CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO33

Telemedicine and Telehealth/Virtual Health Care Services Policy

Governs payment, coding, and billing rules for telemedicine, telehealth, and virtual health care services reimbursed by Blue Cross Blue Shield - New Mexico; applies to eligible providers submitting claims to the Plan.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTelemedicine and Telehealth/Virtual Health Care Services Policy

Policy CodePolicy CPCPO33

Change TypeNo material change

Effective DateMar 1, 2024

Next Review Date

Key ActionSubmit claims with complete documentation including start/end times and append required telehealth modifiers or POS codes as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

FQ, FR, GO, GT, GQ, 93, 95Telemedicine/telehealth modifiers listed

POS 02 & POS 10Place of Service codes

99421–99423, 98970–98972, 62012Digital E/M examples

2024-03-01Plan effective

Telehealth Reimbursement and Billing Rules

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Telehealth reimbursement criteria and billing rules

Requirements and billing rules for reimbursement of virtual health care services:

The provider must maintain complete and accurate medical records including start and end times of the telemedicine/telehealth or virtual health care service.

The method of communication must be documented and HIPAA and applicable federal and state privacy laws must be followed for member communications, recordings, and records.

Qualified providers must possess the necessary license to treat members of the Plan's state.

Billing modifiers

Append telemedicine/telehealth modifiers FQ, FR, GO, GT, GQ, 93, or 95 to non-telemedicine HCPCS or CPT procedure codes when billing telehealth services unless a telemedicine-specific procedure code is billed.
Modifier GO will only be accepted when GQ, GT, and/or 95 are also appended as required by the Plan.

Place of Service

Submit telehealth professional claims with Place of Service (POS) Code 02 or another POS that accurately describes where services were rendered; POS 02 does not apply to originating site facilities billing a facility fee.
Use POS 10 when the patient is located in their home during the telehealth visit.

Originating site facility fee (Q3014)

HCPCS Q3014 may be billed by the originating site that is physically hosting the patient and supplying the room and telecommunication equipment.
A distant site provider (the specialist located off-site) may not bill Q3014 when they are not the originating site physically hosting the patient.

Digital E/M codes and restrictions

When all requirements are met, report online digital evaluation and management codes such as CPT/HCPCS 99421-99423, 98970-98972, and 62012.
Text messaging alone does not meet the requirements for a digital evaluation and management service.
Do not append GQ to standard E/M codes (e.g., 99211, 90832) to indicate asynchronous telemedicine when an asynchronous telemedicine code is more appropriate or when required elements for the standard E/M are not met.

Claims are subject to review against plan documents, provider contract language, medical policies, and coding policies; the Plan reserves the right to request supporting documentation.

Codes, Modifiers, and Billing Codes for Telehealth

Telehealth digital E/M codesCPTCovered

99421	Online digital evaluation and management service
99422	Online digital evaluation and management service
99423	Online digital evaluation and management service
98970	Digital E/M or online digital evaluation service
98971	Digital E/M or online digital evaluation service
98972	Digital E/M or online digital evaluation service
62012	Listed as appropriate for online digital evaluation and management services when requirements are met

Telemedicine modifiersModifier

FQ	Telemedicine/telehealth modifier
FR	Telemedicine/telehealth modifier
GO	Telemedicine/telehealth modifier
GT	Telemedicine/telehealth modifier
GQ	Telemedicine/telehealth modifier
93	Telemedicine/telehealth modifier
95	Telemedicine/telehealth modifier

Originating site facility feeHCPCSCovered

Q3014

Telehealth originating site facility fee (may be billed by the provider physically supplying the room and telecommunication equipment hosting the patient)

Digital E/M requirements - online digital evaluation and management services

Required codesCPT/HCPCS 99421, 99422, 99423, 98970, 98971, 98972, and 62012 are appropriate to report for online digital evaluation and management services when all requirements are met.

Documentation requirementAll requirements for online digital E/M services must be met before reporting these codes.

Prohibited modalityText messaging alone does not meet the requirements of a digital evaluation and management service.

Do not use GQ to indicate asynchronous careStandard E/M codes (for example 99211 or 90832) appended with modifier GQ should not be billed to indicate asynchronous telemedicine when an asynchronous telemedicine code is more appropriate or when required E/M elements are not met.

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation and claims review — maintain accurate records and supply documentation on request

Providers are responsible for submission of accurate documentation of services performed; claims are subject to review against plan documents, provider contract language, medical policies, and coding policies. Providers must maintain complete and accurate medical records for virtual health care services, including start and end times, document the method of communication, and ensure HIPAA and federal/state privacy laws are followed. The Plan may request supporting documentation and review claims on a case-by-case basis.

Submit claims using valid HIPAA-approved code sets and appropriate coding guidelines (UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI/CCI rules).
Maintain complete medical records including start and end times of the telemedicine/telehealth or virtual health care service.
Document method of communication and ensure HIPAA-compliant processes and compliance with federal and state privacy laws.
Be prepared to supply supporting documentation upon request; claims are subject to claim review and code edit protocols.

Definitions and Terminology

Audio only visits

DefinitionAudio only visits: the use of a telephone for visits without video.

Use caseMay be used when video capability is not available or clinically appropriate, subject to Plan documentation and coverage rules.

DocumentationMethod of communication (telephone) must be documented in the medical record per Plan requirements.

Live video

DefinitionLive video: a two-way, face-to-face interaction between a member and a provider using audiovisual communications technology (real-time, synchronous).

Delivery methodClassified as synchronous communication (interactive audio and video).

Technology guidanceProviders should utilize HIPAA-compliant remote technologies as allowed by state and federal laws.

Telemedicine service

DefinitionTelemedicine service: the use of a telecommunication system to provide services for the purpose of evaluation and treatment when the patient is at one location and the rendering provider is at another location.

ScopeTypically involves direct patient evaluation and treatment across different physical locations.

Provider requirementEligible providers must possess the necessary license to treat members in the Plan's state.

Telehealth service

DefinitionTelehealth service: the use of electronic information and telecommunications technologies to support distance clinical health care, patient and professional health-related education, public health, and health administration.

Typical interactionsOften describes provider-to-provider interaction or indirect provider-to-patient interaction.

ApplicationsIncludes a wide range of activities beyond direct evaluation, such as education and public health functions.

Virtual Health Care

DefinitionVirtual Health Care: encompasses care rendered by synchronous and asynchronous delivery methods using two-way video, email, smartphones, wireless tools, store-and-forward, e-visits, remote monitoring, and virtual check-ins.

Delivery methods includedSynchronous (live video), asynchronous (store-and-forward), e-visits, mobile health, remote monitoring, and virtual check-ins.

Expansion noteVirtual health care is expanding and includes a variety of services and applications leveraging telecommunications.