Reimbursement requires adherence to coding, documentation, modifier, POS, and licensure rules; some services and modifiers are excluded.
Provider must maintain complete and accurate medical records including start and end times of the telemedicine/telehealth or virtual health care service and document the method of communication.
Source requires documentation of start/end times and method of communication.
Providers must ensure HIPAA-compliant technologies and implement federal and state privacy laws for member communications, recordings, and records.
HIPAA and privacy compliance required.
Qualified providers must possess the necessary license to treat members in the Plan's state and meet the Plan's definition of eligible provider.
Licensure requirement for eligible reimbursement.
Asynchronous telecommunication services billed with modifier GQ will not be eligible for reimbursement.
Plan will not accept asynchronous telecommunication services (modifier GQ).
Telemedicine/telehealth modifiers (FQ, FR, G0, GT, 93, 95) must be appended to HCPCS or CPT codes when required; only non-telemedicine procedure codes require a telemedicine modifier. Modifier G0 is accepted only when GT and/or 95 are also appended.
Modifier application rules and definitions for FQ, FR, G0, GT, 93, 95 provided.
Report the most appropriate Place of Service (POS) code that accurately describes where the service was rendered; professional telehealth claims must use POS 02 or POS 10. POS 02 does not apply to originating site facilities when billing a facility fee.
POS 02 and 10 requirements and POS 02 exception for originating site facilities.
HCPCS Q3014 (originating site facility fee) may be billed by the provider supplying the room and telecommunication equipment with the member physically present; outside specialists who are not the originating site may not bill Q3014.
Appropriate and inappropriate billing examples for Q3014.
New AMA telemedicine E/M codes 98000-98016 should be used per their code descriptors and time or MDM thresholds; providers must continue to append appropriate telehealth modifiers when billing E/M CPT codes 99202-99205 and 99212-99215 as noted.
Effective Jan 1, 2025 codes 98000-98016 and modifier guidance.
Synchronous audio-only services: codes appropriate for audio-only use require indication by CPT guidance and may require more than 10 minutes of medical discussion for certain codes; report based on total interactive time or majority of interactive time as applicable.
Audio-only thresholds and reference to CPT appendix and modifier 93.
Examples of covered digital/brief services
Online digital E/M services may be reported with CPT codes 99421-99423 when all requirements are met.
Nonphysician online assessment and management services may be reported with 98970-98972 when requirements are met.
Brief synchronous communication technology service (98016) may be reported when patient-initiated, at least 5 minutes of medical discussion, and other descriptor requirements are met; 98016 is not reported with 98000-98015.