Telehealth Crosswalk

Revised November 2, 2020

AFMC will continue to update this document as new information is identified.  Please check back often to ensure you have the most up-to-date information.

This document was developed in collaboration with Dr. Randy Walker’s office and should be used for reference purposes only.

Please refer to the payer for confirmation of covered services.

Go directly to a payer

Medicare

Medicaid – Arkansas

Blue Cross Blue Shield – Arkansas

Ambetter/QualChoice – Arkansas

Aetna – Arkansas

Aetna Medicare Advantage

Cigna – Arkansas

UnitedHealthcare

Humana/TRICARE

Download the condensed Telehealth Crosswalk PDF

Medicare Telehealth Visits

Provider Type

Physicians
Nurse practitioners
Physician assistants
Nurse midwives
Certified nurse anesthetists
Clinical psychologists
Clinical social worker
Registered dietitians
Nutrition professionals

What is the Service?

A visit with a provider who uses real-time telecommunication systems between a provider and a patient (telecommunication must use audio and visual capabilities)

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

Common telehealth services include:

99201-99215 (office or other outpatient visits)
– 95 Modifier or CS Modifier**
– POS 02 OR the POS you would typically report for a face-to-face visit (i.e., POS 11)

G0425-G0427 (telehealth consultations, emergency department or initial inpatient)

G0406-G0408 (follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs)

For a complete list of covered telehealth services: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

Requirements

For new* or established patients

Interactive Telecommunications System – Telehealth services provided via a real-time audio-video

*To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency (coinsurance and deductible would generally apply; however, the HHS OIG is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs.)

**New guidance issued of 04/07/2020 – utilize CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing related services and should NOT charge Medicare patients any coinsurance and/or deductible

Special Instructions

POS 02 OR POS you would typically report for a face-to-face visit (i.e., POS 11)

Modifier 95

 

Virtual Check-in

Provider Type

Physician and other qualified healthcare professionals (LCSW, clinical psychologist, PT, OT, speech-language pathologist)

What is the Service?

A brief (5-10 minutes) check-in with your practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.
OR
A remote evaluation of recorded video and/or images submitted by a new or established patient.

Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication.

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G2012
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

HCPCS code G2010
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

CMS revised to include new and established patients

Requirements

For established or existing patients

– Patient must initiate
– Communication is not related to a medical visit within the previous 7 days or lead to a medical visit within the next 24 hours
– Patient must verbally consent to receive virtual check-in
– Virtual check-ins can be conducted with a broader range of communication methods (i.e., telephone, audio/video, secure text messaging, email, or use of patient portal)

*Coinsurance and deductible would generally apply; however, the HHS OIG is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs.

Special Instructions

 

e-Visit

Provider Type

Physician or other qualified healthcare professional (Nurse practitioner)

What is the Service?

Online Digital Evaluation and Management

Non-face-to-face, patient-initiated communication between a patient and their provider through an online patient portal

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

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

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

99423 (>21 minutes)
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

 

G2061* (5-10 minutes)
Qualified non-physician health care professional online assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes

G2062* (11-20 minutes)
Qualified non-physician 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

G2063* (>21 minutes)
Qualified non-physician 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.

Requirements

– For established patients**
– Service needs to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation.
– Communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hour (or soonest appointment available).
– The patient must verbally consent to receive virtual check-in services.

**The Medicare coinsurance and deductible would generally apply to these services.

Special Instructions

*Clinicians who may not independently bill for evaluation and management visits (physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can utilize the G-codes to provide these e-visits and bill.

Telephone Services

Provider Type

Qualified non-physician health care professional

What is the Service?

Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian

Not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment

HCPCS / CPT Code

Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 21-30 minutes of medical discussion

98966 (5-10 minutes)
98967 (11-20 minutes)
98968 (>21 minutes)
POS that would have been used had the service occurred in person
Modifier 95

Requirements

Requires telephone

Established patient, parent or guardian

Patient-initiated

Cannot be related to a medical visit within the previous 7 days or lead to a visit within 24 hours or soonest available appointment

5-10; 11-20; or 21-30 minutes of medical discussion

Special Instructions

Telephone Only Services

Provider Type

MD/ANP

What is the Service?

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian

Not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

HCPCS / CPT Code

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 20-30 minutes of medical discussion.

99441 (5-10 minutes)
99442 (11-20 minutes)
99443 (20-30 minutes)
POS that would have been used had the service occurred in person
Modifier 95

Requirements

Requires telephone

New or established patient, parent or guardian

Not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

Special Instructions

Annual Wellness Visit, first visit

Provider Type

MD/ANP

What is the Service?

Annual Wellness Visit, Includes a personalized Prevention Plan of Service (PPPS), first visit

– Covered only once, within 12 months of Part B enrollment
– Patient pays nothing

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

G0438
Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit (review of medical and social health history, and preventive services education)

Requirements

Must include personalized prevention plan of services
– Must utilize either interactive audio and video or audio only telecommunication that permits real-time communication​ (4/30/2020)

Special Instructions

Should include all required aspects of the visit.

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Annual Wellness Visit

Provider Type

MD/ANP

What is the Service?

Annual Wellness Visit, subsequent visit

*Covered once every 12 months
*Patient pays nothing

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0439
Annual Wellness Visit, includes a health risk assessment and personalized prevention plan of service (PPPS) subsequent visit

Requirements

Must include personalized prevention plan of services

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Transitional Care Management

Provider Type

MD/ANP  (if legally authorized and qualified to provide the services in the state in which they are furnished – CNMs/CNSs/PAs)

What is the Service?

Transitional Care Management Services with Moderate Complexity Decision Making

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

99495
Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)

Requirements

Within 14 days of discharge

May be provided via telehealth

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

 

Transitional Care Management

Provider Type

MD/ANP/ (if legally authorized and qualified to provide the services in the State in which they are furnished – CNMs/CNSs/PAs)

What is the Service?

Transitional Care Management Services with High Medical Decision Making

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

99496
Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

Requirements

Within 7 days of discharge

May be provided via telehealth

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

 

Advanced Care Planning

Provider Type

MD/ANP

What is the Service?

Advanced Care Planning
(Can be done at the time of an Annual Wellness Visit)

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

99497
Advance Care Planning, first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498
Advance Care Planning, additional 30 minutes

Requirements

– First 30 minutes
– Additional 30 minutes
(Note:  No place of service code limitations.)

May be provided via telehealth

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Nursing Facility Visits

Provider Type

MD/ANP

What is the Service?

Subsequent Nursing Facility Care Services

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

99307-99310
Subsequent nursing facility care, per day, for the evaluation and management of a patient,

Requirements

Frequency restrictions removed via CMS-1744-IFC

Provider should review code requirements for the inclusion of 2 of 3 key components and time spent at bedside and on the patient’s facility floor or unit.

Must use interactive audio and video telecommunications

Limitation of 1 telehealth visit every 30 days

Special Instructions

Telehealth DSM Training

Provider Type

CDE

What is the Service?

Diabetes Self-Management Training Services

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0108 -G0109
Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction furnished in the initial year training period to ensure effective injection training

Requirements

Minimum of 1 hour in-person instruction

May be completed via audio-only

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Behavior Assessment

Provider Type

LCSW

What is the Service?

Behavior Assessments & Intervention

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

96150 – 96154
Individual and group health and behavior assessment and intervention

Requirements

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Individual Psychotherapy

Provider Type

LCSW

What is the Service?

Individual Psychotherapy

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

90832
Individual psychotherapy

90833 w/E&M
Individual psychotherapy

90834
Individual psychotherapy

90836 w/E&M
Individual psychotherapy

90837
Individual psychotherapy

90838 w/E&M
Individual psychotherapy

Requirements

90832 (30 minutes)

90833 (30 minutes)

90834 (45 minutes)

90836 (45 minutes)

90837 (60 minutes)

90838 (60 minutes)

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

 

Telehealth Psychotherapy for Crisis

Provider Type

LCSW

What is the Service?

Psychotherapy for Crisis

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

90839
Psychotherapy for crisis

90840
Psychotherapy for crisis

Requirements

Life Threatening/Complex Patient is in High Distress

90839 (60 minutes)

90840 (additional 30 minutes)

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Individual & Group MNT

Provider Type

CDE

What is the Service?

Individual and Group Medical Nutrition Therapy

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0270
Individual and group medical nutrition therapy

97802
Individual and group medical nutrition therapy

97803
Individual and group medical nutrition therapy

97804
Individual and group medical nutrition therapy

Requirements

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Behavioral Therapy for Cardiovascular Disease

Provider Type

CDE

What is the Service?

Intensive Behavioral Therapy for Cardiovascular Disease

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

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

Requirements

Annual, 15 minutes

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Behavioral Counseling for Obesity

Provider Type

CDE

What is the Service?

Behavioral Counseling for Obesity

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0447
Face-to-face behavioral counseling for obesity, 15 minutes

Requirements

15 minutes

May be completed via audio-only

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Smoking Cessation Services

Provider Type

– MD/ANP
– LCSW

What is the Service?

Smoking Cessation Counseling

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

99406
Smoking cessation services

99407
Smoking cessation services

Requirements

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Alcohol and/or Substance Abuse Services

Provider Type

– MD/ANP
– LCSW

What is the Service?

Alcohol and/or Substance Abuse Counseling

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0396
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services

HCPCS code G0397
Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services

Requirements

Structed Assessment & Intervention Services

May be completed via audio-only

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Annual Alcohol Misuse Screening

Provider Type

– MD/ANP
– LCSW

What is the Service?

Annual Alcohol Misuse Screening

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0442
Annual alcohol misuse screening, 15 minutes

Requirements

15 minutes minimum

May be completed via audio-only

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Behavioral Counseling for Alcohol Misuse

Provider Type

– MD/ANP
– LCSW

What is the Service?

Behavioral Counseling for Alcohol Misuse

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

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

Requirements

Face-to-face, 15 minutes

May be completed via audio-only

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telehealth Annual Depression Screening

Provider Type

– MD/ANP
– LCSW

What is the Service?

Annual Depression Screening

*These services covered through the end of the Public Health Emergency (PHE)

HCPCS / CPT Code

HCPCS code G0444
Annual depression screening, 15 minutes

Requirements

15 minutes

May be completed via audio-only

Special Instructions

For Additional Information reference the MLN Booklet on Telehealth Services​: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telemedicine

Provider Type

Physician
APRN

What Is The Service?

Generally, a provider must have an established relationship with a patient before utilizing telemedicine to treat a patient. See Medicaid Provider Manual § 105.190. However, DMS has the authority to relax this requirement in case of an emergency. Pursuant to Executive Order 20-05 and as allowed under current Medicaid policy, DMS is lifting the requirement to have an established professional relationship before utilizing telemedicine for physicians.

See Medicaid Provider Manual § 105.190

HCPCS / CPT Code

– E&M Code AND
– “GT” Modifier AND
– Place of Service “02”

Medicaid: https://afmc.org/wp-content/uploads/2020/03/Memorandum-DMS-01-physician-telemedicine.pdf

Requirements

DMS has lifted the requirement to have an established professional relationship before utilizing telemedicine for physicians under the following conditions for the duration of the emergency declaration:

– The physician providing telehealth services must have access to a patient’s personal health record maintained by a physician.
– The telemedicine service may be provided by any technology deemed appropriate, including telephone, but it must be provided in real time (cannot be delayed communication).
– Physicians may use telemedicine to diagnose, treat, and, when clinically appropriate, prescribe a non-controlled drug to the patient.

See Medicaid Provider Manual § 105.190

Special Instructions

Include:

– E&M Code
– GT Modifier
– POS 02

Virtual Check-in

Provider Type

Clinician who can bill primary care services

What is the Service?

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report E&M services, provided to an established patient, not originating from a related E&M service provided within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment. Typically, 5-10 minutes of medical discussion.

See Medicaid Provider Manual § 105.190

HCPCS / CPT Code

G2012
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report E&M services, provided to an established patient, not originating from a related E&M service provided within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment. Typically, 5-10 minutes of medical discussion.

*Code will be turned on April 1, 2020, and will be retroactive to date of service March 18, 2020

*Medicaid is opening the virtual check-in for 60 days. The code can be extended as required to address the public health emergency.

Requirements

The physician providing telehealth services must have access to a patient’s personal health record maintained by a physician.

The telemedicine service may be provided by any technology deemed appropriate, including telephone, but it must be provided in real time (cannot be delayed communication).

Physicians may use telemedicine to diagnose, treat, and, when clinically appropriate, prescribe a non-controlled drug to the patient.

Can be any real-time audio (telephone), or “2-way audio interactions that are enhanced with video or other kinds of data transmission.”

Available for established patients only

To be used for:
– Any chronic patient who needs to be assessed as to whether an office visit is needed.
– Patients being treated for opioid and other substance-use disorders.

Nurse or other staff member cannot provide this service. It must be a clinician who can bill primary care services.

If an E&M service is provided within the defined time frames, then the telehealth visit is bundled with that E&M service. It would be considered pre- or post-visit time and not separately billable.

No geographic location restrictions for the patient.

Communication must be HIPAA compliant.

Medicaid is opening the virtual check-in for 60 days. The code can be extended as required to address the public health emergency

See Medicaid Provider Manual § 105.190

Special Instructions

Clinician who can bill primary care services

Telemedicine for Certain Behavioral Health Providers

Provider Type

– Licensed Psychologists
– Licensed Professional Counselor
– (LPC) Licensed Associate Counselors (LACs)
– Licensed Associate Marriage and Family Therapists (LAMFTs)
– Licensed Clinical Social Workers (LCSWs)
– Licensed Master Social Worker ( LMSWs)

What is the Service?

Continuation of critical services provided to established patients while they remain in their homes.

– The rule related to originating site requirements is suspended for 30 days.

– The suspension may be extended for additional 30-day periods throughout the declaration of emergency.

HCPCS / CPT Code

– Place of Service “02”

– Individual Behavioral Health Counseling

90832, U4, GT
Individual psychotherapy

90834, U4, GT
Individual psychotherapy

90837, U4, GT
Individual psychotherapy

– Psychoeducation

H2027, U4, GT

3/18/2020 – The rule will be suspended for 30 days. The suspension may be extended for additional 30-day periods throughout the declaration of emergency.

Behavioral Health: https://afmc.org/wp-content/uploads/2020/03/MEMORANDUM-DMS-02-OBH-telehealth.pdf

Requirements

DMS has suspended the rule related to originating site requirements for certain behavioral health providers to provide certain counseling services. By suspending this rule, these licensed behavioral health professionals will be able to continue to provide critical services to established patients while they remain in their homes.

– Must be established patient

– Any technology deemed appropriate may be used, including telephones, but technology must utilize direct communication that takes place in real-time

– Diagnostic services cannot be provided when the beneficiary is not in a separate originating provider facility

Special Instructions

Existing Telehealth Policy 2015034

Updated Nov. 2, 2020

Provider Type

MD/ANP/DO/PA

What is the Service?

The health care professional at the distant site must submit claims for telemedicine services using HCPCS or CPT Code for the professional service delivered, along with telemedicine modifier GT via interactive audio and video telecommunications systems or 95 synchronous telemedicine services rendered via real time interactive audio and video telecommunications

HCPCS / CPT Code

99201 or
99202 or
99203 or
99204 or
99211 or
99212 or
99213 or
99214

AND

GT modifier or
95 modifier or
CS Modifier*

AND

POS 02

Requirements

Telemedicine or telephonic communication may be used to establish a relationship with provider and maintain the relationship

Waiver of co-pays, coinsurance and deductibles

Self-Funded Plans – verify coverage with payer

COVID-19 Update for Members covered by Arkansas Blue Cross and Blue Shield and Health Advantage (fully insured health plans): The voluntary, expanded COVID-19 related benefits announced for certain Arkansas Blue Cross and Blue Shield and Health Advantage fully insured health plans and individual policies will be extended to align with the federally mandated COVID-19 coverage provisions as specified in the FFCRA (Families First Coronavirus Response Act) and CARES (Coronavirus Aid, Relief and Economic Security) Act. The federal mandate currently runs through January 21, 2021.

Self-Funded Plans: Decisions about coverage changes for members of self-funded health plans served by BlueAdvantage Administrators of Arkansas or Health Advantage are made by the employers or plan sponsors who fund those self-funded programs. If you have questions about your coverage, please call the number on the back of your card.

NOTE: 99205 & 99215 not covered services provided by telemedicine

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

We are providing access to an in-network, statewide panel of almost 2,300 behavioral health professionals already credentialed and ready to serve their emotional/mental health needs via virtual access

See Arkansas BCBS June 2020 Providers’ News for COVID-19 Updates  LINK HERE

Special Instructions

99205 & 99215 not covered services provided by telemedicine

Claim must include E&M code AND modifier AND POS 02

*Any COVID-19 evaluation visit should include “CS” modifier. Visit may include the following screenings:

– 87635-COVID19 (RT-PCR test)
– 87804- Influenza
– 86710– Influenza
– 87880- Streptococcus

*Providers’ News June 2020 – See page 9

September 2020 – UPDATED – COVID-19 Testing Coverage – Page 4

Telephone-based Visit

Updated Nov. 2, 2020

Provider Type

In-network behavioral health professionals
Psychologist
LCSW
Licensed Professional Counselors.

What is the Service?

Arkansas Blue Cross Blue Shield and Health Advantage will provide payment for any in-network provider to visit by telephone with patients who are seeking advice or counsel on either physical or mental health needs.

In addition to creating this entirely new, temporary benefit for our fully insured members, Arkansas Blue Cross Blue Shield and Health Advantage will also waive all co-pays, coinsurance and deductibles for these new telephone-based benefits.

HCPCS / CPT Code

POS 02 or POS 11 or POS 12

99441 Telephone; 5-10 minutes
Telephone evaluation and management service by a qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

99442 Telephone; 11-20 minutes
Telephone evaluation and management service by a qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.

99443 Telephone; 21-30 minutes
Telephone evaluation and management service by a qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

Requirements

Established patient, parent or guardian

Pre-existing exclusions suspended. Verify coverage timeframe of either Fully Insured or Self-Funded updates.

Service provided by telephone

Usual member costs (co-pays, coinsurance and deductibles) are temporarily being waived for telemedicine visits with in-network physicians (MDs, DOs), advance practice nurse practitioners and physician assistants. This includes wellness/preventative visits.

Does not apply to self-funded plans

See Arkansas BCBS June 2020 Providers’ News for COVID-19 Updates  LINK HERE

Special Instructions

E/M code and POS 02 or 11 or 12

Existing Telehealth Policy 2015034 for Behavioral Health

Updated June 5, 2020

Provider Type

LCSW

What is the Service?

HCPCS / CPT Code

90832
Psychotherapy, 30 minutes with patient

90833 w/E&M
Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (list separately in addition to the code for primary procedure)

90834
Psychotherapy, 45 minutes with patient

90836 w/E&M
Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (list separately in addition to the code for primary procedure)

90837
Psychotherapy, 60 minutes with patient

90838 w/E&M
Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)

Requirements

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

We are extending this new, temporary insurance benefit for counseling by in-network behavioral health professionals. Specifically, we will pay for telemedicine counseling to our fully insured members by any in-network psychiatrist, clinical psychologist, advance practice nurse practitioner, licensed clinical social worker or licensed professional counselor. Copays, coinsurance and deductibles for these services are being waived at this time.

See Arkansas BCBS June 2020 Providers’ News for COVID-19 Updates  LINK HERE

Special Instructions

Existing Telehealth Policy 2015034 for Behavioral Health

Provider Type

LCSW

What is the Service?

Behavioral Health Assessment & Intervention

HCPCS / CPT Code

96150
Health and behavior assessment (eg, health focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face to face with the patient; initial assessment

96151
Health and behavior assessment (eg, health focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face to face with the patient; re-assessment

96152
Health and behavior intervention, each 15 minutes, face to face; individual

Requirements

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

We are extending this new, temporary insurance benefit for counseling by in-network behavioral health professionals. Specifically, we will pay for telemedicine counseling to our fully insured members by any in-network psychiatrist, clinical psychologist, advance practice nurse practitioner, licensed clinical social worker or licensed professional counselor. Copays, coinsurance and deductibles for these services are being waived at this time.

Special Instructions

Telehealth Smoking Cessation Services

Provider Type

MD/ANP
LCSW

What is the Service?

Smoking Cessation Counseling

HCPCS / CPT Code

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

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

Requirements

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

Special Instructions

Telehealth Alcohol and/or Substance Abuse Services

Provider Type

MD/ANP
LCSW

What is the Service?

Alcohol and/or Substance Abuse Counseling

HCPCS / CPT Code

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

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

Requirements

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

Special Instructions

Online Digital Evaluation & Management Services

Updated June 5, 2020

Provider Type

MD/ANP

What is the Service?

A communication between a patient and their provider through an online patient portal.

HCPCS / CPT Code

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

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

99423 (<21 minutes) over 7 days
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

Requirements

**Must have POS code 02

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

See Arkansas BCBS June 2020 Providers’ News for COVID-19 Updates  LINK HERE

Special Instructions

Transitional Care Management

Provider Type

MD/ANP

What is the Service?

Transitional Care Management Services with Moderate Complexity Decision Making

HCPCS / CPT Code

99495
Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period face-to-face visit, within 14 calendar days of discharge

Requirements

Within 14 days of discharge

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

Special Instructions

Transitional Care Management

Provider Type

MD/ANP

What is the Service?

Transitional Care Management Services with High Medical Decision Making

HCPCS / CPT Code

99496
Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period face-to-face visit, within 7 calendar days of discharge

Requirements

Within 7 days of discharge

Requirements noted under current Telehealth Policy 2015034: https://secure.arkansasbluecross.com/members/report.aspx?policyNumber=2015034#lblCpt

Special Instructions

Wellness Visits

Provider Type

MD/DO/ANP

What Is The Service?

Wellness Visits

HCPCS / CPT Code

99381 – 99397

POS- 02

Modifier GT or 95

Requirements

Appropriate documentation commensurate with the level of service provided and submitted for payment is to be placed in the medical record.

See Arkansas BCBS June 2020 Providers’ News for COVID-19 Updates – See Page 8 –  LINK HERE

Special Instructions

Ambetter/QualChoice

Revised November 2, 2020

Telemedicine Payment Policy

Provider Type

MD/APRN

What is the Service?

Telehealth services are effective for the duration of the COVID-19 emergency

A visit with a provider that uses telecommunication systems between a provider and a patient

Established patient unless seen by a referral healthcare professional or an on-call healthcare professional, or in an emergency situation where the life or health of the patient is in danger

Any services that can be delivered virtually will be eligible for telehealth coverage.

HCPCS / CPT Code

99201-99205
99211-99215
G2010 and G2012

AND

POS 02
Modifier 95 or GT

Requirements

Testing waived for COVID-19 (diagnostic testing or medical screening) when medically necessary and ordered and/or referred by licensed healthcare provider. Members’ copayment, coinsurance and/or deductible cost-sharing will be waived for testing and/or medical care, along with the associated physician’s visit.    

– Fully insured group plan will cover the cost of treatment and the associated doctor’s visit.
– Self-funded plans refer to Plan Administrator for COVID-19 coverage questions.

QualChoice- see medical policy B1529.  For additional clarification contact your QualChoice Provider Relations Representative.

Special Instructions

Non Face-To-Face Services: Telephonic Only

Revised Nov. 2, 2020

Provider Type

Qualified healthcare professional

What Is The Service?

Telephone-only services have historically not been covered but will now be covered through January 21, 2021. For more information regarding telephone-only visits, please see medical policy BI063.

 

HCPCS / CPT Code

Telephonic services (99441-99443) will be covered through October 23, 2020

Requirements

For additional clarification contact your QualChoice Provider Relations Representative.

Special Instructions

Existing Telemedicine Policy

Revised Nov. 2, 2020

Provider Type

MD/ANP

What is the Service?

A visit with a provider who uses telecommunication systems between a provider and a patient

HCPCS / CPT Code

99201-99205
99211-99215

Requirements

Requires an audiovisual connection or telephone

Testing waived for COVID-19

Telemedicine claims (commercial) must use POS 02 with the GT or 95 modifier will reimburse the same as in-office visit 99213

Telemedicine Coverage Policy Liberalization (extended to 12/31/2020) for Commercial Plans

Special Instructions

Aetna is extending all member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services through 12/31/2020 (Commercial and Medicare Advantage Plans).

Self-insured plans offer this waiver at their own discretion.

Medicare Advantage cost sharing will be waived for covered real-time virtual visits offered by in-network providers (live videoconferencing or telephone-only telemedicine services). Medicare Advantage members are encouraged to use telemedicine for any reason, not just COVID-19 diagnosis.

Online Assessment

Provider Type

Non-physician Health Care Professional

What is the Service?

Qualified non-physician health care professional online assessment, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes; 11 – 20 minutes; or 21 or more minutes

Qualified non-physician 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; 11-20; or 21 or more minutes

HCPCS / CPT Code

Qualified non-physician health care professional online assessment, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes; 11 – 20 minutes; or 21 or more minutes
G2061 (5-10 minutes)
G2062 (11-20 minutes)
G2063 (>21 minutes)

Qualified non-physician 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; 11-20; or 21 or more minutes
98970 (5-10 minutes)
98971 (11-20 minutes)
98972 (>21 minutes)

Requirements

Requires audiovisual connection.

Minor Acute Evaluations will be covered via telephone for general medicine and behavioral health a synchronous audiovisual connection needed.

Aetna members are encouraged to use telemedicine to limit potential exposure in physician offices.

Cost sharing will be waived for all virtual visits through the Aetna-covered Teladoc® offerings and in-network providers.

Self-insured plan sponsors will be able to opt-out of this program at their discretion.

Special Instructions

Additional information refer to Aetna’s telehealth policy

Telephone Assessment & Management

Provider Type

Non-physician Health Care Professional

What is the Service?

Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian

Not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment

HCPCS / CPT Code

Telephone assessment and management service provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 21-30 minutes of medical discussion
98966 (5-10 minutes)
98967 (11-20 minutes)
98968 (>21 minutes)

Requirements

Requires an audiovisual connection or telephone

Established patient, parent or guardian

Cannot be related to a medical visit within the previous 7 days or lead to a visit within 24 hours or soonest available appointment

5-10; 11-20; or 21-30 minutes of medical discussion

For the next 90 days Aetna will cover minor acute evaluation and management services care services rendered via telephone. A visual connection is not required. For general medicine and behavioral health visits – a synchronous audiovisual connection is still required. Aetna’s telemedicine policy is available to providers on the NaviNet and Availity portals.

Special Instructions

Additional information refer to Aetna’s telehealth policy

Telephone Assessment & Management

Provider Type

Physician or other qualified health care professional who may report E&M services

What is the Service?

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian

Not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

HCPCS / CPT Code

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 20-30 minutes of medical discussion.
99441 (5-10 minutes)
99442 (11 – 20 minutes)
99443 (20 – 30 minutes)

Requirements

Requires telephone

Established patient, parent or guardian

Not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment

Physician may provide care from any location

For the next 90 days Aetna will cover minor acute evaluation and management services care services rendered via telephone. A visual connection is not required. For general medicine and behavioral health visits – a synchronous audiovisual connection is still required. Aetna’s telemedicine policy is available to providers on the NaviNet and Availity portals.

Special Instructions

Aetna is extending all member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services through 9/30/2020 (Commercial and Medicare Advantage Plans).

Self-insured plans offer this waiver at their own discretion.

Medicare Advantage cost sharing will be waived for covered real-time virtual visits offered by in-network providers (live videoconferencing or telephone-only telemedicine services). Medicare Advantage members are encouraged to use telemedicine for any reason, not just COVID-19 diagnosis.

Virtual Check-in

Provider Type

MD/ANP

What Is The Service?

Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

HCPCS / CPT Code

HCPCS code G2010
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

HCPCS code G2012
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

Requirements

Requires an audiovisual connection or telephone

Cannot be related to a medical visit within the previous 7 days or lead to a visit within 24 hours

Coinsurance and deductible apply

Physician may provide care from any location

Special Instructions

Aetna is extending all member cost-sharing waivers for covered in-network telemedicine visits for outpatient behavioral and mental health counseling services through 9/30/2020 (Commercial and Medicare Advantage Plans.

Self-insured plans offer this waiver at their own discretion.

Medicare Advantage cost sharing will be waived for covered real-time virtual visits offered by in-network providers (live videoconferencing or telephone-only telemedicine services). Medicare Advantage members are encouraged to use telemedicine for any reason, not just COVID-19 diagnosis.

Online Digital E&M – e-Visit

Provider Type

MD/ANP

What is the Service?

A communication between a patient and their provider through an online patient portal

HCPCS / CPT Code

Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.

99421 (5-10 minutes)
99422 (11-20 minutes)
99423 (>21 minutes)

Requirements

Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.

– For established patients

– Requires audiovisual connection

*Communication with Patient via portal – patient must initiate

– Cost sharing will be waived for all virtual visits through the Aetna-covered Teladoc® offerings and in-network providers.

– Self-insured plan sponsors will be able to opt-out of this program at their discretion.

Special Instructions

Additional information refer to Aetna’s telehealth policy

Behavioral Health and Opioid Treatment

Provider Type

LCSW

What is the Service?

Specific details for these services can be found at https://www.aetna.com/health-care-professionals/provider-education-manuals/covid-faq/billing-and-coding.html

HCPCS / CPT Code

 

Requirements

 

Special Instructions

Additional information refer to Aetna’s telehealth policy

Aetna Medicare Advantage

Updated November 2, 2020

COVID-19: Telemedicine FAQs – Updated Oct. 14, 2020

Telemedicine Policy

Provider Type

MD/ANP

What is the Service?

A visit with a provider that uses telecommunication systems between a provider and a patient

HCPCS / CPT Code

99201-99205
99211-99215

Requirements

For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been, had the service been furnished in-person, along with the 95 modifier indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate. (10/14/2020)
Cost shares are waived for in-network primary care and specialist telehealth visits through 12/31/2020.

Special Instructions

 

e-Visit

Provider Type

MD/ANP

What is the Service?

A communication between a patient and their provider through an online patient portal

HCPCS / CPT Code

G2061 (5-10 minutes)
G2062 (11-20 minutes)
G2063 (>21 minutes)

Requirements

For established patients

Communication with patient via portal – patient must initiate

Through 9/30/2020, Aetna will offer zero co-pay telemedicine visits for any reason to all Individual and Group Medicare Advantage members. Aetna Medicare Advantage members should use telemedicine as their first line of defense to limit potential exposure in physician offices. Cost sharing will be waived for all Teladoc® virtual visits. Cost sharing will also be waived for real-time virtual visits offered by in-network providers (live video conferencing or telephone-only telemedicine services). Medicare Advantage members may use telemedicine for any reason, not just COVID-19 diagnosis.

Special Instructions

E-Visit

Additional information refer to Aetna’s telehealth policy

Cigna

Updated November 2, 2020

Commercial – Updated October 30, 2020: Medicare Telehealth Frequently Asked Questions (FAQs)

 

Virtual Check-in (Telephone Consult)

Provider Type

In-Network Qualified Licensed Healthcare Provider

What is the Service?

Quick telephonic consultation related to COVID-19 screening and/or other necessary consults and will offer appropriate reimbursement to providers for this amount of time

HCPCS / CPT Code

HCPCS G2012
Phone calls for COVID-19 or other necessary consults (e.g.: 5-10 minute virtual visit with or without video with the licensed health care provider)

Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5- 10 minutes of medical discussion

Applies to services submitted on CMS1500 claims or electronic equivalent only

Requirements

Established patient

No co-pay

With or without video

Cost-share will be waived for all services (including non COVID-19 related services)

For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, it would be appropriate to assign the code Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out.

For cases where there is an actual exposure to someone who is confirmed to have COVID-19, it would be appropriate to assign the code Z20.828: Contact with and (suspected) exposure to other viral communicable diseases.

Cigna claims processing systems will be able to accept this coding guidance on April 6, 2020 for dates of service on or after March 2, 2020. 

Updated  7/23/2020: As federal guidelines continue to evolve in support of the COVID-19 pandemic, Cigna is adopting a position consistent with the federal public health emergency period. As such, Cigna is extending the customer cost-share waivers and other enhanced benefits, including our interim virtual care policy, through at least October 31, 2020.

Special Instructions

Use Diagnosis:
– Possible Exposure Z03.818
– Exposure Z20.828
– Other as applicable for non-COVID-19 consults

Virtual or face-to-face visit for screening for suspected or likely COVID-19 exposure

Provider Type

In-Network Qualified Licensed Healthcare Provider (Physicians, Mid-Level Practitioners)

What is the Service?

Real-time, synchronous virtual visit

Related to COVID-19

HCPCS / CPT Code

Usual face-to-face E/M code – 99201 – 99215
– Modifier CR on CMS 1500 claims
– Condition code DR on UB04 claims
– Append with GQ modifier for virtual care*

*Note: contradictory guidance in “Cigna Coronavirus (COVID-19) Interim Billing Guidance for Providers” states on page 4 item e. “No virtual care modifier should be billed”.

Requirements

New or established patient

Cost share will be waived

Services can be performed by phone, video or both
– Cigna will not make any requirements regarding the type of technology used (i.e., phone, video, FaceTime, Skype, etc. are all appropriate to use at this time).

ICD code Z03.818 or Z20.828

For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, it would be appropriate to assign the code Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out

For cases where there is an actual exposure to someone who is confirmed to have COVID-19, it would be appropriate to assign the code Z20.828: Contact with and (suspected) exposure to other viral communicable diseases

Codes effective through at least October 31, 2020.  Coverage applies until December 31, 2020.

Special Instructions

Use Diagnosis:
– Possible Exposure Z03.818
– Exposure Z20.828

Virtual or face-to-face visit for treatment of a confirmed COVID-19 case

Provider Type

In-Network Qualified Licensed Healthcare Provider (Physicians, Mid-Level Practitioners)

What is the Service?

Real-time, synchronous virtual visit

Confirmed COVID-19 Case

HCPCS / CPT Code

Usual face-to-face E/M code
– Append with GQ modifier for virtual care*

*Note: contradictory guidance in “Cigna Coronavirus (COVID-19) Interim Billing Guidance for Providers” states on page 4 item e. “No virtual care modifier should be billed”.

Requirements

Effective on dates of service on and after February 4, 2020

Cost-share will be waived only when providers bill the appropriate ICD10 code (U07.1)

Note that billing B97.29 will no longer waive cost-share. Effective August 1, 2020, U07.1 must be billed to waive cost-share for treatment of a confirmed COVID-19 diagnoses

Cigna will reimburse usual face-to-face rates

Codes effective through at least  October 31, 2020. Coverage applies until December 31, 2020.

Special Instructions

Use Diagnosis:
– 897.29 or
– U07.41

Telehealth (Non-COVID-19 virtual visit)

Provider Type

In-Network Qualified Licensed Healthcare Provider (Physicians, Mid-Level Practitioners)

What is the Service?

Real time, synchronous

HCPCS / CPT Code

Usual face-to-face E/M code – 99201–99215
– Append with GQ modifier for virtual care*
– POS normally billed**

*Note: contradictory guidance in “Cigna Coronavirus (COVID-19) Interim Billing Guidance for Providers” states on page 4 item e. “No virtual care modifier should be billed”.

**Billing a POS 02 or GT/95 modifier for virtual services may result in reduced payment or denied claims due to current system limitations. While we understand CMS guidance is to bill for a POS 02 for virtual care services, billing a typical place of service (POS 11) will ensure providers receive the same reimbursement as they typically get for a face-to-face visit.

Requirements

New or established patients

Services can be performed by phone, video or both
– Cigna will not make any requirements regarding the type of technology used (i.e., phone, video, FaceTime, Skype, etc., are all appropriate to use at this time)

Cigna will reimburse usual face-to-face rates

Standard cost-share will apply

While we encourage providers to bill consistent with an office visit – and understand that certain services can be time consuming and complex even when provided virtually – we strongly encourage providers to be cognizant when billing level four and five codes for virtual services. While we will reimburse these services consistent with face-to-face rates, we will monitor the use of level four and five services to limit fraud, waste and abuse.

Codes effective through at least October 31, 2020. Coverage applies until December 31, 2020.

Special Instructions

Telehealth Visit (Cigna Medicare Advantage and Cigna Medicare-Medicaid​)

Provider Type

Qualified Providers

What Is The Service?

A visit with a provider that uses telecommunication systems between provider and patient.

HCPCS / CPT Code

99201-99215 (office or other outpatient visits, new or established patients)
POS

*Billing a POS 02 or GT/95 modifier for virtual services may result in reduced payment or denied claims due to current system limitations. While we understand CMS guidance is to bill for a POS 02 for virtual care services, billing a typical place of service (POS 11)  will ensure providers receive the same reimbursement as they typically get for a face-to-face visit.

Requirements

New or established patients

May take place at a patient’s residence

Telephones that have audio and video capability

Visit will be reimbursed depending on place of service

The following codes should be utilized when COVID-19 is confirmed:
– 897.29
– U07.1

Codes effective through at least October 31, 2020. Coverage applies until December 31, 2020.

Special Instructions

Virtual Check-In (Cigna Medicare Advantage and Cigna Medicare-Medicaid)

Provider Type

Qualified Providers

What Is The Service?

A brief (5-10) minute check-in/conversation with the provider to determine whether office visit or other service is needed.

HCPCS / CPT Code

G2012
– Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

G2010

Requirements

Established Patients

With or Without Video

Codes effective through at least October 31, 2020. Coverage applies until December 31, 2020.

Special Instructions

E-Visit (Cigna Medicare Advantage and Cigna Medicare-Medicaid)

Provider Type

Qualified Providers

What Is The Service?

A communication between a patient and their provider through an online patient portal

HCPCS / CPT Code

A communication between a patient and their provider through an online patient portal

99421 (5-10 Minutes)

99422 (11-20 Minutes)

99423 (>21 Minutes)

G2061 (5-10 Minutes)

G2062 (11-20 Minutes)

G2063 (>21 Minutes)

Requirements

Established Patient

Online Patient Portal

Codes effective through at least October 31, 2020. Coverage applies until December 31, 2020.

Special Instructions

Virtual Visit

Provider Type

In-Network Qualified Licensed Healthcare Provider

What is the Service?

Virtual Office Consultation of new or established patient

HCPCS / CPT Code

99241
Virtual Office consultation for a new or established patient, which requires these 3 key components: a problem-focused history; a problem-focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.

Requirements

New or established patient

Will be reimbursed for all other synchronous real-time virtual visits when billed with Place of Service 11

If the visit is related to COVID-19, the ICD10 diagnosis codes (Z03.818 or Z20.828) are required to be billed and reimbursement will be without customer co-pay/cost share

If the virtual visit is not related to COVID-19, the ICD10 code for the visit should be billed and reimbursement will be made according to applicable benefits and related cost share.

No virtual care modifier should be billed

Cigna claims processing systems will be able to accept this coding guidance on April 6, 2020, for dates of service on or after March 2, 2020.

Special Instructions

UnitedHealthcare

Revised November 2, 2020

UnitedHealthcare Expands Access to Care, Support and Resources to Help People and Families Address COVID-19 – March 18, 2020

COVID-19 Telehealth Services – Updated October 7, 2020

¥ Update October 12, 2020:  Summary of COVID-19 Dates by Program LINK

§ Update: June 26, 2020:  COVID-19 UnitedHealthcare Telehealth Services: Care Provider Coding Guidance LINK

Electronic Visit

Revised June 5, 2020

Provider Type

Physician or other Qualified Healthcare Provider

What is the Service?

These services are for established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available) using online patient portal

UHC:  Last update: June 26, 2020

For Medicare Advantage, Individual and Group Market health plan and Medicaid members, UnitedHealthcare will reimburse for patients to communicate with their doctors using online patient portals, using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable.

Our Medicare Advantage, Medicaid, and Individual and Group Market health plans currently reimburse for “e-visits” for patients to connect with their doctors remotely. These services are for established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available).

HCPCS / CPT Code

Established patients may have non-face-to-face, patient-initiated communications with their doctors, without going to the doctor’s office, by using online patient portals.

Physician, ANP, PA:
99421 (5-10 minutes)
99422 (11-20 minutes)
99423 (>21 minutes)

Other qualified non-physician (PT, OT, ST):
G2061 (5-10 minutes)
G2062 (11-20 minutes)
G2063 (>21 minutes)

Requirements

Use of online patient portal

Established patient

Patient must generate initial inquiry

Communication can occur over a seven-day period

Patient must verbally consent to receive virtual check-in services

Use appropriate Place of Service (11, 20, 22, 23)

No modifiers are required for commercial, Medicare Advantage or (UHC) Medicaid

The benefits describe federal requirements and UnitedHealthcare national policy. Additional benefits may be available in some states and under some plans.

Review the “Summary of COVID-19 Dates by Program” document for a quick reference guide to the beginning and ending dates of temporary program, process or procedure changes implemented by payer because of COVID-19. ¥

Medicaid:  State regulations will apply ¥

Special Instructions

E-visits will be covered in accordance with the member’s benefit plan. – Updated July 24, 2020

Virtual Check-in: Audio Only

Revised Nov. 2, 2020

Provider Type

Physician or Qualified Health Care Professional

What is the Service?

Virtual check-in, by a Physician or Other Qualified Health Care Professional who can report evaluation and management services, provided to a new or an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment – using audio only technology

UHC:  Last update: October 7, 2020

Our Individual and Group market health plans and Medicare Advantage plans currently reimburse for virtual check-in patients to connect with their doctors remotely. These services are for new or established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available). These services can be billed when furnished through several communication technology modalities, such as telephone (Healthcare Common Procedure Coding System (HCPCS) code G2012) or captured video or image (HCPCS code G2010).

Telephone evaluation and management service for both physician and qualified non-physician health care professionals (CPT codes 99441-99443 and 98966-98968) can also be used for new or established patients.” ¥

HCPCS / CPT Code

G2012
These virtual check-ins are for patients with a new or an established (or existing) relationship with a physician or certain practitioners, where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available).

5-10 minutes of medical discussion

Requirements

Use appropriate Place of Service (11, 20, 22, 23)

New of established patient

5-10 minutes of medical discussion

Furnished through communication technology modalities such as telephone

The patient must verbally consent to receive virtual check-in services

The benefits describe federal requirements and UnitedHealthcare national policy. Additional benefits may be available in some states and under some plans

Review the “Summary of COVID-19 Dates by Program” document for a quick reference guide to the beginning and ending dates of temporary program, process or procedure changes implemented by payer because of COVID-19. ¥

Medicaid:  State regulations will apply ¥

Special Instructions

 

Medicare Telehealth Visits

Revised June 5, 2020

Provider Type

Eligible Care Providers

What is the Service?

Telehealth

A visit with a provider who uses real-time telecommunication systems between a provider and a patient (telecommunication may use audio-video or audio only)

UnitedHealthcare – Last updated June 29, 2020:  

UnitedHealthcare is waiving the Centers for Medicare and Medicaid (CMS) originating site restriction.” §

“The policy changes apply to members whose benefit plans cover telehealth services and allow those patients to connect with their doctor through live, interactive audio-video or audio-only visits.” §

HCPCS / CPT Code

Common telehealth services include:

99201-99215 (office or other outpatient visits)
– 95 Modifier for Medicare Advantage, Medicaid and individual and fully insured group market health plans. (not required for 99441-99443) ​
– POS 11, 20, 22 or 23

Audio-only – Medicare Advantage (including DSNP members) must use audio only E/M codes
– 99441-99443 as of May 13, 2020
– POS 11, 20, 22 or 23

Requirements

These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits

Telehealth services provided via the use of HIPAA-compliant or non-HIPAA-compliant audio-video or audio-only technology, such as FaceTime or Skype*

For new or established patients

95 Modifier for Medicare Advantage, Medicaid and individual and fully insured group market health plans. (not required for 99441-99443)

Review the “Summary of COVID-19 Dates by Program” document for a quick reference guide to the beginning and ending dates of temporary program, process or procedure changes implemented by payer because of COVID-19. ¥

Medicaid:  State regulations will apply ¥

(some of our self-funded customers may not cover provider-based telehealth services under their member benefit plans.)

* United States Department of Health and Human Services (HHS) is exercising enforcement discretion and waiving penalties of HIPAA during the COVID-19 emergency period.

While the 1135 waiver is in force, care providers may also use telephones that have audio and video capabilities for Medicare or commercial telehealth services during the COVID-19 public health emergency.

To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency

Special Instructions

Telehealth services will be reimbursed in accordance with the member’s benefit plan. – Updated October 7, 2020

Virtual Check-in: Remote Evaluation of Recorded Video and/or Images

Provider Type

MD/ANP

What is the Service?

Remote evaluation of recorded video and/or images submitted by a new or an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days

“Our Individual and Group market health plans and Medicare Advantage plans currently reimburse for “virtual check-in” patients to connect with their doctors remotely. These services are for new or established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available). These services can be billed when furnished through several communication technology modalities, such as telephone (Healthcare Common Procedure Coding System (HCPCS) code G2012) or captured video or image (HCPCS code G2010).

Telephone evaluation and management service for both physician and qualified non-physician health care professionals (CPT codes 99441-99443 and 98966-98968) can also be used for new or established patients.”

HCPCS / CPT Code

G2010
Remote evaluation of recorded video and/or images submitted by a new or an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days

Requirements

For new or established patients

No modifiers required for commercial, Medicare Advantage or UHC Medicaid

Use appropriate Place of Service code (11, 20, 22, 23)

Cannot be related to a medical visit within the previous 7 days or lead to a visit within 24 hours

Furnished through captured video or image

The patient must verbally consent to receive virtual check-in services

Review the “Summary of COVID-19 Dates by Program” document for a quick reference guide to the beginning and ending dates of temporary program, process or procedure changes implemented by payer because of COVID-19. ¥

Medicaid:  State regulations will apply ¥

To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency

Coinsurance and deductible apply

The benefits describe federal requirements and UnitedHealthcare national policy. Additional benefits may be available in some states and under some plans.

Special Instructions

 

Other Telehealth Visits

Revised June 5, 2020

Provider Type

What Is The Service?

UnitedHealthcare is allowing all codes on the CMS Covered Telehealth Services list  for this national emergency for Medicare Advantage, Medicaid*, and Individual and Group Market health plans.

Guidance for physical, occupational and speech therapy can be found here and here. ¥ §

For all other questions, you may either contact your local UnitedHealthcare representative, or visit the UnitedHealthcare COVID-19 web page

HCPCS / CPT Code

Requirements

Review the “Summary of COVID-19 Dates by Program” document for a quick reference guide to the beginning and ending dates of temporary program, process or procedure changes implemented by payer because of COVID-19. ¥

Medicaid:  State regulations will apply ¥

Special Instructions

Telemedicine

Provider Type

MD/ANP

What is the Service?

A visit with a provider who uses telecommunication systems between a provider and a patient

HCPCS / CPT Code

99201-99205

99211-99215

Requirements

Humana understands that not all telehealth visits will involve the use of both video and audio interactions. For providers or members who don’t have access to secure video systems, we will temporarily accept telephone (audio-only) visits. These visits can be submitted and reimbursed as telehealth visits.

Please follow CMS or state-specific guidelines and bill as you would a standard telehealth visit.

In response to this emergency, Humana will temporarily reimburse for telehealth visits with participating/in-network providers at the same rate as in-office visits. In order to qualify for reimbursement, telehealth visits must meet medical necessity criteria, as well as all applicable coverage guidelines.

To encourage members to seek care safely while protecting the health care workforce, Humana is waiving member cost share for all telehealth services delivered by participating/in-network providers. This includes:
– All telehealth services delivered by participating/in-network providers, either through audio or video
– All telehealth services delivered through MDLive to Medicare Advantage members, and also to Commercial members in Puerto Rico
– All telehealth services delivered through Doctor on Demand to Commercial members

• Please do not collect traditional member responsibility for these services from any Humana member, as it will result in avoidable refund transactions and may inhibit members from seeking needed care.

Beginning March 6, 2020 and for the duration of the COVID-19 public health emergency

*Cost Share waivers are effective May 1 through remainder of 2020.  https://press.humana.com/press-release/humana-waive-member-costs-all-primary-care-and-behavioral-health-office-visits-medicar

*Eliminating out-of-pocket costs for office visits so that Medicare Advantage members can reconnect with their health care providers (all telehealth visits- PCP, Specialty and Behavioral Health for in-network providers.

Special Instructions

E-Visit

Provider Type

Physician

What Is The Service?

Online digital evaluation and management non-face-to-face communication through an online patient portal.

HCPCS / CPT Code

Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes; 11-20 minutes; 21 or more minutes.

– 99421 – 99423

Bill with proper code utilizing POS as the medical office and modifier according to CMS Guidance, state-specific rules and Humana policy.

Requirements

Services for established patient.

Service initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation.

Communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours.

The patient must verbally consent to receive services

Please follow CMS or state-specific guidelines and bill as you would a standard telehealth visit.

In response to this emergency, Humana will temporarily reimburse for telehealth visits with participating/in-network providers at the same rate as in-office visits. In order to qualify for reimbursement, telehealth visits must meet medical necessity criteria, as well as all applicable coverage guidelines.

To encourage members to seek care safely while protecting the health care workforce, Humana is waiving member cost share for all telehealth services delivered by participating/in-network providers.

Early prescription refills allowed through July 25, 2020

See payer details for cost sharing information

Special Instructions

Telephone Visits

Provider Type

Qualified health care professional

What Is The Service?

Non-face-to-face telephone services: Telephone evaluation and management service by a physician or other qualified health care professional

HCPCS / CPT Code

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes; 11-20 minutes; 21-30 minutes of medical discussion

– 99441-99443

Bill with proper code utilizing POS as the medical office and modifier according to CMS Guidance, state-specific rules and Humana policy.

Requirements

Special Instructions

Services for established patient

Service provided via telephone

Communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours

See payer details for cost sharing information

Virtual Check-In

Provider Type

Physician or other qualified health care professional

What Is The Service?

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional.

HCPCS / CPT Code

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional.

Virtual Check-in use HCPCS: G2012

Requirements

Services for new or established patient

Patient must initiate

Communication is not related to a medical visit within the previous 7 days or lead to a medical visit within the next 24 hours

Patient must verbally consent to receive virtual check-in

See payer details for cost sharing information

Special Instructions

Online Digital Evaluation and Management

Provider Type

Qualified nonphysician health care professional

What Is The Service?

Online digital evaluation and management service by a qualified nonphysician health care professional

HCPCS / CPT Code

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;

98970 – 5-10 minutes

98971 – 11-20 minutes

98972 – 21 or more minutes

Requirements

Service for established patient

Special Instructions

Telephone Assessment

Provider Type

Qualified nonphysician health care professional

What Is The Service?

Brief communication by a qualified nonphysician health care professional

HCPCS / CPT Code

Telephone evaluation and management service by a physician or other qualified nonphysician health care professional who may report evaluation and management services provided to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;

98966 – 5-10 minutes

98967 – 11-20 minutes

98968 – 21-30 minutes of medical discussion

Requirements

Services for established patient

Service provided via telephone

Communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours

Special Instructions

Telehealth Services

Provider Type

What Is The Service?

Effective 4/23/2020 – TRICARE has approved use of telehealth services to include otherwise-covered behavioral health services during the COVID-19 outbreak

HCPCS / CPT Code

Telehealth services to include otherwise-covered behavioral health services during the COVID-19 outbreak

Requirements

These services include:

– Telemental health services, including individual psychotherapy, crisis management, family therapy or group therapy (expected to continue after the coronavirus pandemic)

– Medication assisted treatment (only during the coronavirus pandemic)

– Opioid treatment programs (only during the coronavirus pandemic)

– Intensive outpatient programs, including medication management, case management, recreational therapy, occupational therapy and discharge planning (only during the coronavirus pandemic)

Refer to your TRICARE portal for policy update details

Special Instructions