Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.
Note: This communication does not address services provided through the Company's contracted telemedicine vendor.
Speech therapy performed through telemedicine via a secure Health Insurance Portability and Accountability Act (HIPAA)--compliant telecommunications system using interactive, synchronous (real-time) two-way audio and video communications is covered and is eligible for reimbursement consideration by the company when reported by one of the procedure codes in the coding section below.
NOT ELIGIBLE FOR REIMBURSEMENT
Speech therapy performed through telemedicine is not eligible for reimbursement consideration for the following:
- Transmission of digitalized data between the provider and individual reported with modifier GQ is not reimbursed separately from the subsequent synchronous service.
- Administrative matters, including but not limited to, scheduling, registration, updating billing information, reminders, requests for medication refills or referrals, ordering of diagnostic studies, and medical history intake completed by the patient.
- Any CPT or HCPCS code that is not listed in the code section of this communication if billed with modifier 95 or GT or place of service 02.
- Any equipment used for telemedicine communications.
- Communications including, but not limited to reporting of test results and provision of educational materials are incidental to medical services included in this communication.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the professional provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Professional providers performing speech therapy through telemedicine must report the appropriate modifier (modifier GT or 95) and place-of-service code 02 (Telehealth) to represent telemedicine services.
Speech therapy performed through telemedicine reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report the appropriate revenue code (shown below) along with the corresponding procedure code representing the service provided appended by the GT or 95 modifier, as needed.
Speech therapy performed through telemedicine is only reimbursed when reported with eligible procedure codes, appropriate
modifiers, and the place of service code identified in this communication. Any
applicable member cost-share will be applied.
Inclusion of a code in this communication does not imply reimbursement. Eligibility,
benefits, limitations, exclusions, precertification/referral requirements,
provider contracts, and Company policies apply.