CurrentBlue Cross Blue Shield - KansasPolicy N/A

Office/Outpatient Visit Policy

Governance of billing, coverage and reimbursement practices for office and outpatient evaluation and management (E/M) services, including telemedicine, consultations, and what may be billed separately; applies to Blue Cross and Blue Shield of Kansas contracted providers.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyOffice/Outpatient Visit Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen atypical or unusual office/outpatient visit fees are billed, include supportive medical records with the claim for individual consideration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1One E/M per day

3 yrsEstablished patient timeframe

coveredTelemedicine covered

includedTelephone/web included

Office and Outpatient Visit Coverage Criteria

Coding and Modality Limits

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E/M CodesCPT

E/M	Evaluation and Management service levels per CPT

Telehealth ModifierModifier

GT	Telehealth modifier recommended for billing

Physical therapy modal limit — Coding threshold

Policy thresholdMedical necessity must be supported for any physical therapy modality and/or procedure in excess of four billed on the same day.

ContextServices may be billed separately for combinations of office/home visits with physical therapy (modalities and/or procedures).

Documentation requirementOffice records must support medical necessity for >4 modalities/procedures on the same day; see CPT for specific reporting of codes.

Billing Guidance and Documentation Requirements

Documentation Required

Provide supporting medical records for atypical visit fees and document consultations

When atypical or unusual office/outpatient visit fees are billed, supportive medical records must accompany the claim for individual consideration. Consultations require documentation of the request, the evaluation, and a report sent to the requesting physician.

Atypical office/outpatient visit fees are eligible for individual consideration only when supportive medical records accompany the claim.
For consultations, document the request, the evaluation, and include a copy of the report sent to the requesting/referring physician.

Billing Rule

Use POS 02/10 and GT modifier for telehealth; avoid inappropriate telehealth billing

Bill telehealth services with place of service 02 or 10 and include the GT modifier; do not bill telehealth for services inappropriate to telehealth such as laboratory services, vaccine administration, injections, or radiology.

Use POS 02 or POS 10 for telehealth encounters and append the GT modifier.
Do not submit telehealth billing for services that are inappropriate as telehealth (e.g., labs, vaccines, injections, radiology).

Key Definitions

New Patient — Definition

DefinitionA patient who is new to the practice/physician or a patient who has not been seen for three or more years.

Group practice noteWithin a group practice, a consulting physician of a different specialty may bill as new if the consulting physician's new-patient definition is met (does not apply to covering arrangements).

TimeframeNot seen by the practice/physician for three or more years defines 'new'.

Established Patient — Definition

DefinitionA patient who has been previously treated by the practice/physician and for whom records have been established within the past three years.

Established vs. newIf the patient has records within the past three years with the practice/physician, they are considered established rather than new.

Consulting physician billing noteWithin a group practice, billing status depends on the consulting physician meeting the new/established definition for that physician; covering arrangements excluded.

Telemedicine / Telehealth — Definition

DefinitionDelivery of health care services or consultations while the patient is at an originating site and the health care provider is at a distant site using real-time two-way interactive audio, visual, or audio-visual communications (including secure video conferencing or store-and-forward technology).

ExclusionsDoes not include voice-only telephone conversations, email, text, or facsimile transmissions when those are the sole means of communication.

Coverage statusTelemedicine/telehealth is a covered service per the Kansas Telemedicine Act.

Non-covered therapyPhysical therapy, speech therapy, occupational therapy, and audiology services are not covered as telehealth services under this policy.