The following is a grid of Telehealth billing guidelines by payer. We will attempt to update this table as we garner more information from our various clients and various resources.
Related: Performing Telemedicine Visits in AthenaPractice (formerly Centricity Practice Solutions)
Billing Guidelines Grid
| Payer | Notes | CPT | Modifier | POS |
|---|---|---|---|---|
| Aetna-Commercial Plans | Aetna will offer zero-copay telemedicine visits for any reason until June 4, 2020. Aetna will waive cost sharing for all video visits through the Aetna covered Teladoc system and in-network providers who deliver synchronous virtual care (a real-time visual connection) for all commercial plans (please note- self-insured plan sponsors can opt out of this program at their discretion) | G2010, G2012, 99441,99442 and 99443 | GT or 95 | 02 |
| Aetna - Medicare Advantage Plans | Until further notice, Aetna is expanding coverage of telemedicine visits to its Aetna Medicare members. With this change and the new flexibilities announced by CMS and Medicaid services, Aetna Medicare members can now see their providers virtually via telephone or video. Aetna is also offering its Medicare Advantage members brief virtual check-in visits and waiving the copayments. Aetna will offer zero-copay telemedicine visits for any reason until June 4, 2020. Aetna will waive cost sharing for all video visits through the Aetna covered Teladoc system and in-network providers who deliver synchronous virtual care (a real-time visual connection). | See Medicare CPT Code Listing and G2010, G2012 | N/A | 02 |
| Allways Healthcare | Allways Healthcare is working with Microsoft to offer a virtual visit platform for providers in the network. Allways Healthcare will host free webinars for providers who are interested in adding virtual visits to their services. Please refer to the Allways Healthcare website for additional information. Allways Healthcare is not reimbursing for telephone (only) communication/visits at this time. | TBD | TBD | TBD |
| BCBS of Massachusetts – Commercial Plan | Blue Cross Blue Shield of Massachusetts providers must deliver telehealth (telemedicine) services via a secure and private data connection. All transactions and data communication must comply with the HIPAA. Blue Cross of Massachusetts does not reimburse for telephone (only) communication/visits at this time | 99201-99205, 99211-99215 99401-99403 | GT or 95 | 02 |
| BCBS of Massachusetts – Medicare Advantage Plans | Blue Cross Blue Shield of Massachusetts providers must deliver telehealth (telemedicine) services via a secure and private data connection. All transactions and data communication must comply with the HIPPA. Blue Cross of Massachusetts does not reimburse for telephone (only) communication/visits at this time | 99201-99205, 99211-99215 99401-99403 | GT or 95 | 02 |
| Cigna Healthcare - Commercial Plan | Cigna will reimburse phone calls, real-time synchronous virtual visits without copay or cost share for all individuals. | G2012 & 99241 | n/a | 02/11 |
| Harvard Pilgrim Health Care - Commercial Plan | Telemedicine Services using telemedicine technologies between a provider in one location and a patient in another location, may be reimbursed when all of the following conditions are met: Medical information is communicated in real-time with the use of interactive audio and video communications equipment. The real-time communication is between the patient and a physician or health care specialist who is performing the service reported where the patient is present and participating at the time of service. The components of any evaluation and management services (E&M) provided via the telemedicine technologies includes at least a problem focused history and straight forward medical decision making, as defined by the current version of the Current Procedural Terminology (CPT) manual. All services provided are medically appropriate and necessary. Providers performing and billing telemedicine/telehealth services are eligible to independently perform and bill the equivalent face to face service. The encounter satisfies the elements of the patient provider relationship, as determined by the relevant healthcare regulatory board of the state where the patient is physically located. The service is conducted over a secured and encrypted channel and a permanent record of online communications relevant to the ongoing medical care and follow-up of the patient is maintained as part of the patient’s medical record. Services that are filed with the required modifiers and place of service codes Telehealth Reimbursement is provided for telephone E&M services (5-10 minutes of medical discussion) up to a maximum of two visits per calendar year for members with specific behavioral health diagnosis, for the purposes of medical management. Such E&M services must be documented in the member’s medical record. | 99201-99215, 99441-99443 | GT or 95 | 02 |
| Mass Health (MA Medicaid) | Mass Health will also reimburse physicians, including mid-level practitioners, for telephonic codes beginning on April 1, 2020 for dates of service on or after March 12, 2020. Mass Health is not imposing specific requirements for technologies used to deliver services via telehealth and will allow reimbursement for MassHealth covered services delivered through telehealth as long as the services are medically necessary and clinically appropriate. Requirements for Telehealth Encounters are that Providers must adhere to and document the following best practices when delivering services via telehealth. 1. Providers must properly identify the patient using, at a minimum, the patient’s name, date of birth, and MassHealth ID. 2. Providers must disclose and validate the provider’s identity and credentials, such as the provider’s license, title, and, if applicable, specialty and board certifications. 3. For an initial appointment with a new patient, the provider must review the patient’s relevant medical history and any available medical records with the patient before initiating the delivery of the service. 4. For existing provider-patient relationships, the provider must review the patient’s medical history and any available medical records with the patient during the service. 5. Prior to each patient appointment, the provider must ensure that the provider is able to deliver the service to the same standard of care and in compliance with licensure regulations and requirements, programmatic regulations, and performance specifications related to the service (e.g., accessibility and communication access) using telehealth as is applicable to the delivery of the services in person. If the provider cannot meet this standard of care or other requirements, the provider must direct the patient to seek in-person care. The provider must make this determination prior to the delivery of each service. 6. To the extent feasible, providers must ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform members of any relevant privacy considerations. 7. Providers must follow consent and patient information protocol consistent with those followed during in person visits. 8. Providers must inform patients of the location of the provider rendering services via telehealth (i.e., distant site) and obtain the location of the patient (i.e., originating site). 9. The provider must inform the patient of how the patient can see a clinician in-person in the event of an emergency or as otherwise needed | 99441, 99442, 99443 and for | N/A | 02 |
| Tufts Health Plan - Commercial Plans | Tufts Health Plan will compensate providers at 100% of the in-office rate as specified in their provider agreements or fee schedules for telehealth All Tufts Health Plan contracting providers can provide telemedicine services to our members (medical, behavioral health and ancillary health visits) This will also include telephone consultation Tufts Health Plan will waive member cost share for any primary care and behavioral health service Documentation requirements for a telehealth service are the same as those required for any face-to-face encounter, with the addition of the following: A statement that the service was provided using telemedicine or telephone consult The location of the patient The location of the provider The names of all persons participating in the telemedicine service or telephone consultation service and their role in the encounter. This applies for all diagnoses and is not specific to a COVID-19 diagnosis This is intended to prevent people from having to leave their house to receive care Note for Behavioral Health Providers: For the time period specified above, there are no restrictions on service type. Additionally, the usage of audio without video is acceptable. Providers must use appropriate modifiers to indicate when telehealth services have been rendered | qualified non physicians | GT/GQ | 02 |
| United Healthcare Commercial Plans & Medicare Advantage | Latest UHC updates: Please click here for the latest UHC updates Currently reimburse for “virtual check-in” patients to connect with their doctors remotely. These services are for established patients, not related to a medical visit within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available). These services can be billed when furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010). Audio Only For commercial, Medicaid, and Medicare Advantage members, UnitedHealthcare reimburses the following audio-only or digital services for virtual check-in: 1) Services through several communication technology devices, such as telephone (Healthcare Common Procedure Coding System (HCPCS) code G2012) 2) Captured video or image (HCPCS code G2010) These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners, where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. For audio and video telecommunications, during the public health emergency, the requirement for a pre-existing patient relationship has been waived. This applies to all of our Medicare, Medicaid and commercial plan members. https://www.uhcprovider.com/en/resource-library/news/Novel-Coronavirus-COVID-19/covid19-telehealth-services/covid19-telehealth-services-virtual-visits.html | G2012 & G2010 98966, 98967 & 98968 | GT/GQ/95 | 02 |
| Medicare | Documentation requirements for a telehealth service are the same as that required for any face-to-face patient encounter, with the addition of the following: • A statement that the service was provided using telemedicine; • The location of the patient; • The location of the provider; and • The names of all persons participating in the telemedicine service and their role in the encounter. | 99201-99205 99211-99215 | GT | 02 |
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