Telehealth Services

Policy ID: NDRP-GC-015
Section: Telehealth Services
Effective Date: July 01, 2018
Last Reviewed: December 31, 2019

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Description:

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.

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.

Billing Guidelines for Reimbursable Telehealth Services

Telehealth Method

CMS-1500 Billing Guidelines

UB-04 Billing Guidelines

Telehome Monitoring (Asynchronous)

Providers may report the following codes once per month
for reimbursement:

  • CPT 99091 – Collection and interpretation of physiologic data digitally stored and/or transmitted requiring a minimum of 30 minutes of time, each 30 days
  • HCPCS S9110 – Telemonitor equipment rental

Providers should report these services on the CMS-1500 Claim Form only

Originating Site – Location of the patient (Synchronous)

Providers must report on the CMS-1500 Claim Form when the patient is not in a hospital place of service (POS).

  • HCPCS – Q3014 (Telehealth originating site facility fee)
  • POS – Use valid POS code reflecting the location of the patient and not POS 02 (Telehealth).

Report on the UB-04 Claim Form when the patient is in a hospital place of service (POS).

  • HCPCS – Q3014 (Telehealth originating site facility fee)
  • Revenue Code – 0780 (Telemedicine, General Classification)

Distant Site – Location of the practitioner (Synchronous)

Providers must report distant site services on the CMS-1500 Claim Form.

  • CPT/HCPCS – Report code based on documented services rendered
  • 95 Modifier [Synchronous Telemedicine Service] – Report Modifier 95 attesting the visit was rendered via an interactive audio-visual technology
  • G0 (Zero) Modifier [Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke.] – This modifier may be reported to indicate the telehealth service was for treatment of symptoms of an acute stroke
  • POS – 02 (Telehealth)

Providers are not allowed to report Distant Site services on the UB-04 Claim Form

Online Digital Visit – Patient Initiated (Synchronous)

Providers may only bill for online digital visits on the CMS-1500 Claim Form. Below is a listing of coding guidelines for each reimbursable Online Digital Visit.

  • Online Digital Evaluation and Management Services for an established patient by a Physician or Qualified Healthcare Practitioner (QHP):
    • CPT 99421 [5-10 Minutes], 99422 [11-20 Minutes] or 99423 [21 or more minutes] – Code selected must represent time spent during the cumulative seven days
    • 95 Modifier [Synchronous Telemedicine Service]
    • POS – 02 [Telehealth]
  • Online Lactation Counseling:
    • HCPCS S9443 [Lactation Class]
    • 95 Modifier [Synchronous Telemedicine Service]
    • POS – 02 [Telehealth]
  • Online Digital Evaluation and Management Services for an established patient by a qualified non-physician professional healthcare professional (e.g. but not limited to, Social Worker, Physical Therapist, Occupational Therapist)
    • CPT/HCPCS 98970/G2061 [5-10 Minutes], 98971/G2062 [11-20 Minutes] or 98972/G2063 [21 or more minutes] – Code selected must represent time spent during the cumulative seven days. Providers may use either the CPT or HCPCS code, but only one code may be used.
    • 95 Modifier [Synchronous Telemedicine Service]
    • POS – 02 [Telehealth]

Providers are not allowed to report Online Digital Visits on the UB-04 Claim Form

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.

Revision Date

History

12/31/2019

  • Removed Definitions and added links to Medical Policy – Telehealth which contains Telehealth Definitions
  • Updated policy description to broaden the policy scope for additional telehealth services outside of distant/originating telehealth services
  • Added Asynchronous and Synchronous policy guidelines and specified reimbursement within each of these categories.
  • Added additional detail for each telehealth method and items within each method.
  • Added the billing and coding guidelines for both the CMS-1500 Claim Form and UB-04 Claim Guidelines for new specifications.
  • Added Online Digital Visit policy and billing guidelines.
  • Added Limitation and Exclusion statement and removed former exclusion statement.

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.