Telemedicine Services for AmeriHealth Pennsylvania Members (Updated May 19, 2020)




    Policy Impacted

    Supersedes Policy #00.10.41f: Telemedicine Services (AmeriHealth Pennsylvania)

    Coverage of Preventive Well Visits through Telemedicine in Response to COVID-19 for AmeriHealth Pennsylvania Members

    00.10.01ab: Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

    00.03.06f: Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products




    Purpose

    The purpose of this News Article is to provide advance notice regarding coverage for telemedicine services for our AmeriHealth Pennsylvania members in response to Coronavirus Disease 2019 (COVID-19).

    This News Article addressing telemedicine services is effective from March 6, 2020 through December 31, 2020 and supersedes Policy #00.10.41f: Telemedicine Services during this time period.



    Background

    There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected both nationally and internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.

    In response to the current COVID-19 outbreak, the Centers for Disease Control and Prevention (CDC) recommends that professional providers conduct telephonic and telemedicine services to triage and assess individuals to prevent transmission of the respiratory virus.

    To help reduce potential exposure, members and participating providers may utilize telemedicine services as detailed below and available as part of a member’s plan.

    .

    Indications

    N/A



    Coverage Statement

    Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

    Note: This communication does not address services provided through the Company's contracted telemedicine vendor.

    Telemedicine services are eligible for reimbursement consideration by the Company when all the following criteria are met:
    • The services are medically necessary and able to be delivered using one of the following modes of communication:
      • Interactive, synchronous (real-time) two-way audio and video communications
        • Note: The services that are only covered if delivered through an audiovisual (Interactive, synchronous (real-time)) telecommunication are outlined in the table below
      • A telephone (i.e., audio telecommunication only/telephone call) or online digital communication
    • Covered services provided through the Company's network of eligible providers include, but are not limited to:
      • Primary care
      • Specialty care (including behavioral health/ applied behavioral analysis)
      • Medical nutrition therapy
      • Physical therapy
      • Occupational therapy
      • Speech therapy
      • Home care
        • Skilled nursing (intermittent; not including private duty nursing)
        • Physical therapy
        • Occupational therapy
        • Speech therapy
        • Medical nutrition therapy
        • Social services
      • Urgent care
    • The telemedicine services are reported with one of the procedure codes listed in the coding section below.


    Services covered through audiovisual only (interactive, synchronous (real-time) telecommunication mode)
    Behavioral Health - Applied Behavioral Analysis
    Outpatient Physical Therapy/Occupational Therapy
    Urgent Care
    Home Care - Skilled Nursing (intermittent; not including private duty nursing)
    Home Care - Physical Therapy
    Home Care - Occupational Therapy
    Orthotics/Prosthetic Training
    Preventive Well Visits

    For products with capitation arrangements, services delivered through telemedicine are considered included in capitation with the exception of those services identified in applicable policies identifying fee for service reimbursement. Refer to the appropriate claim payment policies for a list of exceptions to capitation arrangements.

    REQUIRED DOCUMENTATION

    The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

    The Company may conduct reviews and audits of services to our members, regardless of the participation status of the professional provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

    BILLING REQUIREMENTS

    Eligible professional providers performing telemedicine services must report the appropriate modifier (modifiers GT or 95) and place-of-service (POS) code 02 (Telehealth) to ensure payment of eligible telemedicine services.

    Telemedicine services performed through a telephone or online digital communication must report the appropriate place of service 02 (Telehealth) to ensure payment. Use of modifiers GT or 95 will not be required.

    Telemedicine evaluation and management reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report revenue code 0780 along with an appropriate evaluation and management procedure code appended by the GT or 95 modifier, as needed.

    Telemedicine ancillary services (e.g. PT/OT/ST) reported by facilities billing on a UB-04 claim form, or the equivalent form 837i, should report the appropriate revenue code (shown below) along with the corresponding procedure code representing the service provided appended by the GT or 95 modifier, as needed.

    Inclusion of a code in this News Article does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.



    Dosing and Administration

    N/A



    Black Box Warnings and/or Contraindications

    N/A



    Coding


    PROCEDURE CODES

    ELIGIBLE PROCEDURE CODES

    Primary Care / Specialty Care (including Behavioral Health)

    0362T, 0373T, 77427, 90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849, 90853, 90875, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 92002, 92004, 92012, 92014, 92601, 92602, 92603, 92604, 94002, 94003, 94004, 94664, 96110, 96112, 96113, 96116, 96121, 96125, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171, 97150, 97151, 97153, 97154, 97155, 97156, 97157, 97158, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99406, 99407, 99421, 99422, 99423, 99441, 99442, 99443, 99468, 99469, 99471, 99472, 99473, 99475, 99476, 99477, 99478, 99479, 99480, 99483, 99497, 99498, G0071 , G0108, G0109, G0296, G0396, G0397, G0406, G0407, G0408, G0420, G0421, G0425, G0426, G0427, G0438, G0439, G0442, G0443, G0444, G0445, G0446, G0447, G0459, G0506, G0508, G0509, G2025, G9685


    Virtual Check-ins

    G2010, G2012, G2061, G2062, G2063


    Transitional Care Management

    99495, 99496


    Lactation

    99401, 99402, 99403, 99404, 99411, 99412, S9443


    Cardiac Rehabilitation

    93797, 93798, S9472


    Pulmonary Rehabilitation

    G0424, S9473


    Intensive Outpatient Services

    H0015, S9480


    Partial Hospitalization

    H0035, S0201


    Medical Nutrition Therapy

    97802, 97803, 97804, G0270


    Physical / Occupational Therapy

    97110, 97112, 97116, 97129, 97130, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97542, 97750, 97755, 97760, 97761


    Speech Therapy

    92507, 92508, 92521, 92522, 92523, 92524, 92607, 92608, 92609, 97129, 97130, G0153, G0161, S9128, S9152


    Urgent Care Providers

    S9083



    MODIFIERS

    95, GT



    REVENUE CODES

    Home Care - Social Services

    0561, 0562


    Home Care - Nurse

    0551


    Physical Therapy

    0420, 0421, 0422, 0424


    Occupational Therapy

    0431, 0432, 0434


    Speech Therapy

    0441, 0442, 0444


    Home Care - Medical Nutrition Therapy

    0590


    Intensive Outpatient Services

    0905, 0906


    Partial Hospitalization

    0912, 0913


    Hospice

    0651, 0652, 0655, 0656


    Cardiac Rehabilitation

    0943


    Pulmonary Rehabilitation

    0948


    Telemedicine

    0780



    THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES NOT CONSIDERED TELEMEDICINE AND ARE NOT ELIGIBLE FOR REIMBURSEMENT:

    98970, 98971, 98972, 99446, 99447, 99448, 99449, 99451, 99452, Q3014



    THE FOLLOWING CODES ARE USED TO REPRESENT SERVICES NOT CONSIDERED TELEMEDICINE AND ARE CONSIDERED BENEFIT EXCLUSIONS:

    98966, 98967, 98968, S0320, S5185











    Issued on - 05/19/2020