Telehealth and telemedicine are terms that are frequently used interchangeably. Telehealth allows for health care services such as telemedicine, telemonitoring, store and forward, health care education for patients and professionals, and related administrative services. For this policy, telehealth will be used as an umbrella term used to describe all variations of telehealth and telemedicine. For detailed definitions of the telehealth service variations refer to the North Dakota Blue Cross Blue Shield (NDBCBS) Telehealth Medical Policy.

The Telehealth Reimbursement policy is based on the Centers for Medicare & Medicaid (CMS) Telehealth (telemedicine) guidelines, North Dakota State Rules and Regulations (NDSRR) around telehealth services, and specific BCBSND reimbursement guidelines.

BCBSND provides reimbursement for certain telehealth services. Telehealth services must be between a patient and practitioner. Interprofessional (provider to provider) telehealth services are not reimbursable.

Asynchronous Communications is used for electronic medical information, imaging, or communication that is transferred, recorded, or otherwise stored to be reviewed at a distant site by a health care provider without the patient present in real time during the review of the stored data.

E-visits for non-face-to-face services (e.g. electronic patient inquires or completed questionnaires) using Internet resources in response to a patient’s on-line inquiries are not separately payable.

Teleradiology refers to practitioners reading, interpreting and reporting on radiology images. Separate payment will not be made for teleradiology services. Providers completing an interpretation and report for a radiology service must bill using the appropriate CPT/HCPCS code for the radiology service and append modifier 26 indicating he/she did not perform the global radiology service.

Telehome Monitoring will receive separate payment for electronic remote monitoring devices for purposes such as blood pressure checks, weight checks via a telescale as well as other remote medical intervention and assessment tools for data collected sent from the convenience of the patient’s place of residence.

Synchronous Communications (e.g. Interactive Video/Television, Audio/Visual Secure Online Digital Portals, and Videoconferencing) is reimbursable when provided through a HIPAA compliant and encrypted, real-time communication system. Examples of synchronous communication include, but are not limited to, Evaluation and Management services, Diabetic Self-management Training, Individual Psychotherapy Services, Medical Nutrition Training, etc.

The following services are reimbursable synchronous communication services:

Originating (Location of Patient)/Distant Site (Location of Practitioner) Telehealth services – Separate payment will be made when the patient is physically present and participating at the originating site with the distant site practitioner.

Online Digital Visits (Patient located at home and practitioner located at distant site) – Patient initiated online digital visits via a Secure Online Provider Portal/Internet Site are separately reimbursable when the visit allows the patient and practitioner to have a face-to-face encounter using online technology and the billing provider appends modifier 95. Modifier 95 must be appended to attest the visit provided synchronous and allowed for face-to-face interaction. Reimbursement will not be made for claims submitted without modifier 95.

Payment will not be made for online digital visits occurring within seven days from a prior evaluation and management (E/M) service by the billing provider relating to the same problem. Payment will not be made for online digital visits resulting in an E/M service within seven days after the prior online digital visit for the same problem by the same billing provider.

If an E/M visit is for a problem unrelated to the online digital visit, the billing provider must append a modifier 25 to indicate the service is separately identifiable. However, if the billing provider submits an online digital visit and an E/M service without modifier 25 with a date of service within seven days from the online digital visit; whichever claim is received first will receive reimbursement. The second claim without modifier 25 will be rejected as the service has been unbundled.

Limitations and Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Subject to changes, updates, or other requirements of coding rules and guidelines
• All codes are subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-10), only codes valid for the date(s) of service may be submitted or accepted
• All payment for codes based on Relative Value Units (RVU) will include a site of service differential and will be calculated, if appropriate, using the appropriate facility or non-facility components, based on the site of service identified, as submitted by Provider
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference

• Medical Policy – Telehealth
• Medical Policy – Telehome Telemonitoring for Congestive Heart Failure and/or Chronic Obstructive Pulmonary Disease
• CMS Medicare Learning Network (MLN) Telehealth Booklet