Medicare Advantage

Telehealth Services for Medicare Advantage Members (updated May 13, 2021)


Policy Impacted


Supersedes MA00.036g Telehealth Services

Purpose


The purpose of this document is to provide advance notice regarding coverage for telehealth services for our Medicare Advantage members in response to Coronavirus Disease 2019 (COVID-19).


This communication addressing telehealth services is effective from March 6, 2020 through the duration of the Federal Public Health Emergency.​


This policy communication addressing telehealth services for Medicare Advantage members has been revised as follows:

  • This document replaces the version published on March 19, 2021.

  • The following CPT codes, which became effective March 30, 202​1, have been added to this policy: 92526, 92550, 92552, 92553, 92555, 92556, 92557, 92563, 92565, 92567, 92568, 92570, 92587, 92610, 92625, 92626, 92627.

Background


There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected both nationally and internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.

In response to the current COVID-19 outbreak, the Centers for Disease Control and Prevention (CDC) recommends that professional providers conduct telephonic and telemedicine services to triage and assess individuals to prevent transmission of the respiratory virus.

The CDC discusses prevention and treatment of COVID-19 on their website at https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html.

To help reduce potential exposure, members and participating providers may utilize telehealth services as detailed below and available as part of a member’s plan.

Coverage Statement


Coverage is subject to the terms, conditions, and limitations of the member's contractThe 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.

Telehealth services are eligible for reimbursement consideration by the Company when all the following criteria are met:
  • The services are medically necessary and able to be delivered using one of the following modes of communication:
    • Interactive, synchronous (real-time) two-way audio and video communications
      • Note: The services that are covered only if delivered through an audiovisual (Interactive, synchronous (real-time) telecommunication are outlined in the table below
    • A telephone (i.e., audio telecommunication only/telephone call) or online digital communication
  • Covered services provided through the Company's network of eligible providers include, but are not limited to:
    • Primary care 
    • Specialty care (including behavioral health)
    • Medical nutrition therapy
    • Physical therapy
    • Occupational therapy
    • Speech therapy
    • Home care
      • Skilled nursing (intermittent; not including private duty nursing)
      • Physical therapy
      • Occupational therapy
      • Speech therapy
      • Medical nutrition therapy
      • Social services
    • Urgent care
  • The telehealth services are reported with one of the procedure codes listed in the coding section below.
    Services covered through audiovisual only (Interactive, synchronous (​real-time) telecommunication mode)
    Outpatient Physical Therapy/Occupational Therapy
    Urgent Care
    Home Care - Skilled Nursing (intermittent; not including private duty nursing)
    Home Care - Physical Therapy
    Home Care - Occupational Therapy
    Orthotics/Prosthetic Training

For products with capitation arrangements, services delivered through telehealth are considered included in capitation with the exception of those services identified in applicable policies identifying fee for service reimbursement. Refer to the appropriate claim payment policies for list of exceptions to capitation arrangements.

REQUIRED DOCUMENTATION

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.

BILLING REQUIREMENTS

Eligible professional providers performing telehealth services must report the appropriate place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine services.

Telemedicine evaluation and management reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report revenue code 0780 along with an appropriate evaluation and management procedure code appended by the GT or 95 modifier, as needed.

Telemedicine ancillary services (e.g. PT/OT/ST) 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.

Inclusion of a code in this communication does not imply reimbursement. Eligibility, benefits, limitations, exclusions, provider contracts, and Company policies apply.​

Coding


PROCEDURE CODES

ELIGIBLE PROCEDURE CODES

Primary Care / Specialty Care (including Behavioral Health)

77427, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90875, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 92002, 92004, 92012, 92014, 92601, 92602, 92603, 92604, 93750, 94002, 94003, 94004, 94664, 95970, 95971, 95972, 95983, 95984, 96110, 96112, 96113, 96116, 96121, 96125, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 96170, 96171, 97150, 97151, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99406, 99407, 99421, 99422, 99423, 99441, 99442, 99443, 99468, 99469, 99471, 99472, 99473, 99475, 99476, 99477, 99478, 99479, 99480, 99483, 99495, 99496, 99497, 99498, G0071, G0108, G0109, G0296, G0396, G0397, G0406, G0407, G0408, G0420, G0421, G0425, G0426, G0427, G0438, G0439, G0442, G0443, G0444, G0445, G0446, G0447, G0459, G0506, G0508, G0509, G0513, G0514, G2025, G2086, G2087, G2088, G2212, G9685​

Virtual Check-ins

G2010, G2012, G2061, G2062, G2063, G2250, G2251, G2252​


Cardiac Rehabilitation

93797, 93798, G0422, G0423, S9472

Pulmonary Rehabilitation

G0424, S9473

Medicare Diabetes Prevention Program (MDPP)

G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880, G9881, G9882, G9883, G9884, G9885, G9890, G9891

Intensive Outpatient Services

H0015, S9480

Partial Hospitalization

H0035, S0201

Medical Nutrition Therapy

97802, 97803, 97804, G0270

Physical / Occupational Therapy

97110, 97112, 97116, 97129, 97130, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97542, 97750, 97755, 97760, 97761​​

Speech Therapy

92507, 92508, 92521, 92522, 92523, 92524, 92526, 92550, 92552, 92553, 92555, 92556, 92557, 92563, 92565, 92567, 92568, 92570, 92587, 92607, 92608, 92609, 92610, 92625, 92626, 92627, 97129, 97130, G0153, G0161, S9128, S9152


Urgent Care Providers

S9083

Remote Monitoring

99453, 99454, 99457, 99458

MODIFIERS

95, GT, G0

REVENUE CODES

Home Care - Social Services

0561, 0562

Home Care - Nurse

0551

Physical Therapy

0420, 0421, 0422, 0424

Occupational Therapy

0431, 0432, 0434

Speech Therapy

0441, 0442, 0444

Home Care - Nutritional Therapy

0590

Intensive Outpatient Services

0905, 0906

Partial Hospitalization

0912, 0913

Hospice

0651, 0652, 0655, 0656

Cardiac Rehabilitation

0943

Pulmonary Rehabilitation

0948

Telemedicine

0780

NON-COVERED

98970, 98971, 98972, S0320, S5185

NOT ELIGIBLE FOR REIMBURSEMENT

Q3014



5/13/2021