CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary expansion of telemedicine coverage for preventive visits

Temporarily expands reimbursement and billing rules to allow preventive medicine visits (well-child, adult annual preventive exams, and AWVs) to be delivered via telemedicine or telephone-only for participating providers across all lines of business during the COVID-19 emergency period.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary expansion of telemedicine coverage for preventive visits

Policy CodePolicy N/A

Change TypeTemporary expansioneffective period extended

Effective DateMar 18, 2020

Next Review DateN/A

Key ActionSubmit the appropriate preventive E&M or AWV CPT/HCPCS code on the date of the telemedicine/telephone encounter; records may be audited for adherence.

SourceLink

POLICY UPDATE CHANGES

Temporary expansion to reimburse preventive medicine E&M and AWV visits delivered via telemedicine or telephone-only at 100% of the in-office allowable amount.

Policy effective period extended in accordance with the Executive Order extension to July 26, 2020.

100%reimbursement of in-office allowable for preventive telemedicine/telephone visits

All linesapplies to lines of business

No cost sharemember responsibility

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Covered Services and Exclusions

Covered and excluded services

Covered preventive services and exclusions under the temporary telemedicine expansion:

ALL of the following

Covered preventive services
- Adult Annual Preventive Exams (may be delivered via telemedicine or telephone-only under this temporary policy).
- Pediatric Preventive Exams (Well-child visits). For children age 24 months and under and those over 24 months in need of vaccination, the AAP recommends continuation of in-person well-child visits to ensure critical immunizations and screenings are administered at an appropriate age; these in-person visits are not supplanted by telemedicine.
- For children over 24 months of age (or children under 24 months who are unable to be seen in person), well-child visits may be conducted using telemedicine/telephone-only modalities consistent with this policy; remaining elements that require in-person completion should be done as soon as community circumstances allow.
- Annual Wellness Visit (AWV) for INTEGRITY members may be delivered via telemedicine or telephone-only under this temporary policy.
Exclusions
- The policy does not apply to the 'Welcome to Medicare' initial preventive physical examination HCPCS code G0402; that visit must be a face-to-face visit (services limited to new beneficiaries during the first 12 months of Medicare enrollment).
Member cost sharing
- No member cost sharing is applied for any preventive service delivered under this policy.

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Allowed Codes and Claim Submission Rules

Covered CPT/HCPCS Codes (Preventive E&M / AWV via telemedicine/telephone)mixedCovered

99381	Initial comprehensive preventive medicine E&M, new patient, infant <1 year
99382	Initial comprehensive preventive medicine E&M, new patient, age 1-4
99383	Initial comprehensive preventive medicine E&M, new patient, age 5-11
99384	Initial comprehensive preventive medicine E&M, new patient, adolescent 12-17
99385	Initial comprehensive preventive medicine E&M, new patient, 18-39 years
99386	Initial comprehensive preventive medicine E&M, new patient, 40-64 years
99387	Initial comprehensive preventive medicine E&M, new patient, 65+ years
99391	Periodic comprehensive preventive medicine E&M, established patient, infant <1 year
99392	Periodic comprehensive preventive medicine E&M, established patient, age 1-4
99393	Periodic comprehensive preventive medicine E&M, established patient, age 5-11

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Claim Submission Rules for Split Encounters

Telemedicine/Telephone claim for preventive E&M/AWVSubmit the preventive E&M (99381-99387, 99391-99397) or AWV (G0438 for initial, G0439 for subsequent) only once on the date the telemedicine/telephone service occurs. Use place of service (POS) 02 for that claim.

In-person follow-up claimBill only the services actually provided in-person on the subsequent date (immunizations, vitals, screenings, separate sick E&M if applicable). Do NOT re-bill the preventive E&M or AWV code on the in-person date. Use POS 11 or other appropriate POS for the in-person visit.

Separate sick E&MIf additional non-preventive concerns are addressed during the in-person visit, the provider may bill an appropriate sick E&M code for a separately identifiable encounter; standard documentation and cost-share rules apply.

DocumentationMedical record must reflect both encounters. The face-to-face note must reference the date of the initial telemedicine/telephone encounter and link to that encounter in the EMR.

Medicaid / EOHHSFor Medicaid, the second visit should be billed directly to EOHHS for reimbursement by Medicaid FFS per EOHHS guidance.

Claims Submission and Audit Guidance

Documentation Required

Claims submission and audit — bill preventive E&M/AWV on telemedicine date

Submit the preventive E&M or AWV CPT/HCPCS code on the telemedicine/telephone date and maintain documentation for audits. The claim for the Preventive Medicine E&M or AWV with the appropriate CPT/HCPCS code must be submitted only once, on the initial date of service the telemedicine/telehealth or telephone encounter occurs; Neighborhood reserves the right to audit medical and administrative records for adherence to policy requirements.

Bill the preventive E&M/AWV CPT/HCPCS code on the telemedicine/telephone encounter date (submit only once).
Document both the telemedicine/telephone encounter and any subsequent in-person encounter in the member's medical record; the face-to-face progress note must reference the date of the initial telemedicine/telephone encounter and be tied to that initial encounter in the EMR.
Be prepared for Neighborhood to audit medical and administrative records related to adherence to this policy.

Key Definitions

Preventive telemedicine visit (inv-05)

DefinitionA preventive telemedicine visit is a preventive medicine evaluation and management (E&M) or Annual Wellness Visit (AWV) delivered via telemedicine or telephone-only during the temporary expansion; the appropriate in-office preventive E&M/AWV CPT/HCPCS code should be submitted on the date the telemedicine/telephone service occurs with POS 02.

Reimbursement stanceUnder the temporary policy, preventive telemedicine/telephone visits are reimbursed at 100% of the in-office allowable amount (temporary expansion tied to OHIC/EOHHS guidance).

Codes allowedPreventive E&M and AWV codes eligible when delivered via telemedicine/telephone include 99381-99387, 99391-99397, and G0438/G0439.

Member cost shareNo member cost sharing applies for preventive services delivered under this temporary policy.

Split encounter (inv-06)