CurrentFlorida BluePolicy N/A

Telehealth services and coding/documentation guidance

Governs definitions, types of telehealth, Medicare/Medicare Advantage risk adjustment eligibility, and documentation and coding guidelines for telehealth services; affects providers submitting telehealth claims to Florida Blue and related Medicare Advantage considerations.

Policy Summary

PayerFlorida Blue

PolicyTelehealth services and coding/documentation guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument whether the visit used interactive audio with video or was audio-only and include modifier 93 for audio-only or modifier 95 for audio-video where appropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

June 2022document date stamp

Modifier 93audio-only identifier

POS 02/10place-of-service codes

Medicare Advantage Risk Adjustment & Telehealth Eligibility

MA risk adjustment and billing guidance

Covered for Medicare Advantage risk adjustment when the service and billing meet CMS face-to-face encounter and coding requirements.

ALL of the following

Telehealth service is an allowable inpatient, outpatient, or professional service resulting from a face-to-face encounter (including telehealth with interactive audio plus video).
Service was performed using interactive audio telecommunication simultaneously with video telecommunication (real-time audio+video).
Documentation in the medical record indicates whether the visit used interactive audio with video or other virtual mechanisms (e.g., audio-only).

Documentation, Modifier Use, and Risk-Adjustment Face-to-Face Rules

Documentation Required

Document whether the visit used real-time interactive audio with video or was audio-only (or other virtual mechanism). Include clear documentation in the medical record noting the modality used (interactive audio+video versus audio-only) and the technology (e.g., smartphone vs. landline).

Document modality: indicate whether service was delivered via interactive audio telecommunication simultaneously with video telecommunication or via audio-only/other virtual mechanisms.
Record device/technology: note if a smartphone (meets MA face-to-face for risk adjustment) or a standard landline/non-smartphone (does not meet risk-adjustment face-to-face) was used.

Billing Rule

Modifier Use and Risk-Adjustment Face-to-Face Rules

Use the appropriate modifiers to clearly indicate the telehealth modality on claims. Modifier 93 identifies synchronous telemedicine services rendered via telephone or other real-time interactive audio-only systems (audio-only); these services are not eligible for Medicare Advantage (MA) risk adjustment face-to-face requirements. Modifier 95 indicates services furnished via synchronous interactive audio and video telecommunication (interactive audio+video). Billing the correct modifier helps determine risk-adjustment eligibility and claim adjudication.

Modifier 93 — synchronous telemedicine via telephone or other real-time interactive audio-only system (audio-only). Will not meet MA risk-adjustment face-to-face requirement.
Modifier 95 — synchronous interactive audio with video telecommunication. Use with the appropriate CPT/HCPCS codes (telehealth CPTs) and any place of service (POS) as applicable.
For MA risk-adjustment: telehealth services must be performed using interactive audio telecommunication simultaneously with video telecommunication to meet the face-to-face requirement; audio-only encounters (modifier 93) do not qualify.

Telehealth Terminology

Telehealth

DefinitionUse of electronic information and telecommunication technologies to extend care when the provider and the patient are not in the same place at the same time.

Also calledTelemedicine

PurposeEnables remote delivery of care when provider and patient are not co-located.

Live Video

DefinitionA two-way, face-to-face interaction between a patient and a provider using audiovisual communication technology (real-time).

Also referred to asReal-time interaction

ModalitySynchronous audio and video for live clinical encounters.

Store-and-Forward

DefinitionRemote evaluation of recorded video and/or images submitted by an established patient.

Use caseAsynchronous review of patient-submitted media for clinical assessment.

RequirementPatient must be established (per source wording).

Remote Patient Monitoring

DefinitionUse of digital technologies to collect health data from patients in one location and electronically transmit that information securely to providers in a different location.

Data typesCan include vital signs, weight, blood pressure (among others).

PurposeSupports remote monitoring and management of patient health status.

Audio-only Visits

DefinitionUse of telephone for visits without video (audio-only).

ContextUsed to support patients managing chronic conditions and to screen or triage when appropriate (source notes COVID-19 context).

IdentifierAudio-only services are specifically described as telephone-based visits.

E-visits

DefinitionNon-face-to-face patient-initiated communications through an online patient portal.

ModalityAsynchronous electronic messaging via a secure portal initiated by the patient.

UseFacilitates remote communication without a live encounter.

Mobile Health (mHealth)

DefinitionAllows patients to review their personal health data via mobile devices (e.g., cell phones, tablets) to assist in communicating their health status and any changes.

DevicesCell phones and tablet computers used to access personal health information.

PurposeSupports patient engagement and communication of health status remotely.

Case-based Teleconferencing

DefinitionInterdisciplinary teleconferencing, often using dedicated application software (apps), to provide coordinated, holistic, integrated services across providers and supports.

ParticipantsInternal and external providers and, when appropriate, the client and family members or close supports.

PurposeFacilitates coordinated care planning and service delivery across disciplines.