, typically 30 minutes Extended during PHE

97530
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve
functional performance), each 15 minutes Extended during PHE

97535
Self-care/home management training and compensatory training, meal preparation, safety
procedures, and instructions in use of assistive technology devices/adaptive equipment) direct
one-on-one contact, each 15 minutes

Extended during PHE

97542 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes Extended during PHE

97750 Physical performance test or measurement with report, each 15 minutes Extended during PHE

97755 Assistive technology assessment to enhance functional performance, each 15 minutes Extended during PHE

97760
Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15
minutes Extended during PHE

97761 Training in use of prosthesis for arms and/or legs, per 15 minutes Extended during PHE

97802 Medical nutrition therapy; initial assessment and intervention, individual, face -to-face with the patient, each 15 minutes In Existing Policy

97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes In Existing Policy

97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes In Existing Policy

98960
Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient

Extended during PHE

98961
Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 2-4 patients

Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 7

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

98962
Education and training for patient self-management by a qualified, nonphysician health care
professional using a standardized curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 5-8 patients

Extended during PHE

98966 Telephone assessment and management service, 5-10 minutes of medical discussion Extended during PHE

98967 Telephone assessment and management service, 11-20 minutes of medical discussion Extended during PHE

98968 Telephone assessment and management service, 21-30 minutes of medical discussion Extended during PHE

98970
Qualified nonphysician health care professional online digital evaluation and management
service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5 -10
minutes

Extended during PHE

98971
Qualified nonphysician health care professional online digital evaluation and management
service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11 -20
minutes

Extended during PHE

98972
Qualified nonphysician health care professional online digital evaluation and management
service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or
more minutes

Extended during PHE

99201 New patient office or other outpatient visit, typically 10 minutes In Existing Policy

99202 New patient office or other outpatient visit, typically 20 minutes In Existing Policy

99203 New patient office or other outpatient visit, typically 30 minutes In Existing Policy

99204 New patient office or other outpatient visit, typically 45 minutes In Existing Policy

99205 New patient office or other outpatient visit, typically 60 minutes In Existing Policy

99211 Established patient office or other outpatient visit, typically 5 minutes In Existing Policy

99212 Established patient office or other outpatient visit, typically 10 minutes In Existing Policy

99213 Established patient office or other outpatient visit, typically 15 minutes In Existing Policy

99214 Established patient office or other outpatient, visit typically 25 minutes In Existing Policy

99215 Established patient office or other outpatient, visit typically 40 minutes In Existing Policy

99217 Hospital observation care on day of discharge Extended during PHE

99218 Hospital observation care, typically 30 minutes Extended during PHE

99219 Hospital observation care, typically 50 minutes Extended during PHE

99220 Hospital observation care, typically 70 minutes Extended during PHE

99221 Initial hospital inpatient care, typically 30 minutes per day Extended during PHE

99222 Initial hospital inpatient care, typically 50 minutes per day Extended during PHE

99223 Initial hospital inpatient care, typically 70 minutes per day Extended during PHE

99224 Subsequent observation care, typically 15 minutes per day Extended during PHE

99225 Subsequent observation care, typically 25 minutes per day Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 8

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

99226 Subsequent observation care, typically 35 minutes per day Extended during PHE

99231 Subsequent hospital inpatient care, typically 15 minutes per day In Existing Policy

99232 Subsequent hospital inpatient care, typically 25 minutes per day In Existing Policy

99233 Subsequent hospital inpatient care, typically 35 minutes per day In Existing Policy

99234 Hospital observation or inpatient care low severity, 40 minutes per day Extended during PHE

99235 Hospital observation or inpatient care moderate severity, 50 minutes per day' Extended during PHE

99236 Hospital observation or inpatient care high severity, 55 minutes per day Extended during PHE

99238 Hospital discharge day management, 30 minutes or less Extended during PHE

99239 Hospital discharge day management, more than 30 minutes Extended during PHE

99241 Patient office consultation, typically 15 minutes In Existing Policy

99242 Patient office consultation, typically 30 minutes In Existing Policy

99243 Patient office consultation, typically 40 minutes In Existing Policy

99244 Patient office consultation, typically 60 minutes In Existing Policy

99245 Patient office consultation, typically 80 minutes In Existing Policy

99251 Inpatient hospital consultation, typically 20 minutes In Existing Policy

99252 Inpatient hospital consultation, typically 40 minutes In Existing Policy

99253 Inpatient hospital consultation, typically 55 minutes In Existing Policy

99254 Inpatient hospital consultation, typically 80 minutes In Existing Policy

99255 Inpatient hospital consultation, typically 110 minutes In Existing Policy

99281 Emergency department visit, self limited or minor problem Extended during PHE

99282 Emergency department visit, low to moderately severe problem Extended during PHE

99283 Emergency department visit, moderately severe problem Extended during PHE

99284 Emergency department visit, problem of high severity Extended during PHE

99285 Emergency department visit, problem with significant threat to life or function Extended during PHE

99291 Critical care delivery critically ill or injured patient, first 30-74 minutes Extended during PHE

99292 Critical care delivery critically ill or injured patient Extended during PHE

99304 Initial nursing facility visit, typically 25 minutes per day Extended during PHE

99305 Initial nursing facility visit, typically 35 minutes per day Extended during PHE

99306 Initial nursing facility visit, typically 45 minutes per day Extended during PHE

99307 Subsequent nursing facility visit, typically 10 minutes per day In Existing Policy

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 9

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

99308 Subsequent nursing facility visit, typically 15 minutes per day In Existing Policy

99309 Subsequent nursing facility visit, typically 25 minutes per day In Existing Policy

99310 Subsequent nursing facility visit, typically 35 minutes per day In Existing Policy

99315 Nursing facility discharge day management, 30 minutes or less Extended during PHE

99316 Nursing facility discharge management, more than 30 minutes Extended during PHE

99324 New patient assisted living visit, typically 20 minutes Extended during PHE

99325 New patient assisted living visit, typically 30 minutes Extended during PHE

99326 New patient assisted living visit, typically 45 minutes Extended during PHE

99327 New patient assisted living visit, typically 60 minutes Extended during PHE

99328 New patient assisted living visit, typically 75 minutes Extended during PHE

99334 Established patient assisted living visit, typically 15 minutes Extended during PHE

99335 Established patient assisted living visit, typically 25 minutes Extended during PHE

99336 Established patient assisted living visit, typically 40 minutes Extended during PHE

99337 Established patient assisted living visit, typically 60 minutes Extended during PHE

99341 New patient home visit, typically 20 minutes Extended during PHE

99342 New patient home visit, typically 30 minutes Extended during PHE

99343 New patient home visit, typically 45 minutes Extended during PHE

99344 New patient home visit, typically 60 minutes Extended during PHE

99345 New patient home visit, typically 75 minutes Extended during PHE

99347 Established patient home visit, typically 15 minutes Extended during PHE

99348 Established patient home visit, typically 25 minutes Extended during PHE

99349 Established patient home visit, typically 40 minutes Extended during PHE

99350 Established patient home visit, typically 60 minutes Extended during PHE

99354 Prolonged office or other outpatient service first hour In Existing Policy

99355 Prolonged office or other outpatient service each 30 minutes beyond first hour In Existing Policy

99356 Prolonged inpatient or observation hospital service first hour In Existing Policy

99357 Prolonged inpatient or observation hospital service each 30 minutes beyond first hour In Existing Policy

99381 Initial new patient preventive medicine evaluation infant younger than 1 year Extended during PHE

99382 Initial new patient preventive medicine evaluation, age 1 through 4 years Extended during PHE

99383 Initial new patient preventive medicine evaluation, age 5 through 11 years Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 10

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

99384 Initial new patient preventive medicine evaluation, age 12 through 17 years Extended during PHE

99385 Initial new patient preventive medicine evaluation age 18-39 years Extended during PHE

99386 Initial new patient preventive medicine evaluation age 40-64 years Extended during PHE

99387 Initial new patient preventive medicine evaluation, age 65 years and older Extended during PHE

99391 Established patient periodic preventive medicine examination infant younger than 1 year Extended during PHE

99392 Established patient periodic preventive medicine examination, age 1 through 4 years Extended during PHE

99393 Established patient periodic preventive medicine examination, age 5 through 11 years Extended during PHE

99394 Established patient periodic preventive medicine examination, age 12 through 17 ye ars Extended during PHE

99395 Established patient periodic preventive medicine examination age 18 -39 years Extended during PHE

99396 Established patient periodic preventive medicine examination age 40 -64 years Extended during PHE

99397 Established patient periodic preventive medicine examination, age 65 years and older Extended during PHE

99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes Private Payor Plan Extended during PHE

99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes Private Payor Plan Extended during PHE

99403 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes Private Payor Plan Extended during PHE

99404 Preventive medicine counseling and/or risk factor reduction intervention(s) provi ded to an individual (separate procedure); approximately 60 minutes Extended during PHE

99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes In Existing Policy

99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes In Existing Policy

99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST),
and brief intervention (SBI) services; 15 to 30 minutes

In Existing Policy

99409 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST),
and brief intervention (SBI) services; greater than 30 minutes

In Existing Policy

99421 Online digital evaluation and management service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 5-10 minutes

Extended during PHE

99422 Online digital evaluation and management service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 11-20 minutes

Extended during PHE

99423 Online digital evaluation and management service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 21 or more minutes

Extended during PHE

99441 Physician telephone patient service, 5-10 minutes of medical discussion Extended during PHE

99442 Physician telephone patient service, 11-20 minutes of medical discussion Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 11

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

99443 Physician telephone patient service, 21-30 minutes of medical discussion Extended during PHE

99468 Initial inpatient hospital critical care of newborn, 28 days of age or younger, per day Extended during PHE

99469 Subsequent inpatient hospital critical care of newborn, 28 days of age or younger, per day Extended during PHE

99471
Initial inpatient hospital critical care of infant or young child, 29 days through 24 months of
age, per day Extended during PHE

99472 Subsequent inpatient hospital critical care of infant or young child, 29 days through 24 months
of age, per day

Extended during PHE

99473 Self-measured blood pressure using a device validated for clinical accuracy; patient
education/training and device calibration

Extended during PHE

99475 Initial inpatient hospital critical care of infant or young child, 2 through 5 years of age, per day Extended during PHE

99476
Subsequent inpatient hospital critical care of infant or young child, 2 through 5 years of age,
per day Extended during PHE

99477 Initial intensive care of newborn, 28 days of age or younger, per day Extended during PHE

99478 Subsequent intensive care of recovering low birth weight infant, per day Extended during PHE

99479 Subsequent intensive care of recovering low birth weight infant, per day Extended during PHE

99480 Subsequent intensive care of recovering low birth weight infant, per day Extended during PHE

99483
Assessment of and care planning for patient with impaired thought processing, typically 50
minutes Extended during PHE

99495 Transitional care management services, moderately complexity, requiring face -to-face visits
within 14 days of discharge

In Existing Policy

99496
Transitional care management services, highly complexity, requiring face -to-face visits within 7
days of discharge In Existing Policy

99497 Advance care planning by the physician or other qualified health care professional In Existing Policy

99498 Advance care planning by the physician or other qualified health care professional (add -on
code)

In Existing Policy

0373T Adaptive behavior treatment with protocol modification for patient exhibiting destructive behavior, each 15 minutes of technicians' face-to-face time Extended during PHE

S9152 Speech therapy, re-eval Extended during PHE

0362T Behavior identification supporting assessment for patient exhibiting destructive behavior, each
15 minutes of technicians' face-to-face time

Extended during PHE

0373T
Adaptive behavior treatment with protocol modification for patient exhibiting destructive
behavior, each 15 minutes of technicians' face-to-face time Extended during PHE

90887 HF Explanation of psychiatric, medical examinations, procedures, and data to other than patient; substance abuse program Extended during PHE

90887 UC
Explanation of psychiatric, medical examinations, procedures, and data to other than patient;
Medicaid level of care 12 Extended during PHE

G0108 Diabetes outpatient self-management training services, individual, per 30 minutes In Existing Policy

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 12

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes In Existing Policy

G0270
Medical nutrition therapy; reassessment and subsequent intervention(s) following second
referral in same year for change in diagnosis, medical condition or treatment regimen, each 15
minutes

In Existing Policy

G0296 Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making) In Existing Policy

G0396
Alcohol and/or substance (other than tobacco) abuse structured assessment (eg, AUDIT,
DAST). and brief intervention 15 to 30 minutes In Existing Policy

G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment (eg, AUDIT,
DAST). and intervention, greater than 30 minutes

In Existing Policy

G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth In Existing Policy

G0407
Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes
communicating with the patient via telehealth In Existing Policy

G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes
communicating with the patient via telehealth

In Existing Policy

G0410
Group psychotherapy other than of a multiple-family group, in a partial hospita lization setting,
approximately 45 to 50 minutes Extended during PHE

G0420 Face-to-face educational services related to the care of chronic kidney disease; individual, per
session, per one hour

In Existing Policy

G0421 Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour In Existing Policy

G0422
Intensive cardiac-rehabilitation; with or without continuous ECG monitoring with exercise, per
session Extended during PHE

G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise,
per session

Extended during PHE

G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions per day Extended during PHE

G0425
Telehealth consultation, emergency department or initial inpatient, typically 30 minutes
communicating with the patient via telehealth In Existing Policy

G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes
communicating with the patient via telehealth

In Existing Policy

G0427
Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or
more communicating with the patient via telehealth In Existing Policy

G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit Extended during PHE

G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit Extended during PHE

G0442 Annual alcohol misuse screening, 15 minutes Extended during PHE

G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Extended during PHE

G0444 Annual depression screening, 15 minutes Extended during PHE

G0445 High intensity behavioral counseling, 30 minutes In Existing Policy

G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15
minutes

In Existing Policy

G0447 Face-to-face behavioral counseling for obesity, 15 minutes Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 13

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

G0459 Inpatient telehealth pharmacologic management, including prescription, use, and review of
medication with no more than minimal medical psychotherapy

Extended during PHE

G0506 Comprehensive assessment of and care planning for patients requiring chronic care
management services (add-on code)

In Existing Policy

G0508 Telehealth consultation, critical care, initial , physicians typically spend 60 minutes
communicating with the patient and providers via telehealth

In Existing Policy

G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes
communicating with the patient and providers via telehealth

In Existing Policy

G0513
Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in
the office or other outpatient setting requiring direct patient contact beyond the usual service;
first 30 minutes (add-on code)

In Existing Policy

G0514
Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in
the office or other outpatient setting requiring direct patient contact beyond the usual service;
each additional 30 minutes (add-on code)

In Existing Policy

G2010 Remote evaluation of recorded video and/or images submitted by an established patient Extended during PHE

G2012 Brief communication technology-based service, e.g., virtual check-in, 5-10 minutes of medical
discussion

Extended during PHE

G2025
Payment for a telehealth distant site service furnished by a rural health clinic (rhc) or federally
qualified health center (fqhc) only Extended during PHE

G2061 Qualified nonphysician health care professional online assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5 -10 minutes Extended during PHE

G2062
Qualified nonphysician health care professional online assessment and management service,
for an established patient, for up to 7 days, cumulative time during the 7 days; 11 -20 minutes Extended during PHE

G2063
Qualified nonphysician qualified health care professional assessment and management service,
for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more
minutes

Extended during PHE

G2067 Medication assisted treatment, methadone; weekly bundle including dispensing and
counseling

Extended during PHE

G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and
counseling

Extended during PHE

G2073 Medication assisted treatment, naltrexone; weekly bundle including dispensing and counseling Extended during PHE

G2074 Medication assisted treatment, weekly bundle not including the drug, including counseling Extended during PHE

G2076 Intake activities, includes preparation of a treatment plan (add-on code) Extended during PHE

G2077 Periodic assessment; for services and treatment (add-on code) Extended during PHE

G2080 Each additional 30 minutes of counseling in a week (add-on code) Extended during PHE

G2086
Office-based treatment for opioid use disorder, including development of the treatment plan,
care coordination, individual therapy and group therapy and counseling; at least 70 minutes in
the first calendar month

Extended during PHE

G2087
Office-based treatment for opioid use disorder, including care coordination, individual therapy
and group therapy and counseling; at least 60 minutes in a subsequent calendar month Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020



Page | 14

Code Service Description

Telemedicine
Reimbursement
Policy Position

Medicaid

G2088
Office-based treatment for opioid use disorder, including care coordination, individual therapy
and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes
(add-on code)

Extended during PHE

G9685
Physician service or other qualified health care professional for the evaluation and
management of a beneficiary's acute change in condition in a nursing facility. this service is for
a demonstration project

Extended during PHE

H0001 Alcohol and drug assessment Extended during PHE

H0002 Behavioral health screening to determine eligibility for admission to treatment program Extended during PHE

H0004 Behavioral health counseling and therapy, per 15 minutes Extended during PHE

H0006 HF Navigator services (Maintenance) Extended during PHE

H0006 HF
HG

Navigator psychosocial assessment & patient-specific Treatment plan development (Initiation) Extended during PHE

H0006 HF
SU

Navigator services (Stabilization) Extended during PHE

H0014 Alcohol and/or drug services; ambulatory detoxification Extended during PHE

H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) Extended during PHE

H0020 HF Methadone (per diem) Extended during PHE

H0020 HF
26

Methadone (bundled) Extended during PHE

H0032 Mental Health service plan development by a non-physician, per 15 minutes Extended during PHE

H0033 HF non-Methadone (per diem) Extended during PHE

H0033 HF
26

non-Methadone (bundled) Extended during PHE

H0035 Mental health partial hospitalization, treatment, less than 24 hours Extended during PHE

H0047 Alcohol and/or other drug abuse services, not otherwise specified Extended during PHE

H2036 HF Alcohol and/or other drug treatment program, per diem; substance abuse program Extended during PHE

S9152 Speech therapy, re-evaluation Extended during PHE

Please note: Additional benefits may be available as codes are subject to change frequently based on evolving guidance from CMS.
CPT? is a registered mark of the American Medical Association.

Horizon NJ Health Existing and Extended
Telemedicine Policy Codes

Updated on November 13, 2020