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
Term
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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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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 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 as indicated below.
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. (Place of service (POS) 02 or 10)
- Distant Site Telehealth services: 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. Providers may include modifier 95 (audio-visual) or 93 (audio only) to attest the visit was provided synchronous or asynchronous.
Note: Providers must use place of service (POS) 02 or 10 to indicate the service was rendered via telehealth. Claims submitted for distant site telehealth services prior to January 1, 2025 without modifier 95 will not be considered for reimbursement, with the exception of Online Digital E-visits and Virtual Check-Ins. Providers should only append modifier 95 if the service was provided through audio-visual telecommunications. Effective January 1, 2025, providers are no longer required to report modifier 95 for distant site telehealth reimbursement consideration. Providers should refer to the Telehealth Medical Policy for additional requirements.
Note: Effective January 1, 2025, providers may report the new E/M telehealth codes [98000 – 98015] which distinguish between audio-visual and audio-only visits. Providers must report POS 02 or 10 with these Telehealth codes or the services will be rejected.
- Online Digital E-visit (98970, 98971, 98972, 99421, 99422, 99423) or Brief Virtual Check-in (98016, 98966, 98967, 98968, G2010, G2012, G2251, G2252):
Separate payment will be made if:
- 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 and 99443 were deleted by the AMA as of 1/1/2025 and if reported with a DOS (date of service) on or after this date, will reject.
