CurrentBlue Cross Blue Shield - TexasPolicy CPCP033

Telemedicine and Telehealth/Virtual Health Care Services Policy

Governs payment and coding requirements for telemedicine, telehealth, and other virtual health care services provided to members under Blue Cross Blue Shield of Texas plans; affects eligible providers submitting claims for such services.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyTelemedicine and Telehealth/Virtual Health Care Services Policy

Policy CodePolicy CPCP033

Change TypeAdded telemedicine E/M codes, modifier 93 guidance, POS clarification

Effective DateJan 1, 2025

Next Review DateFeb 20, 2025

Key ActionProviders must submit accurate documentation and be prepared to provide supporting documentation upon request; claims must use required telemedicine modifiers and POS codes as specified.

SourceLink

POLICY UPDATE CHANGES

New AMA telemedicine evaluation and management codes (98000-98016) and guidance on their use were added.

Modifier 93 guidance and appendix reference for synchronous audio-only telemedicine was added.

Clarification that POS code '02' or '10' must be used on CMS 1500 telehealth/telemedicine professional claims.

98000-98016new telemedicine E/M code range referenced

>=1telemedicine modifiers listed

02,10required POS codes

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Reimbursement and Coverage Criteria

Reimbursement criteria for virtual health care services

Services appropriately provided via virtual health care are reimbursable when provider- and claim-level requirements are satisfied.

Provider maintains complete and accurate medical records including start and end times of the telemedicine/telehealth or virtual health care service

Method of communication must be documented and HIPAA, federal, and state privacy requirements must be followed for member communications, recordings, and records

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

Claims must append appropriate telemedicine/telehealth modifiers (for example: FQ, FR, G0, GT, GQ, 93, 95) when billing non-telemedicine procedure codes; telemedicine-specific procedure codes do not require a modifier

Telehealth professional claims submitted on a CMS 1500 form must use Place of Service (POS) Code '02' or '10' as appropriate to accurately describe where services were rendered

New telemedicine E/M codes (98000-98016) are reported based on medical decision making (MDM) or total time; these codes may not be reported on the same calendar date as another E/M unless elements and time are aggregated

Audio-only / time-based requirements

Synchronous audio-only E/M codes have minimum medical discussion time plus total time thresholds (examples: 98008 straightforward—total time 15 minutes; 98009 low MDM—30 minutes; 98011 high MDM—60 minutes)
Some audio-only services permit reporting only when a minimum discussion time (e.g., more than 10 minutes) is met as specified in the code descriptors

Virtual check-in brief synchronous communication code (98016) is patient-initiated, requires a minimum of 5 minutes, and must not be reported with the telemedicine E/M codes 98000–98015 or when it is related to an E/M within the prohibited timeframes

Services that exceed specified total time thresholds may be reported with prolonged service code 99417 where noted in the code guidance

Plan may request supporting documentation and reserves the right to deny or adjust claims based on plan documents, provider contracts, or policy interpretation

Telemedicine, Telehealth and Virtual Care Coding

Covered CPT/HCPCS CodesmixedCovered

99421	Online digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes.
99422	Online digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes.
99423	Online digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.
98970	Nonphysician qualified health care professional online digital assessment and management service, for an established patient, for up to 7 days; 5-10 minutes.
98971	Nonphysician qualified health care professional online digital assessment and management service, for an established patient, for up to 7 days; 11-20 minutes.
98972	Nonphysician qualified health care professional online digital assessment and management service, for an established patient, for up to 7 days; 21 or more minutes.
98016	Brief synchronous communication technology service (eg, virtual check-in) for established patient; patient-initiated; typically 5-10 minutes; video not required.
99411	Group health education/behavioral management (may be applicable in some telehealth group contexts)

Time and MDM thresholds for telemedicine E/M codes — examples and prolonged service guidance

Virtual check-in (98016) — rules and exclusions

Documentation, Submission and Review

Documentation Required

Submit and retain accurate documentation; expect reviews and requests for supporting records

Providers must maintain complete and accurate medical records for virtual health care encounters (including start and end times) and document the method of communication; they must also ensure HIPAA and applicable state/federal privacy laws are followed and hold the necessary license to treat members in the Plan's state. Claims are subject to plan, contract, and policy review and the provider may be asked to submit additional supporting documentation upon request.

Maintain complete and accurate medical records including start and end times of the telemedicine/telehealth service (see policy).
Document the method of communication used for the encounter and ensure HIPAA/state privacy compliance for communications, recordings, and records.
Hold the necessary professional license to treat members in the Plan's state.
Be prepared to submit additional supporting documentation when requested; claims are subject to claim review and may be denied or adjusted per plan, contract, or policy terms.

Key Definitions

Telemedicine / Telehealth / Virtual Health Care — definition and scope

DefinitionUse of telecommunications/electronic technologies to provide evaluation, treatment, provider-to-provider interactions, and other health services when provider and patient are at different physical locations; telemedicine and telehealth may be used interchangeably and virtual health care describes a broader range of services, including synchronous and asynchronous methods.

Scope — delivery methodsIncludes synchronous (live audio/video), asynchronous/store-and-forward (image or video reviewed later), e-visits, mobile health, store-and-forward, and remote monitoring services as allowed by state and federal law.

Coverage implicationServices appropriately provided through virtual health care are reimbursable when provider and claim-level requirements are met and necessary documentation is maintained.

Audio-only visit — definition and modifier 93 guidance

DefinitionAn audio-only visit is the use of a telephone for visits without video.