CurrentBlue Cross Blue Shield - MainePolicy C-08002

Virtual Visits - Professional and Facility

Governs reimbursement and billing requirements for professional and facility virtual visit services (telehealth, e-visits, virtual check-ins, telephone visits, remote patient monitoring) for Anthem Blue Cross Blue Shield - Maine commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyVirtual Visits - Professional and Facility

Policy CodePolicy C-08002

Change TypeMaterial updates (added async/audio-only, POS 10, modifier guidance)

Effective Date01/01/2022

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit correct CPT/HCPCS, POS and telehealth modifiers to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

Added language to allow asynchronous and audio only transmission and added definitions for Asynchronous and Synchronous.

Updated policy name from Telemedicine to Virtual Visits - Professional and Facility and defined services allowed and not allowed for reimbursement for professional and facility.

02,10Place of service codes indicated for telehealth

93,95,FQ,GQ,GTAccepted telehealth modifiers listed

Q3014Originating site fee HCPCS

PT/OT/ST w/o live A/V

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Non-reimbursable examples

Virtual Visit Coverage Criteria

Covered when ALL of the following apply:

Professional or facility virtual visits are reimbursed when interactive services occur between the member and the provider who are not in the same location, unless provider, state, or federal contracts and/or mandates indicate otherwise.

Professional synchronous telehealth billing

Submit Place of Service 02 or 10 to indicate Telehealth, the appropriate CPT/HCPCS code, and the applicable telehealth/telemedicine modifier as listed in Related Coding.

Professional asynchronous telehealth billing

Provider-to-provider asynchronous: submit the place of service appropriate to the location of the billing provider, the appropriate CPT/HCPCS code, and modifier GQ.
Member-to-provider asynchronous: submit Place of Service 02 or 10, the same CPT/HCPCS code(s) that would have been billed for an in‑office visit, and modifier GQ.

Professional remote patient monitoring billing: Submit the place of service appropriate to the location of the billing provider and the appropriate CPT/HCPCS code(s).

Facility synchronous telehealth billing: Submit the appropriate revenue code for the service rendered, the appropriate CPT/HCPCS code, and the applicable telehealth modifier as indicated in Related Coding.

Facility remote monitoring billing: Submit the appropriate revenue code for the service rendered and the appropriate CPT/HCPCS code(s).

Facility originating site billing: Submit the appropriate place of service code for the provider rendering in‑person services to the member and the appropriate HCPCS code for the originating site fee (e.g., Q3014 when applicable).

Non-reimbursable services: Do not reimburse: non-direct member services other than Remote Patient Monitoring; services that require equipment and/or direct physical hands‑on care that cannot be provided remotely; services rendered virtually that are not eligible for reimbursement when rendered to the member in‑person; PT/OT/ST services provided without live audio/visual communication. Note: In‑person services not rendered in an office or facility setting are not eligible for virtual reimbursement under this policy.

State and contract requirements: Refer to applicable state mandates and provider/member contract terms for state‑specific lists of allowable Virtual Visits; policy is subject to federal/state laws and member benefit terms.

Place of Service, Modifiers, and Originating Site Codes

Covered Place of Service codesmixedCovered

02	Place of service: Telehealth
10	Place of service: Telehealth (professional location-based)

Covered Telehealth ModifiersmixedCovered

93	Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
95	Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
FQ	The service was furnished using audio-only communication technology (applies to Behavioral Health Services)
GQ	Via asynchronous telecommunications system
GT	Via interactive audio and video telecommunication systems

Covered Originating Site HCPCSHCPCSCovered

Q3014

Telehealth originating site fee (facility)

Place of service reporting rule

Professional synchronous telehealthSubmit Place of Service 02 or 10, the appropriate CPT/HCPCS code, and the applicable telehealth modifier as indicated in Related Coding. Services billed with POS 02 or 10 are eligible for office POS reimbursement.

Professional asynchronous telehealth (provider-to-provider)Use the place of service appropriate to the billing provider's location, the appropriate CPT/HCPCS code, and modifier GQ.

Professional asynchronous telehealth (member-to-provider)Use Place of Service 02 or 10, the same CPT/HCPCS code(s) that would have been billed for an in‑office visit, and modifier GQ.

Professional remote patient monitoringUse the place of service appropriate to the location of the billing provider and the appropriate CPT/HCPCS code(s).

Facility synchronous telehealthSubmit the appropriate revenue code, the appropriate CPT/HCPCS code, and the applicable telehealth modifier as indicated in Related Coding.

Authorization and Billing Requirements

Note

Authorization, documentation, coding and denial risk for Virtual Visits

Ensure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and follow state/provider contracts; use industry standard CPT/HCPCS/revenue codes and supportive documentation or claims may be rejected, denied, or recouped.

Obtain any required prior authorization when the member's benefit plan or state/federal mandates require it.
Use industry-standard CPT, HCPCS, and revenue codes that accurately reflect the service provided and submit them with supporting documentation in the medical record or office notes.
Report the appropriate place of service and telehealth modifiers (see coding section) as required for synchronous, asynchronous, or remote monitoring services.
Be aware that failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or other corrective action.

Definitions

Asynchronous (store-and-forward)

DefinitionAsynchronous telehealth (store-and-forward): occurs over time with a delay between contributions from each party such that the interaction occurs independently of time; also known as 'store-and-forward.'

Store and forward descriptionTransmission of a member's medical information from an originating site to the physician or practitioner at the distant site; the clinician can review the case without the member being present.

Usage notesUsed for provider-to-provider and member-to-provider communications; when billed, follow POS and modifier guidance for asynchronous services.

Synchronous (real-time audio/video)

DefinitionSynchronous telehealth: occurs when real-time technology allows the patient or client to interact with a practitioner using a telephone or video connection, or a combination of both (real-time audio and/or video).

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyVirtual Visits - Professional and Facility

Policy CodePolicy C-08002

Change TypeMaterial updates (added async/audio-only, POS 10, modifier guidance)

Effective Date01/01/2022

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit correct CPT/HCPCS, POS and telehealth modifiers to avoid denial or recoupment.

SourceLink

On This Page

Real-time audio and/or video interaction between patient and practitioner enabling live communication.

Billing implicationSubmit POS 02 or 10 and applicable telehealth modifier for professional synchronous services per policy coding guidance.

Distant Site

DefinitionDistant Site: the site where the physician or practitioner providing the professional service is located at the time the service is provided via a telecommunications system.

RoleLocation of the clinician delivering telehealth services (provider's physical location during the encounter).

RelevanceUsed to determine appropriate coding and billing (distant site professional submissions follow telehealth POS/modifier rules).

Originating Site

DefinitionOriginating Site: the location of the member at the time the service is furnished via a telecommunications system.

Facility billingFor facility originating site services submit the appropriate place of service code for the provider rendering in-person services to the member and the HCPCS code for the originating site fee (e.g., Q3014 where applicable).

Use caseDetermines whether originating site facility fees and revenue codes apply when the member is at a facility during the telehealth encounter.

Remote Patient Monitoring / Remote Physiologic Monitoring

DefinitionRemote Patient Monitoring / Remote Physiologic Monitoring: treatment management services provided by medical professionals to manage a patient under a specific treatment plan via live interactive communication or store-and-forward through a medical device defined by the FDA and ordered by a physician or other qualified health care professional.

Billing for professionalsProfessional RPM services must be submitted with the place of service appropriate to the location of the billing provider and the appropriate CPT/HCPCS code(s).

Billing for facilitiesFacility RPM services must be submitted with the appropriate revenue code for the service rendered and the appropriate CPT/HCPCS code(s).

Virtual Visits

DefinitionVirtual Visits: technology-based services including telehealth/telemedicine, e-visits, virtual check-ins, telephone visits, and remote patient monitoring.

ScopeEncompasses synchronous telehealth (real-time audio/video), asynchronous store-and-forward communications, virtual check-ins, e-visits, telephone visits, and RPM as described in this policy.

Billing guidanceFollow the specific POS, revenue code, CPT/HCPCS, and modifier instructions for each service type (see Professional and Facility submission requirements).