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 Blue Cross Blue Shield North Dakota (BCBSND) Telehealth Medical Policy.
Definitions
Definition
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Asynchronous Communications
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An 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
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Distant Site
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Location of the Practitioner
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Online Digital E-visits
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Face-to-face digital communication initiated by a patient to a provider through the provider’s online patient portal
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Originating Site
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Location of the patient
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Remote Physiological Monitoring (RPM)
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Also known as Telehome Monitoring, is used for electronic remote monitoring devices, for example 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
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Synchronous Communications
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Provided through a real-time audio and/or visual communication system. Examples of synchronous communication include, but are not limited to, Evaluation and Management (E/M) services, Diabetic Self-management Training, Individual Psychotherapy Services, Medical Nutrition Training, etc
(e.g. Interactive Video/Television, Audio/Visual Secure Online Digital Portals, and Videoconferencing)
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Teleradiology
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Practitioners reading, interpreting, and reporting on radiology images
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Virtual Check-in
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A brief communication via telephone or other telecommunication device to decide whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient
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Policy
Reimbursement for Telehealth services are based on the Centers for Medicare & Medicaid (CMS) Telehealth (telemedicine) guidelines, Current Procedural Terminology (CPT) & Healthcare Common Procedure Coding System (HCPCS) guidelines, North Dakota State Rules and Regulations (NDSRR) around telehealth services, and specific BCBSND reimbursement guidelines.
BCBSND provides reimbursement for certain telehealth services, which must be between a patient and practitioner. Interprofessional (provider to provider) telehealth services are not reimbursable. Additionally, 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 with modifier 26 appended indicating they did not perform the global radiology service.
Separate Reimbursement may be allowed for the following services
- Remote Physiological Monitoring (RPM): Separate payment may be allowed for remote medical intervention and assessment tools for data collected from the patient’s residence. Providers should refer to the appropriate year’s CPT manual for coding guidelines and the Telehealth Medical Policy for additional requirements.
- Originating Site Telehealth services: Separate payment will be made if patient is physically present at an originating site location such as a clinic or facility setting.
- Note: Separate payment for the originating site location where the patient is participating with a distant site practitioner will not be reimbursed if it is the patient’s home, community setting, or other non-provider owned location.
- Distant Site Telehealth services: Separate payment will be made for distant site locations when the patient is present at an originating site and the visit allows for a face-to-face encounter. Separate payment will be made when the patient is at home using a consumer device via telehealth platforms such as mobile health apps, kiosks, or web-based video available through an electronic health record (EHR) portal to obtain a patient and practitioner face-to-face telehealth services.
- Note: Effective for claims processed on August 1, 2021, separate payment will be made Online Digital E-visits and Virtual Check-Ins provided via face-to-face online communication or non-face-to-face patient-initiated telephone encounters.
Coding & Billing Guidelines
Distant site telehealth services must include modifier 95 to attest the visit was provided synchronous and allowed for face-to-face interaction for all telehealth services with the except of Online Digital E-visits and Virtual Check-Ins. Reimbursement will not be made for telehealth services billed without modifier 95, with the exception of Online Digital E-visits and Virtual Check-Ins. Providers must list place of service (POS) 02 or 10 for all distant site telehealth services. Online Digital E-visits and Virtual Check-Ins billed with a POS other than 02 or 10 will be rejected as an incorrect place of service. Refer to below table for billing guidelines.
Payment will not be made for Online Digital E-Visits or Virtual Check-Ins occurring within seven days from a prior E/M service by the same billing provider relating to the same problem. Payment will not be made for Online Digital E-Visits or Virtual Check-Ins resulting in an E/M service within seven days after the prior Online Digital E-Visit or Virtual Check-Ins for the same problem by the same billing provider.
If an E/M visit is for a problem unrelated to the Online Digital E-Visits or Virtual Check-Ins, 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, Virtual Check-In, or an E/M service without modifier 25 with a date of service within seven days from another Online Digital Visit, Virtual Check-In, or an E/M service; 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
