Services on Telemedicine Platforms

Reimbursement Policy:
Services on Telemedicine Platforms

Effective Date:
June 1, 2016

Last Revised Date:
June 27, 2017

Purpose:
Provide guidelines for services identified as through telemedicine platforms, and identify when these services may be eligible for reimbursement independent of any existing vendor agreements or special arrangements. This policy applies to professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

  • Medicare Advantage.

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

  • Services on Telemedicine Platforms: The delivery of healthcare services through the use of HIPAA-compliant secure interactive audio-video, or other electronic media for the purpose of diagnosis, consultation, and/or treatment of a patient when the patient is in one location (i.e. “originating site”) and the provider is in any other location (i.e., “distant site”) at the time service is provided.

Policy:
Reimbursement for services on telemedicine platforms may be available as follows:

  1. Real time (synchronized) services on telemedicine platforms may be eligible for separate reimbursement as part of this Health Plan’s benefits when such services meet all the requirements of a face-to-face consultation or contact between a health care provider and patient.

    Reimbursement for telemedicine/telehealth services is limited to services involving the use of interactive audio-video or other interactive electronic media for the purpose of diagnosis, consultation, or treatment.

  2. In order for services on telemedicine platforms to be eligible for reimbursement as part of this Health Plan’s benefits, the provider shall be appropriately licensed in the state where the patient is physically located at the time of the telehealth encounter (“originating site”).

  3. Professional services rendered via an interactive telecommunication system as part of a Health Plan’s benefits are only eligible for reimbursement to the distant site provider rendering the services on telemedicine platforms. Any originating site provider rendering in-person services should report the appropriate code for the in-person services

  4. Distant site providers should utilize the appropriate CPT or HCPCS codes with modifiers GT or 95 to facilitate a telemedicine encounter where applicable as described below relative to Evaluation and Management codes. These modifiers must be reported to differentiate a telemedicine encounter from an encounter when the physician and patient are at the same site.

  5. The following list of codes is provided as an informational tool only, to help identify some of the applicable Current Procedural Terminology (CPT®) codes/code ranges and Healthcare Common Procedure Coding System Level II (HCPCS) codes that may be utilized in reporting services provided on telemedicine platforms. The inclusion of a specific code does not indicate eligibility for reimbursement and/or coverage in all situations.

    Codes that ordinarily describe direct face-to-face services but signify services provided on telemedicine platforms when used with modifier GT (via interactive audio and video telecommunications systems):

    CPT Codes

    99201-99205, 99211-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99407, 99408-99409, 90791-90792, 90832-90838, 90839-90840, 90863, 90951-90961, 90963-90965, 90967-9970, 96116, 96150-96151, 96152-96154, 97802-97804, 99497-99498

    HCPCS Codes

    G0108-G0109, G0270, G0396-G0397, G0406, G0407, G0408, G0420-G0421, G0425-G0427, G0436-G0437, G0438-G0439, G0442-G0447, G0459, G0466-G0470, G0473, G0508-G0509, S0199

Evaluation and Management codes that ordinarily describe direct face-to-face services but signify services provided on telemedicine platforms when used with modifier 95 (synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system):

CPT Codes

99201-99205, 99212-99215, 99231-99233, 99241-99245, 99251-99255, 99307-99310, 99406-99409

The following services shall not be considered for reimbursement under this policy:

  • Non-direct patient services (e.g. coordination of care rendered before or after patient interaction will not be considered for reimbursement.

  • Services rendered by audio-only telephone communication, facsimile, e-mail, or any other on-secure electronic communication.

  • Claims submitted with modifier “GQ”, which signifies services provided via asynchronous telecommunications system, as these services do not include direct in-person patient contact.

  • Any service that is not eligible for separate reimbursement when rendered to the patient in-person.

  • Presentation/origination site facility fee

  • Services rendered by a primary care provider (PCP) to a patient on their capitation list

  • CPT Codes 99441-99444.

Utilization review may be performed. Documentation in the medical record must be maintained and must support the services rendered.

CMS 2017 place of service code ‘02’ does not apply to this policy.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall consider for reimbursement services provided on telemedicine platforms when the CPT/HCPC codes provided in this policy are appropriately billed with modifier GT or modifier 95..

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit

  • Provider Participation Agreement

  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity

  • Mandated or legislative required criteria will always supersede.

History:
2/1/2016: Policy Approved
2/26/2016: Per DOBI request, changed all references to Telemedicine Services to Services on Telemedicine Platform.
6/27/2017: Updated policy to include 2017 AMA modifier 95 and services applicable to modifier 95. Added language about HIPAA compliant technology and provider subjectivity to utilization and medical records review. Clarified applicability of CMS place of service value 02. Removed references to “Horizon approved programs”.

CPT® is a registered mark of the American Medical Association.

Policy 093_v1.0_06272017