Telehealth Billing Guidelines for Commercial Insurance plans
We are covering billing guidelines updated by commercial payers and Medicare in the last few days. This information was updated as of March 22, 2020. Most of the payers have time bound the easing of requirements for teleheath services – everyone has different dates varying between 60 to 90 days, so please make sure you check with your payer for benefits if you are looking at this later then May of 2020.
Table of Contents
Pay for Results – Google Ads.
Get in front of patients searching for telehealth services.
Yes, It’s legal and it works!
Questions to ask during Verification of Benefits
Blue Cross Blue Shield (BCBS) of IL Guidelines
The following telehealth codes are now accepted by BCBSIL for use by health care professionals authorized by Illinois State law to provide services via telehealth.
Providers submitting claims for telehealth services using these codes must append with modifier 95.
Available telehealth visits with BCBSIL providers currently include 2-way, live interactive telephone communication and digital video consultations, which can allow members to connect with physicians while reducing the risk of exposure to contagious viruses or further illness.
As a reminder, it’s critical to check eligibility and benefits for each member at every visit prior to rendering services. Providers may connect with a Customer Advocate to check eligibility and telehealth benefits via phone or verify general coverage by submitting an electronic 270 transaction via the Availity® Provider Portal or other preferred vendor portal. This step will help providers determine coverage information, network status, benefit preauthorization/pre-notification requirements and other important details.
Psych diagnostic evaluation
Psych diagnostic evaluation w/medical services
Psychotherapy 30 min
Psychotherapy 30 min w/e&m evaluation
Psychotherapy 45 min w/e&m evaluation
Psychotherapy 60 min
Psychotherapy 60min w/e&m evaluation
Office visit established patient 15 min
Office visit established patient 25 min
Office visit established patient 40 min
Physician /Qualified Health Professional telephone evaluation 5-10 min
Physician /Qualified Health Professional telephone evaluation 11-20 min
Physician/Qualified Health Professional telephone evaluation 21-30 min
Physician/Qualified Health Professional online digital evaluation 5-10 min
Physician/Qualified Health Professional online digital evaluation 11-20 min
Physician/Qualified Health Professional online digital evaluation 21-30 min
Nonphysician telephone assessment 5-10 min
Nonphysician telephone assessment 11-20 min
Nonphysician telephone assessment 21-30 min
QNHP online digital E/M SVC EST PT <7 D 5-10 min
QNHP online digital E/M SVC EST PT <7 D 11-20 min
QNHP online digital E/M SVC EST PT <7 D 21+ min
Aetna Health Care Guidelines
For the next 90 days, until June 4, 2020, Aetna will waive member cost sharing for a covered telemedicine visit regardless of diagnosis. Aetna members are encouraged to use telemedicine to limit potential exposure in physician offices. Cost sharing will be waived for all virtual visits through the Aetna-covered Teladoc® offerings and in-network providers. Self-insured plan sponsors will be able to opt-out of this program at their discretion.
For the 90-day period, Aetna has added the following HCPCS codes below. All telemedicine services not noted will be covered according to Aetna’s current policy. All other telemedicine coverage is stated in the Aetna Telemedicine policy which is available to providers on the NaviNet and Availity portals.
The following codes require an audiovisual connection:
- G2061, G2062, G2063 – Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes; 11 – 20 minutes; or 21 or more minutes
- H0015 GT or 95 – Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
- H0035 GT or 95 – Mental health partial hospitalization, treatment, less than 24 hours.
- H2012 GT or 95 – Behavioral health day treatment, per hour.
- H2036 GT or 95 – Alcohol and/or other drug treatment program, per diem
- S9480 GT or 95 – Intensive outpatient psychiatric services, per diem
- 97151 GT or 95 – Behavior identification assessment, administered by a QHP, face to face with patient and/or guardians administering assessments and discussing findings and recommendations. Includes non-face-to-face analyzing of past data, scoring/interpreting the assessment, and preparing the report/treatment plan.
- 97155 GT or 95 – Adaptive behavior treatment with protocol modification, administered by QHP, which may include simultaneous direction of a technician working face to face with a patient.
- 97156 GT or 95 – Family adaptive behavior treatment guidance administered by QHP, with parent/guardian
- 97157 GT or 95 – Multiple-family group adaptive behavior treatment guidance, administered by QHP, with multiple sets of parents/guardians
- 98970, 98971, 98972 – Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.
- 99421, 99422, 99423 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10; 11-20; or 21 or more minutes.
The following codes require an audiovisual connection or telephone:
- G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
- G2012 – Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
- 98966, 98967, 98968 – Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 21-30 minutes of medical discussion.
- 99441, 99442, 99443 – Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10; 11-20; or 20-30 minutes of medical discussion.
- 90791, 90792; GT or 95 – Psychiatric diagnostic interview examination
- 90832, 90833, 90834, 90836, 90837, 90838; GT or 95 – Individual psychotherapy
- 90839, 90840; GT or 95 – Psychotherapy for crisis; first 60 minutes; or each additional 30 minutes
- 90845; GT or 95 – Psychoanalysis
- 90846, 90847, 90853; GT or 95 – Family or group psychotherapy
- 90863; GT or 95 – Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services
- 96116; GT or 95 – Neurobehavioral status examination
IOP Procedure codes – televideo only
- H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education.
- H2012 Behavioral health day treatment, per hour.
- S9480 Intensive outpatient psychiatric services, per diem.
PHP Procedure codes – televideo only
- H0035 Mental health partial hospitalization, treatment, less than 24 hours.
- H2036 Alcohol and/or other drug treatment program, per diem.
All other virtual visits –
- CPT®code 99241 will be reimbursed for all other synchronous real-time virtual visits when billed with Place of Service 11.
- If the visit is related to COVID-19, the above-mentioned ICD10 diagnosis codes (Z03.818 or Z20.828) are required to be billed and reimbursement will be without customer copay/cost-share.
- If the virtual visit is not related to COVID-19, the ICD10 code for the visit should be billed and reimbursement will be made according to applicable benefits and related cost share.
- No virtual care modifier should be billed
- This billing requirement and associated reimbursement applies to services submitted on CMS1500 claim forms or its electronic equivalent only.
United Healthcare Guidelines
Get Tele health guidelines, codes and modifiers, click here.
Access to Telehealth
To increase system access and flexibility when it is needed most, we are expanding our telehealth policies to make it easier for people to connect with their healthcare provider. People will have access to telehealth services in two ways:
- Designated Telehealth Partners – Members can access their existing telehealth benefit offered through one of UnitedHealthcare’s designated partners for free.
- Expanded Provider Telehealth Access – Effective immediately, for the next 90 days, all eligible in-network medical providers who have the ability and want to connect with their patient through synchronous virtual care (live video-conferencing) can do so. We will waive member cost sharing for COVID-19 testing-related visit
Commercial Payment Policy In addition to the policy, claims payments are subject to other plan requirements for the processing and payment of claims, including, but not limited to, requirements of medical necessity and reasonableness and applicable referral or authorization requirements.
Humana requires a provider to submit a charge for a telehealth service with modifier GT, modifier 95 or POS code 02. Humana commercial plans allow telehealth and interprofessional telephone or internet assessment and management services with the following exception:
- Internet-only telehealth services, Current Procedural Terminology (CPT®) codes 99421-99423, 99444 and 98969-98972, are not allowed unless provided pursuant to a Humana telehealth vendor partnership or when required by an applicable state mandate.
- Medicaid Payment Policy In addition to the policy, claims payments are subject to other plan requirements for the processing and payment of claims, including, but not limited to, requirements of medical necessity and reasonableness and applicable referral or authorization requirements.
Humana Medicaid plans allow telehealth services consistent with federal law and state Medicaid agency requirements.
Definitions of Terms
- Additional telehealth services: Telehealth services provided by an MA plan, beginning in plan year 2020, under Section 1852(m) of the Social Security Act and which are treated as a basic benefit rather than a supplemental benefit.
- Electronic information and telecommunication technology: Technologies and devices which enable secure electronic communications and information exchange and typically involve the application of secure real-time audio/video conferencing or similar services, remote monitoring, or store and forward medical data technology to provide or support health care services.
- Interprofessional telephone or internet assessment and management service: A telephone or internet consultation in which a patient’s treating physician or other qualified health care professional requests the opinion and or treatment advice of a physician with specific specialty expertise to assist the treating physician or other qualified health care professional in the diagnosis and or management of the patient’s problem without the need for the patient’s face-to-face contact with the consultant. (CPT codes 99446 through 99449)
- Modifier 95: Services delivered via telemedicine.
- Modifier GT: Services delivered via interactive video and video telecommunication systems. (For Medicare, effective January 1, 2018, modifier GT is only appropriate for use by critical access hospitals.)
- Original Medicare telehealth services: Telehealth services covered by Original Medicare under Section 1834(m) of the Social Security Act.
- Place of service code 02: The location where health services and health related services are provided or received, through a telecommunication system. (Effective January 1, 2017)
- Supplemental benefit: A primarily health-related item or service, covered as a benefit by a specific MA plan, that Medicare part A, B and D would not cover as a benefit. A supplemental benefit is distinguished from such extended offerings as riders.
- Supplemental telehealth services: Telehealth services provided by an MA plan as a supplemental benefit before plan year 2020.
- Telehealth: A means to deliver health care services to a patient at a different physical location than the health professional using electronic information or telecommunications technologies consistent with applicable state and federal law. Telehealth services include telemedicine services and are also known as virtual visits.
Medicare beneficiaries can temporarily use telehealth services for common office visits, mental health counseling and preventive health screenings. This will help ensure Medicare beneficiaries are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital, which puts themselves and others at risk.
If you have an existing healthcare appointment, or think you need to see your doctor, please call them first to see if your appointment can be conducted over a smartphone with video capability or any device using video technology, like a tablet or a laptop. For some appointments, a simple check-in over the phone without video capabilities may suffice.
Telehealth: What it is
Medicare telehealth services include office visits, psychotherapy, consultations, and certain other medical or health services that are provided by an eligible provider who isn’t at your location using an interactive 2-way telecommunications system (like real-time audio and video).
These services are available in rural areas, under certain conditions, but only if you’re located at one of these places:
- A doctor’s office
- A hospital
- A critical access hospital (CAH)
- A rural health clinic
- A federally qualified health center
- A hospital-based dialysis facility
- A skilled nursing facility
- A community mental health center
Common telehealth services include:
For Office setting
- 99201-99215 (Office or other visits)
- Append Modifier GT
For Emergency room and Hospital and Nursing home setting
- G0425-G0427 (Telehealth consultations, emergency department or inpatient)
- G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospital or SNFs)
Virtual check-ins: What it is
Virtual check-ins are brief 5-10 minutes sessions allow you to talk to your doctor or certain other practitioners, like nurse practitioners or physician assistants, using a device like your phone, integrated audio/video system, or captured video image without going to the doctor’s office.
- HCPCS code G2012
- HCPCS Code G2010
Your doctor or other practitioner can respond to you using:
- Secure text messages
- Use of a patient portal
E-visits: What it is
E-visits allow you to talk to your doctor using an online patient portal without going to the doctor’s office.
Practitioners who may furnish these services include:
- Nurse practitioners
- Physician assistants
- Licensed clinical social workers, in specific circumstances
- Clinical psychologists, in specific circumstances
- Therapists, in specific circumstances
Medicare has a long list of telehealth covered codes, please get the full list here
Medicaid and Medicaid MCO Plans
Please check state specific plans and their guidelines.