1 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information. Definition: There are three types of telehealth services: • Asynchronous Telehealth (Store & Forward) is the transfer of digital images, sounds, or previously recorded video from one location to another to allow a consulting practitioner (usually a specialist) to obtain information, analyze it, and report back to the referring practitioner. This is a non-interactive telecommunication because the physician or health care practitioner views the medical information without the patient being present. • Synchronous Telehealth is real-time interactive video teleconferencing that involves communication between the patient and a distant practitioner who is performing the medical service. The practitioner sees the patient throughout the communication, so that two-way communication (sight and sound) can take place. • Remote Patient Monitoring is use of digital technologies to collect health data from individuals in one location and electronically transmit that information to providers in a different location for assessment. For the purposes of this document, the guidelines below are specific to synchronous telehealth with the originating site being the patient’s home, as that will be the most applicable during the COVID-19 pandemic. CPT/HCPCS Codes: Telehealth eligible CPT/HCPCs codes vary by payor, refer to payor guidelines section. Reporting Criteria: • Report the appropriate E/M code for the professional service provided. • Communication must be performed via live two-way interaction with both video and audio. • Please refer to the BCBS NE section of this document for their recent changes on this requirement. • All payors had previously required that communications be performed over a HIPAA compliant platform. CMS has waived this requirement, however some of the other payors have not. • Refer to the HIPAA Compliant section for more details. Documentation Requirements: Telehealth services have the same documentation requirements as a face-to-face encounter. The information of the visit, history, ROS, consultative notes or any information used to make a medical decision about the patient should be documented. In addition, the documentation should note that the service was provided through telehealth, both the location of the patient and the provider, and the names and roles of any other persons participating in the telehealth visit. Obtain verbal consent at the start of the visit and ensure consent is documented. Maintain a permanent record of the telehealth visit in the patient’s medical record. * *Note-NE Medicaid has specific documentation and consent requirements, refer to the Medicaid section for additional details. Definition: Online Digital Evaluation and Management Services (E-Visits) are an E/M service provided by a Qualified Healthcare Professional or an assessment provided by a Qualified Nonphysician Healthcare Professional to a patient using an audio and visual software-based communication, such as a patient portal. CPT/HCPCS Codes: Reportable by a Qualified Healthcare Professionals: • 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes. • 99422: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes. E-VISITS COVID-19 Virtual Visit & Reimbursement Guide Original: March 14 th , 2020 Revised: 03/18/2020, 03/23/2020, 03/24/2020, 03/26/2020, 03/30/2020, 4/6/2020, 4/13/2020, 4/17/2020 VIRTUAL VISIT TYPES TELEHEALTH
Transcript
1 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Definition: There are three types of telehealth services:
• Asynchronous Telehealth (Store & Forward) is the transfer of digital images, sounds, or previously recorded
video from one location to another to allow a consulting practitioner (usually a specialist) to obtain information,
analyze it, and report back to the referring practitioner. This is a non-interactive telecommunication because the
physician or health care practitioner views the medical information without the patient being present.
• Synchronous Telehealth is real-time interactive video teleconferencing that involves communication between
the patient and a distant practitioner who is performing the medical service. The practitioner sees the patient
throughout the communication, so that two-way communication (sight and sound) can take place.
• Remote Patient Monitoring is use of digital technologies to collect health data from individuals in one location
and electronically transmit that information to providers in a different location for assessment.
For the purposes of this document, the guidelines below are specific to synchronous telehealth with the originating site
being the patient’s home, as that will be the most applicable during the COVID-19 pandemic.
CPT/HCPCS Codes:
Telehealth eligible CPT/HCPCs codes vary by payor, refer to payor guidelines section.
Reporting Criteria:
• Report the appropriate E/M code for the professional service provided.
• Communication must be performed via live two-way interaction with both video and audio.
• Please refer to the BCBS NE section of this document for their recent changes on this requirement.
• All payors had previously required that communications be performed over a HIPAA compliant platform. CMS has
waived this requirement, however some of the other payors have not.
• Refer to the HIPAA Compliant section for more details.
Documentation Requirements: Telehealth services have the same documentation requirements as a face-to-face
encounter. The information of the visit, history, ROS, consultative notes or any information used to make a medical
decision about the patient should be documented. In addition, the documentation should note that the service was
provided through telehealth, both the location of the patient and the provider, and the names and roles of any other
persons participating in the telehealth visit. Obtain verbal consent at the start of the visit and ensure consent is
documented. Maintain a permanent record of the telehealth visit in the patient’s medical record. * *Note-NE Medicaid has specific documentation and consent requirements, refer to the Medicaid section for additional details.
Definition: Online Digital Evaluation and Management Services (E-Visits) are an E/M service provided by a Qualified
Healthcare Professional or an assessment provided by a Qualified Nonphysician Healthcare Professional to a patient
using an audio and visual software-based communication, such as a patient portal.
CPT/HCPCS Codes:
Reportable by a Qualified Healthcare Professionals:
• 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during
the 7 days; 5-10 minutes.
• 99422: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during
the 7 days; 11-20 minutes.
E-VISITS
COVID-19 Virtual Visit & Reimbursement Guide
Original: March 14th, 2020 Revised: 03/18/2020,
03/23/2020, 03/24/2020, 03/26/2020, 03/30/2020,
4/6/2020, 4/13/2020, 4/17/2020
VIRTUAL VISIT TYPES
TELEHEALTH
2 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
• 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during
the 7 days; 21 or more minutes.
Reportable by Qualified Nonphysician Healthcare Professionals (Physical Therapists, Occupational Therapists,
Speech Language Pathologists, Clinical Psychologists Registered Dietitian, etc.):
• G2061/98970: Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven
days, cumulative time during the 7 days; 5-10 minutes.
• G2062/98971: Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven
days, cumulative time during the 7 days; 11-20 minutes.
• G2063/98972: Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven
days, cumulative time during the 7 days; 21 or more minutes.
Reporting Criteria:
• Online visits must be initiated by the patient. However, practitioners can educate beneficiaries on the availability
of e-visits prior to patient initiation.
• The patient typically must be established; however, Medicare has recently waived this requirement.
• E-Visit codes can only be reported once in a 7-day period.
• Cannot report when service originates from a related E/M service performed/reported within the previous 7 days,
or for a related problem within a postoperative period.
• E-Visits are reimbursed based on time.
o The 7-day period begins when the physician personally reviews the patient’s inquiry.
o Time counted is spent in evaluation, professional decision making, assessment and subsequent
management.
o Time is accumulated over the 7 days and includes time spent by the original physician and any other
physicians or other qualified health professionals in the same group practice who may contribute to the
cumulative service time.
o Does not include time spent on non-evaluative electronic communications (scheduling, referral
notifications, test result notifications, etc.). Clinical staff time is also not included.
Documentation Requirements: These are time-based codes, and documentation must support what the physician did
and for how long. Time is documented and calculated over the 7-day duration and must meet the CPTs time requirement.
Obtain verbal consent at the start of the visit and ensure the consent is documented. Maintain a permanent record of the
telehealth visit in the patient’s medical record.
Definition: A brief (5-10 minutes) check in with a practitioner via telephone or other telecommunications device to decide
whether an office visit or other service is needed. A remote evaluation is a recorded video and/or images submitted by an
established patient.
CPT/HCPCS Codes:
• 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.
• 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.
• G0071: Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face)
communication between an rural health clinic (RHC) or federally qualified health center (FQHC) practitioner and RHC or
FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner,
occurring in lieu of an office visit; RHC or FQHC only.
VIRTUAL CHECK-IN
3 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Reporting Criteria:
• The patient typically must be established; however, Medicare has recently waived this requirement.
Communication must be a direct interaction between the patient and the practitioner. Not billable if performed by
clinical staff or practitioner not qualified to perform E/M services.
• If the virtual check-in originates from a related E/M provided within the previous 7 days, then the service is
considered bundled into that previous E/M and would not be separately billable.
• If the virtual check-in leads to an E/M within the next 24 hours or soonest available appointment, then the service
is considered bundled into the pre-visit time of the associated E/M and would not be separately billable.
Documentation Requirements:
Documentation should include medical decisions made, the names and roles of any persons participating in the
evaluation, and the communication method (telephone, video/audio software, etc.). Obtain verbal consent at the start of
the visit and ensure the consent is documented. Maintain a permanent record of the telehealth visit in the patient’s
medical record.
Definition: A telephone visit is an evaluation and management service provided by a qualified healthcare professional or
an assessment and management service provided by a qualified nonphysician health care professional via audio
telecommunication.
CPT/HCPCS Codes: Reportable by Qualified Healthcare Professionals:
• 99441: 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 minutes of medical discussion.
ALLOWABLE Coverage: Effective: March 6th, 2020 Patient Type: Established Only Billing: G2010, G2012
ALLOWABLE Coverage: Effective: March 6th, 2020 Patient Type: Established Only Billing: 99441-99443, 98966-98968.
BCBS NE* * Excludes any FEP or
out-of-state BCBS members.
ALLOWABLE Coverage: Effective: March 13th,2020 Patient Type: Established Billing: CPT 99421-99423 & 98970 -98972.
ALLOWABLE Coverage: Effective: March 13th,2020 Patient Type: New or Established Patients Billing: E&M, Therapy, or Telehealth code w/ Modifier 95 and POS 02.
CONDITIONAL
Virtual Check-In codes (G2012 & G2010) are typically not within the standard BCBS fee schedule, check your fee schedule to see if allowed.
CONDITIONAL
Telephone codes (CPT 99441-99443 & 98966-98968) are typically within the BCBS fee schedule, check your fee schedule to ensure they’re allowable.
MEDICARE ALLOWABLE Coverage: Always Covered Patient Type: New & Established Billing: CPT 99421-99423, HCPCS G2061-G2063.
ALLOWABLE Coverage: Effective: March 6th 2020 Patient Type: New & Established Billing: Professional: Modifier 95 and POS typically used for in-person visit. Method II: Modifier GT.
ALLOWABLE Coverage: Always Covered Patient Type: New & Established Billing: HCPCS G2010, G2012.
ALLOWABLE Coverage: Effective: March 6th 2020 Patient Type: New & Established Billing: 99441-99443, 98966-98968.
NEBRASKA TOTAL CARE
NOT ALLOWABLE ALLOWABLE Coverage: Always Covered Patient Type: Not Specified Billing: POS 02 & GT Modifier.
CONDITIONAL Coverage: Effective: March 1st, 2020 Patient Type: Established Only Billing: Allowed for COVID-19 related DX only. Use HCPCS G2012.
CONDITIONAL Coverage: Effective: March 1st, 2020 Patient Type: Established Only Billing: Allowed for COVID-19 Non-Related DX only. CPT 99441-99443 & 98966-98969.
UHC COMMERICAL
& MEDICARE
ADVANTAGE
ALLOWABLE Coverage: Always Covered Patient Type: Established Only Billing: CPT 99421-99423, HCPCS G2061-G2063.
ALLOWABLE Coverage: Effective: March 14th, 2020 End: June 18th, 2020 Patient Type: Not Specified Billing: Modifier GT (CMS CPTs) 95 (Appendix P). Mcr Advantage-POS 02.
ALLOWABLE Coverage: Always Covered Patient Type: Established Only Billing: HCPCS G2010, G2012.
NOT ALLOWABLE
UHC COMMUNITY
PLAN
ALLOWABLE Coverage: Effective: March 14th, 2020 End: June 18th, 2020 Patient Type: Established Only Billing: CPT 99421-99423, HCPCS G2061-G2063.
ALLOWABLE Coverage: Always Covered Patient Type: Not Specified Billing: Modifier GT (CMS CPTs) 95 (Appendix P) and POS 02.
CONDITIONAL Coverage: Effective: March 1st, 2020 Patient Type: Established Only Billing: Allowed for COVID-19 related DX only. HCPCS G2012.
CONDITIONAL Coverage: Effective: March 1st, 2020 Patient Type: Established Only Billing: Allowed for COVID-19 Non-Related DX only. CPT 99441-99443 & 98966-98969.
WELLCARE NOT ALLOWABLE ALLOWABLE Coverage: Always Covered Patient Type: Not Specified Billing: GT Modifier and POS
02.
ALLOWABLE Coverage: Effective: March 1st, 2020 Patient Type: Established Only Billing: COVID-19 Releated-G2012. Non-Releated-99441-99443.
CONDITIONAL Coverage: Effective: March 1st, 2020 Patient Type: Established Only Billing: Allowed for COVID-19 Non-Related DX only. CPT 99441-99443 & 98966-98969.
PAYOR MATRIX
5 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Effective March 6th, 2020, Aetna expanded their code set to allow E-visit, Virtual Check-In, and Telephone codes as
detailed in the below matrix. Aetna has always allowed synchronous telehealth but had previously followed CMS
guidelines for their Medicare Advantage plans, which restricted the originating site. However, effective March 6th, 2020,
Aetna waived the originating site restriction, allowing telehealth to be performed when a patient is located at their home.
Payor Specific Key Points:
• Modifiers/POS: Use modifier GT for CMS recognized CPTs, modifier 95 for AMA Appendix P CPTs, and modifier
G0 for telehealth services for evaluation or treatment of an acute stroke. Aetna does not have a place of service
requirement in their policy.
• HIPPA Compliant Platform: Non-HIPAA Compliant software can be used, such as Skype & FaceTime.
• Direct Patient Contact: Aetna will not reimburse for services that don’t include direct patient contact. One
example of time spent without direct patient contact is physician standby services.
• Transmission & Originating Site Fees: T1014 and Q3014 are not eligible for payment, Aetna considers these
services as incidental to the charges associated with the E/M.
9 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Nebraska Medicaid and the Nebraska Medicaid MCOs (Nebraska Total Care, WellCare, and UHC Community Plan) cover
telehealth services originating from a patient’s home or any other location where a patient is located.
Payor Specific Key Points:
• Modifiers/POS:
o Nebraska Total Care: Modifier GT and place of service 02.
o UHC Community Plan: Modifier GT for CMS recognized CPTs and modifier 95 for AMA Appendix P
CPTs. Place of service 02.
o WellCare: Modifier GT with place of service 02.
• Patient Type: New & Established for Telehealth.
• Transmission Fees: Medicaid does reimburse practitioners for transmission costs if services were NOT provided
by an internet service provider. Transmission costs can be billed in minutes with HCPCS code T1014.
• Originating Site Fee: If applicable, Medicaid will reimburse an originating site fee (HCPCS Q3014).
• Audio Only: Per the NE Medicaid FAQ updated March 23rd, 2020, “In instances where it is documented that the
beneficiary does not have access to audio/visual (telehealth) equipment, DHHS will allow telephonic treatments or
services if it is clinically appropriate and the treatment or service can meet the standard service expectations.”
• Qualified Telehealth Providers: Under Nebraska statutes, including but not limited to N.R.S. § 38-1,143,
currently authorize “any credential holder under the Uniform Credentialing Act” to use telehealth in establishing a
provider-patient relationship, except those holding credentials under the following: o Cosmetology, Electrology, Esthetics, Nail Technology, and Body Art Practice Act; Dialysis Patient Care Technician Registration Act;
Environmental Health Specialists Practice Act; Funeral Directing and Embalming Practice Act; Massage Therapy Practice Act;
Medical Radiography Practice Act; Nursing Home Administrator Practice Act; Perfusion Practice Act; Surgical First Assistant
Practice Act; Veterinary Medicine and Surgery Practice Act; and Water Well Standards and Contractors’ Practice Act.
• HIPAA Compliant Platform: Although the OCR announced that it will waive penalties for HIPAA violations
against providers that provide services to patients in good faith through everyday communications technologies,
Medicaid has NOT waived their HIPAA compliant platform requirement. There is some conflicting information in
NE Medicaid’s telehealth FAQ, however ruralMED did confirm with a NE Medicaid Representative that providers
must use a certified HIPAA-compliant platform.
• Documentation Requirements: Along with standard documentation requirements, Medicaid also requires
documentation of which site initiated the call, the telecommunication technology utilized, and the time the
telehealth service began and ended.
• Cost Share Waiver:
o Nebraska Total Care: Will waive member cost sharing for COVID-19 related diagnostic testing and
COVID-19 related treatments in the doctor’s office, emergency room, and telehealth.
o UHC Community Plan: Will waive member cost sharing for COVID-19 related diagnostic testing and
telehealth visits associated with COVID-19 or any other DX through June 18th.
o WellCare: Will waive member cost sharing for COVID-19 related diagnostic testing and telehealth.
• Medicaid Informed Consent:
o Per the Nebraska DHHS Medicaid Program Manual, section 1-006.05, before an initial telehealth
consultation, the health care practitioner shall provide the client the following written information which
must be acknowledged by the client in writing or via email:
▪ Alternative options are available, including in-person services, and these alternatives are specifically listed
on the client’s informed consent statement.
▪ All existing laws and protections for services received in-person also apply to telehealth, including
confidentiality of information, access to medical records, and dissemination of client identifiable information.
▪ Whether the telehealth consultation will be or will not be recorded.
▪ The client has a right to be informed of all the parties who will be present at each telehealth consultation and
has the right to exclude anyone from the originating or the distant site.
• On March 23rd, 2020, Nebraska Medicaid announced that due to the current COVID-19 emergency in
effect for Nebraska, they will not require written consent prior to a telehealth service being
provided and insurance claims for telehealth will not be denied solely on the basis of lack of a
signed written statement. However, they do state written consent should occur when possible, and the
NEBRASKA MEDICAID
MEDICAID TELEHEALTH
10 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
provider must document the reason the written consent was unable to be obtained. Even though written
consent is not required to be obtained during this emergency time period; the patient must receive the
following information verbally:
▪ Patient has the option to refuse telehealth without affecting patient’s right to future care
▪ Provider must inform the patient all existing confidentiality protections shall apply to service being provided
by telehealth
▪ Sharing of any patient identifiable images or information from the telehealth visit to researchers or other
individuals will not occur without the consent of the patient
• Safety Plan:
▪ For each adult client or for a client who is a child but who is NOT receiving telehealth behavioral
health services, a safety plan must be developed, should it be needed at any time during or after
the provision of telehealth. This plan shall document the actions the client and the health care
practitioner will take in an emergency or urgent situation that arises during or after the telehealth
consultation.
(There are additional consent and safety plan requirements for a child receiving telehealth behavioral health services
that can be found in the Nebraska DHHS Medicaid Program Manual, section 1-006.05).
• Reimbursement: Medicaid has not published a specific list of telehealth allowable codes. Reimbursement rates
are the same as the comparable in-person rates published in the Medicaid 2020 Physician Fee Schedule. Any
treatment or service that requires “hands-on” service by the provider cannot be done via telehealth or telephone.
o Although Medicaid has not published a list of allowable telehealth codes, on March 23rd, 2020, they did
state in their FAQ that the following services are allowable:
▪ Physical Therapy: “MLTC has allowed some routine services, such as occupational therapy and physical therapy, to
be delivered via telehealth in accordance with existing service definitions. Services that are available via telehealth, which
needs to be both audio and visual, are: Therapeutic procedure, one or more areas, each 15 minutes; therapeutic
exercises to develop strength, endurance and flexibility (97110). Therapeutic procedure, one or more areas, each 15
minutes; neuromuscular and or proprioception for sitting and or standing activities (97112). Re-evaluation of occupational
therapy established plan of care typically 30 minutes (97168). Re-evaluation of physical therapy, typically 20 minutes
(97164). Any service that requires “hands on” service by the provider cannot be done via telehealth or telephone.”
▪ Speech Therapy: “MLTC has allowed some routine services, such as speech therapy, to be delivered via telehealth in
accordance with existing service definitions. This remains unchanged. Services that are available via telehealth, which
needs to be both audio and visual are: Treatment of speech, language, voice, communication, and or auditory processing
disorder, individual (92507). Group treatment of speech, language, voice, communication, and or auditory processing
disorder (92508). Speech therapies are not allowed to be provided via telephone.”
• Excluded Telehealth Services: Includes inpatient services, crisis stabilization, mental health and substance use
disorder residential services, mental health respite, social detoxification, hospital diversion, and day treatment.”
On March 17th, 2020, Nebraska Medicaid announced that they would expand coverage to include additional forms of clinical services, specifically audio only (telephone) visits. These services can be billed retrospectively to March 1st, 2020. Payor Specific Key Points:
The following are related to audio only (telephone) services:
• COVID-19 Related: If a patient is actively experiencing mild symptoms of COVID-19 (fever, cough, shortness of
breath), then report G2012.
• COVID-19 Related RHC & FQHC: If a patient is actively experiencing mild symptoms of COVID-19 (fever, cough,
shortness of breath), then report G0071.
• Unrelated COVID-19 Visits: If a patient is requiring routine, uncomplicated follow-up for chronic disease or
routine primary care, and are not experiencing symptoms of COVID-19, utilize CPT 99441-99443.
• Behavioral Health Visits: If a patient is requiring a behavioral health assessment utilize CPT 98966-98968.
• Reimbursement:
MEDICAID TELEPHONE SERVICES
CPT Allowable CPT Allowable
99441 $14.47 98966 $11.75
99442 $28.71 98967 $20.67
99443 $46.40 98968 $32.42
G2012 $13.82 G0071 Pending Received on March 20th, 2020 via e-mail from a Nebraska
Medicaid Program Manager
MEDICAID TELEPHONE/VIRTUAL CHECK-IN
11 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Effective March 18th, 2020, UHC is temporarily waiving the CMS originating site restriction on telehealth for their
Commercial and Medicare Advantage plans. Furthermore, UHC will reimburse E-Visits and Virtual Check-Ins for all their
service lines (Commercial, Medicare Advantage, and Medicaid). These changes will be effective until June 18th, 2020.
Payor Specific Key Points:
• Modifiers/POS:
o Telehealth: Use modifier GT for CMS recognized CPTs, modifier 95 for AMA Appendix P CPTs, and
modifier G0 for telehealth services for diagnosis, evaluation, or treatment, of an acute stroke. UHC
recognizes, but does not require, place of service 02 for their commercial plan. However, they do require
place of service 02 for their Medicare Advantage Plan.
o E-Visits & Virtual Check-Ins: These services do not require a modifier or specific place of service.
• Video Component: UHC is waiving the audio-video requirement for Medicare Advantage, Medicaid and
Commercial members from March 18, 2020 -June 18, 2020. Eligible care providers can bill for telehealth services
performed using interactive audio/video or audio only, except in the cases where we have explicitly denoted the
need for interactive audio/video such as with PT/OT/ST.
• Eligible Providers: UHC follows CMS’ policies on the types of care providers eligible to deliver telehealth
services. These include physician, nurse practitioner, physician assistant, nurse-midwife, clinical nurse specialist,
registered dietitian or nutrition professional, clinical psychologist, clinical social worker, certified registered nurse
anesthetists. However, on 4/5/2020 UHC added the following statement to their eligible provider list: “Due to
updated legislation, we have also expanded reimbursement for providers as well as physical, occupational,
speech and chiropractic therapists for telehealth services.”
• Transmission & Originating Site Fees: T1014 and Q3014 are not eligible for payment, UCH considers these
services as incidental to the charges associated with the E/M.
• Cost Share Waiver: Beginning March 31st, 2020 through June 18th, 2020, UHC will waive member cost sharing
for all in-network telehealth visits. UHC is also waiving member cost sharing for treatment of COVID-19 through
May 31st, 2020. These changes are applicable to their Commercial, Medicare Advantage, and Medicaid Plans.
• Allowable Telehealth Codes: Effective March 18th-June 18th 2020, UHC will allow all codes on the CMS covered
telehealth code list. Any code on UHC’s telehealth eligible code list can still also be used.
• Reimbursement: Refer to your United Healthcare contract for reimbursement rates.
13 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
CMS issued two new HCPCS codes for COVID-19 diagnostic testing, U001 and U002. The AMA also released a new
CPT code (87635) for COVID-19 diagnostic testing on March 13th, 2020. CMS announced on March 23rd, 2020 that
laboratories can also use CPT 87635 to bill Medicare if the lab uses the method specified by CPT 87635.
CPT/HCPCS CODES
CPT Issuer Description
U0001 CMS 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when
specimens are sent to the CDC and CDC-approved local/state health department laboratories.
U0002 CMS 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or
subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial
laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health
department laboratories.
87635 AMA Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique. Note: Only report 87635 OR U0001-U0002. CPT and HCPCS codes should not both be reported on the same claim. Determination of which code to use
depends solely on the payor’s requirements.
PAYOR REIMBURSMENT GUIDELINES
Payor HCPCS
U0001
HCPCS
U0002
CPT
87635
Aetna
Accepted: Yes
Reimbursement: $35.92
Accepted: Yes
Reimbursement: $51.31
Accepted: Yes
Reimbursement: $51.31
BCBS NE Accepted: Yes
Reimbursement: $51.31
Accepted: Yes
Reimbursement: $51.31
Accepted: Yes
Reimbursement: $51.31
Medicare Accepted: Yes
Reimbursement: $35.92
Accepted: Yes
Reimbursement: $51.31
Accepted: Yes
Nebraska
Total Care
Accepted: Yes
Reimbursement: $35.91
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Accepted: Yes
Reimbursement: $51.31
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Accepted: Yes
Reimbursement: Pending
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
UHC
All Lines of
Business
Accepted: Yes
Reimbursement: $35.92
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Accepted: Yes
Reimbursement: $51.33
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Accepted: Yes
Reimbursement: $51.33
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Wellcare Accepted: Yes
Reimbursement: Pending
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Accepted: Yes
Reimbursement: Pending
Billable: April 1st, 2020
DOS: February 4th, 2020 Forward
Accepted: Unknown
On March 11th, 2020 President Donald Trump announced that major U.S. insurance companies "have agreed to waive all
copayments for coronavirus treatments", however America’s Health Insurance Plans (AHIP), clarified that insurance
companies are only waiving copays for “testing.” For those who test positive for COVID-19, any treatment costs will not be
waived, including physician office visits.
All major insurance companies have issued statements that costs will be waived for physician ordered diagnostic testing
related to COVID-19 provided at approved locations in accordance with CDC guidelines. Self-insured plan sponsors are
not required to implement the same policy. Other payors have gone a step further and issued waivers for other services
14 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
On March 27th, 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law. As part of
the CARES Act, Congress has authorized RHCs to be a “distant site” for telehealth visits, therefore allowing RHC
practitioners to provide telehealth services.
On April 17th, 2020 CMS issued the following billing and reimbursement guidance for RHCs billing telehealth. RHCs can
begin billing telehealth visits for dates of service effective January 27th, 2020. Any claims you’ve been holding can be
submitted beginning April 17th, 2020.
• Billing:
o For telehealth distant site services furnished between January 27, 2020, and June 30, 2020, RHCs
should apply modifier 95 to the claim. RHCs will be paid at their all-inclusive rate (AIR).
▪ These claims will be automatically reprocessed in July when the Medicare claims processing
system is updated with the new payment rate. RHCs do not need to resubmit these claims for the
payment adjustment.
o For telehealth distant site services furnished between July 1, 2020, and the end of the COVID19 PHE,
RHCs will use an RHC/FQHC specific G code, G2025, to identify services that were furnished via
telehealth. RHC claims with the new G code will be paid at the $92 rate. If the COVID-PHE is in effect
after December 31, 2020, this rate will be updated for 2021.
• Reimbursement: The RHC telehealth payment rate is set at $92.00 per visit, which is the average amount
for all PFS telehealth services on the telehealth list, weighted by volume for those services reported under the
PFS This rate will apply to telehealth visits performed by independent or provider based RHCs.
• Cost Report: Costs for furnishing distant site telehealth services will not be used to determine the RHC AIR
rate but must be reported on the appropriate cost report form. RHCs must report both originating and distant
site telehealth costs on Form CMS-222-17 on line 79 of the Worksheet A, in the section titled “Cost Other
Than RHC Services.”
• Co-Insurance Waiver: “During the COVID-19 PHE, CMS will pay all of the reasonable costs for any service
related to COVID-19 testing, including applicable telehealth services, for services furnished beginning on
March 1, 2020. For services related to COVID-19 testing, including telehealth, RHCs must waive the
collection of co-insurance from beneficiaries. For services in which the coinsurance is waived, RHCs
and FQHCs must put the “CS” modifier on the service line. RHC claims with the “CS” modifier will be paid
with the coinsurance applied, and the Medicare Administrative Contractor (MAC) will automatically reprocess
Payor Cost Sharing Guidelines
Aetna COVID-19 Related Diagnostic Testing Telehealth Visits for ANY Diagnosis- Effective March 6th, 2020 Ends June 4th, 2020
BCBS NE
COVID-19 Related Diagnostic Testing Telehealth Visits for ANY Diagnosis- Effective March 13th, 2020-June 30th 2020
Medicare
COVID-19 Related Diagnostic Testing Telehealth: “Beneficiaries are generally liable for their deductible and coinsurance; however, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs”
Nebraska Total Care
COVID-19 related diagnostic testing and COVID-19 treatments provided in the doctor’s office, emergency room, or via telehealth.
UHC All Lines of Business
Beginning March 31st, 2020 through June 18th, 2020, UHC will waive member cost sharing for all in-network telehealth visits. UHC is also waiving member cost sharing for treatment of COVID-19 through May 31st, 2020. These changes are applicable to their Commercial, Medicare Advantage, and Medicaid Plans
Wellcare COVID-19 related diagnostic testing and telehealth
RURAL HEALTH CLINICS
RURAL HEALTH CLINICSMEDICARE
15 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
these claims beginning on July 1. Coinsurance should not be collected from beneficiaries if the coinsurance is
waived.”
Expanded Virtual Communication Services: Medicare has always allowed for G0071 to be billed, however announced
on April 17th, 2020 CMS is now allowing E-visits (CPTs 99421-9423) and Virtual Check-Ins (G2012 and G2010) to be
performed in the RHC. However, RHCs must submit their claim with HCPCS G0071 instead of using the E-Visit and
Virtual Check-In Codes.
• For claims submitted with G0071 on or after March 1, 2020, and for the duration of the COVID-19 PHE, payment
for G0071 is set at the average of the national non-facility PFS payment rates for the 5 E-visits and Virtual Check-
In codes.
• Claims submitted with G0071 on or after March 1 and for the duration of the PHE will be paid at the new rate of
$24.76, instead of the CY 2020 rate of $13.53. MACs will automatically reprocess any claims with G0071 for
services furnished on or after March 1 that were paid before the claims processing system was updated.
G0071: Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face)
communication between an rural health clinic (RHC) or federally qualified health center (FQHC) practitioner and RHC or
FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC
practitioner, occurring in lieu of an office visit; RHC or FQHC only.
When we asked NE Medicaid if they would be issuing updated billing and reimbursement guidance in response to the
CARES act which allowed RHCs to be a distant telehealth site, an NE Medicaid Public Information Officer stated the
following:
“FQHC and RHC’s are allowed to bill their normal encounter services as they would have prior to COVID, with the GT
Modifier, as long as they are fulfilling the service definition of what they are billing for. If they are performing a service
outside of what would be paid under a typical encounter rate, they would need to bill that separately and get paid on a fee-
for-service basis.”
It is problematic that payors are not consistent in what is allowed for hospitals to bill. The following list is a summary of
telehealth services that some payors are allowing – see payor’s allowable telehealth code list in the payor’s section.
• Professional Fees such as emergency department visits, initial and subsequent observation and observation
discharge day management, initial and subsequent hospital care and hospital discharge day management, critical
care services, initial and continuing intensive care services, etc.
• Most payors allow diabetes management training (individual & group) and individual medical nutritional (initial and
subsequent) CMS, along with many other payors, considers Registered Dietitians and Nutritional Professionals as
eligible telehealth clinicians.
• Specialty Clinic Visits: If a patient comes into the hospital to have a telehealth visit with a provider, and you were
eligible to bill an originating site fee before, then you can continue to bill this.
• Facility Fees: If the patient is not coming into the hospital, you CANNOT bill a facility fee. For example, an
Oncology Center/Wound Center may typically bill a professional fee and facility fee, but if patient located at home
then a facility fee cannot be billed.
Follow your normal billing practices (professional fees on a UB or 1500) with the appropriate telehealth service indicator
(modifier/POS) to indicate the service was provided telehealth.
HOSPITAL OUTPATIENT
MEDICARE
16 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Virtual visits for physical therapy, occupational therapy, and speech therapy have been a point of confusion for many
hospitals and stand-alone therapists. The two main points of confusion are:
1.) If physical, occupational, and speech therapists are considered by the payor a provider qualified to perform
telehealth services.
2.) If hospital-based physical, occupational, and speech therapists that bill for services on a UB-04 under the
hospital NPI can perform virtual visits.
Please see the below matrixes to determine what virtual visit codes therapists can bill. We are still seeking payor
clarification and will provide updates as we have them.
PT/OT/ST
17 Disclaimer: Although the data found here has been produced and processed from payer sources believed to be reliable, no warranty
expressed or implied is made regarding accuracy, adequacy, completeness, legality, reliability or usefulness of any information.
Clarification on HIPAA Compliant Virtual Visit Platform: On March 17, 2020 CMS has issued the following statement:
“The new waiver in Section 1135(b) of the Social Security Act explicitly allows the Secretary to authorize use of
telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the
COVID-19. In addition, effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement
discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith
through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide
public health emergency.”
As a point of clarification, Medicare is allowing non-HIPAA compliant software to be used for virtual visits. However,
Nebraska Medicaid has confirmed they are still requiring HIPAA compliant software be used for virtual visits for
reimbursement to be issued. BCBS NE also does state in their policy that they require HIPAA compliant software,
however we are seeking clarification from them. Lastly, Aetna and UHC have waived
Listed below are several HIPAA Compliant software programs with estimated price ranges.
Name Pricing
ruralMED Telehealth (Powered by Bryan Telemedicine)
Contact Sara Glaser at 402-710-0884 for pricing
Doxy.me Free-Allows for basic video conferencing Professional (1 Provider)- $35/mo Clinic (Multiple Providers)-Varies per month
simplepractice.com Essential Plan-$39/mo Professional Plan-$59/mo
Zoom for Healthcare Starts at $200/mo
Vsee For Individuals: Free-up to 25 visits/mo. Plus-$49/mo For Clinics: Standard-$199/provider/mo Advanced $499/provider/mo
*Note-ruralMED is not endorsing any of these software programs
