Description
Telehealth services are the use of medical or behavioral health information to diagnose and/or treat a Member exchanged from one site to another via a Synchronous Interaction audio-only or audio/video telecommunication system.
The services for both types of encounters are evaluation and management focused. Only services specifically defined by Centers for Medicare & Medicaid (CMS) Telehealth (telemedicine) guidelines, Current Procedural Terminology (CPT) & Healthcare Common Procedure Coding System (HCPCS) guidelines, the North Dakota State Rules and Regulations (NDSRR) or our health plan’s published policies and member benefits as suitable for delivery via Telehealth/Telemedicine are eligible for reimbursement. When specified in this policy, other types of services may be applicable.
Please note that there is not yet industry consensus on the use of the terms "Telemedicine" and "Telehealth." In light of this, we continue to include our own definition of these two terms in our policies. For this reason, Blue Cross Blue Shield of North Dakota (BCBSND) will utilize an umbrella term “Telehealth” to describe the variations of telehealth and telemedicine. Refer to the BCBSND Telehealth Medical Policy.
Definitions
Term
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Definition
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ANSI ASC X12 837
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ANSI ASC X12 837: The Health Insurance Portability and Accountability Act (HIPAA) requires that all health insurance payers in the United States comply with the electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services (HHS). Medical claims that providers submit to payers are in electronic format of the HIPAA 837 standard.
- 837P (Professional): The standard format used by health care professionals and suppliers to transmit health care claims electronically.
- 837I (Institutional): The standard format used by institutional providers to transmit health care claims electronically.
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Asynchronous Communications
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Transmission of a Member’s health care information over secure connection enabling a Member-to-Provider or Provider-to-Provider interaction that is not simultaneous or concurrent in time and where the participants are separated by distance. The interaction must result in medical diagnosis or management of the Member and the technology cannot include the use of audio-only telephone, fax or standard email.
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Covered Service
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Medically Necessary health care services and supplies rendered or furnished by a Provider that are eligible for benefit consideration under a Member Agreement.
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Distant Site
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Site at which the Provider delivering the telehealth service is located at the time of the service.
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Established Relationship
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The member has had at least one in-person appointment within the past year with the physician or other provider rendering the services, with a provider employed at the same clinic as the provider, or with a locum tenens or other provider who is the designated back up or substitute provider for the provider rendering services who is on leave and is not associated with an established clinic.
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In-Person
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Face-to-face interaction when a Member and a Provider are physically in the same location.
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Modifier 93
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Used to indicate services furnished real-time (synchronous) using telephone or other interactive audio-only telecommunications system.
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Modifier 95
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Used to indicate services furnished real-time (synchronous) using audio and visual telecommunication systems.
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Modifier FQ
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Used to indicate services furnished using audio-only communication technology. This must be appended to any procedure using Audio-only Technology even if the provider has the capability of Audio/Video Technology.
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Modifier GT
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Used to indicate the use of an interactive audio and video communication system for an encounter between a distant provider and the patient.
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Modifier GQ
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Used to indicate services rendered to a patient via an asynchronous telecommunications system, one that does not involve live two way communication.
This modifier must be submitted with ' Store and Forward' services. Generally, asynchronous telecommunications must be used to permit non-real-time communication between the distant site Provider and the member.
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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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Physical location of the Member at the time the service is provided.
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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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Store and Forward Services
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The Provider’s professional services of diagnosis and medical management of the Member that result from the use of Store and Forward Technology.
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Store and Forward Technology
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Use of an Asynchronous Interaction to transmit a Member’s medical information from an Originating Site to a Provider at a Distant Site, which results in medical diagnosis and management of the Member and does not include the use of audio-only telephone, fax, or email.
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Synchronous Communications
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Live real-time communication through interactive technology that enables a Member and a Provider who are separated by distance to interact simultaneously. (e.g. Interactive Video/Television, Audio/Visual Secure Online Digital Portals, and Videoconferencing)
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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. Does not require the use of audio or video technology and is expected to be patient-initiated.
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Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
Policy
Reimbursement for Telehealth services are based on the Telehealth (telemedicine) guidelines, (CPT) & (HCPCS) guidelines, (NDSRR) or our health plan’s published policies and member benefits as suitable for delivery via Telehealth/Telemedicine are eligible for reimbursement.
Telehealth
Telehealth/Telemedicine services are synchronous, real-time services performed via interactive audio/video or audio-only technology received at an Originating Site where the Member is physically located and the provider is located at a separate, distant site.
Services must be initiated at the request of the member or authorized caregiver seeking access to a provider.
Services must replace the need for an in-person visit. The member must be present and able to participate.
The plan will consider reimbursement for telehealth/telemedicine services when the following criteria are met:
- Audio only technology is only allowed when the member is in their home (POS 10) and the physician or practitioner has audio-video communication technology available, but the member does not have or does not consent to using audio-video communication technology.
- The place of service (POS) must reflect the location of the patient when receiving the Telehealth/Telemedicine services.
- POS 02: Services provided other than in patient’s home. Use this POS when the originating site is a health care facility. Not reimbursable for audio only services.
- POS 10(effective 1/1/2022): Services provided in patient’s home. Use this POS when the originating site is not a healthcare facility.
- Telehealth identifying modifiers must be used to reflect the technology used to deliver the service. If one of these modifiers is not submitted on the claim line, the claim may be rejected.
- Modifier 93/FQ: This modifier must be used when services are performed using audio-only technology.
- Modifier 95/GT: This modifier must be used when services are performed using audio and video technology.
Separate Reimbursement may be allowed for the following services
Remote Physiological Monitoring (RPM):
Remote Physiologic Monitoring (RPM) is used by providers to access data remotely in order to appropriately manage a disease. These monitoring services measure responses to therapy delivered via a device or software. Examples of RPM include but are not limited to glucose monitoring, oximetry, Blood pressure, or cardiac monitoring.
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:
The originating site is where the member is located during a telemedicine visit. For the originating site Facility Fee to be considered for reimbursement, the following must be met:
- The Member must be physically located in the Health Care Facility billing as the originating site
- Claims should be submitted using the same date of service for the originating and distant site.
- Service must include audio and video in order for an originating site facility fee to be reimbursed (facility fee billings for audio-only are not reimbursable)
- The originating site must be providing health services to the Member
- Providers billing on ANSI 837P must submit with appropriate place of service, HCPCS Q3014 with no modifier. It is not appropriate for place of service 02 or 10 to be used when billing facility fee.
- Providers billing on ANSI 837I must submit with revenue code 0780 range with HCPCS Q3014 with no modifier.
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. (Place of service (POS)10)
Distant Site Telehealth Services:
The distant site location is where the Provider delivering the Telehealth service is located at the time of the service.
- Separate payment will be made for distant site locations when the patient is present at an originating site.
- 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.
- Modifiers must be added 95 (audio-visual) or 93/FQ (audio only) to attest the visit was provided synchronous or asynchronous.
- Modifier 93/FQ: This modifier must be used when services are performed using audio-only technology.
- Modifier 95/GT: This modifier must be used when services are performed using audio and video technology.
Note: Effective June 20, 2026, providers must report distant site telehealth services with POS 02 or 10 and the appropriate telehealth modifier to identify the type of telehealth service provided.
Online Digital E-visit or Brief Virtual Check-in
Online Digital E-visit (98970, 98971, 98972, 99421, 99422, 99423) or Brief Virtual Check-in (98016, 98966, 98967, 98968, G2010, G2251, G2252):
The online digital e-visit or brief virtual check-in is 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. Does not require the use of audio or video technology and is expected to be patient-initiated.
- Modifier 93/95/FQ/GT – Providers must include the appropriate telehealth modifier.
- POS is 10
- Service was not initiated from a related E/M service provided within the previous 7 days
- Service did not lead to a related E/M service or procedure within the next 24 hours or soonest available appointment.
Note: If the billing provider submits an Online Digital Visit, Brief 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 the first claim received will receive reimbursement. The second claim without a modifier 25 will be rejected as the service has been unbundled.
Note: Codes 99441, 99442, 99443 and G2012 were deleted by the AMA as of 1/1/2025 and if reported with a DOS (date of service) on or after this date, the claim will be rejected.
