Telehealth and Communication Technology-Based Services (CTBS) A Guide for Providers During the COVD-19 Public Health Emergency (PHE)

Telehealth Telehealth is a service that allows providers to consult with their patients through audio/ communication technology. *Risk adjustment: Diagnoses from telehealth services will be accepted for hierarchal condition category (HCC) capture for both Medicare Advantage (MA) and Qualified Health Plan (QHP) patients under the Centers for Medicare and Medicaid Services (CMS)-HCC and the U.S. Department of Health and Human Services (HHS)-HCC risk-adjustment models. Telehealth visits using real-time audio/video technology will be considered a valid face-to-face encounter. Services are still subject to risk-adjustment requirements, such as provider type and diagnostic value.

Communication Methods Synchronous real-time interactive communication through audio and video is a valid method. Section 1135(b) waiver of the Social Security Act allows the use of phones that have audio or video capabilities (such as FaceTime, Skype, etc.) for telehealth serviced during the COVID-19 PHE.

Qualified Providers Qualified providers include physicians, nurse practitioners, physician assistants and certified nurse midwives. Other qualified nonphysician healthcare professionals, such as certified nurse anesthetists, licensed clinical social worker (LCSW), clinical psychologists, registered dietitians or nutrition professionals may provide covered telehealth services within their scope of practice – this includes Federally Qualified Health Centers(FQHCs)/ Rural Health Centers (RHCs).

Patient Qualifications New and established patients may receive telehealth services from any healthcare facility or in their home, regardless of geographic location.

Covered Services Common and expanded covered services during the PHE include: • Outpatient evaluation and management services (99201-99215) • Medicare annual wellness visits (G0438-G0439) • Preventive exams* (99381-99387; 99391-99397) *Preventive exams are only acceptable for risk adjustment HCC capture under the HHS-HCC model for QHP plans. • Home visits (99341-99345; 99347-99350) • Psychological and neuropsychological testing (96130-96133; 96136-96139) • Therapy services, physical and occupational therapy (97161-97168; 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507) • Emergency department or initial inpatient consultations (G0425-G0427) • Follow-up inpatient hospital or skilled nursing facility consultations (G0406-G0408) CMS has published a full list of services that may be provided through telehealth at: cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

Billing Requirements • Bill services with either place of service (POS) 02 or with the place of service that would have been used if the services had been provided in person and attach modifier 95 to the respective CPT/HCPC code. • FQHCs/RHCs: For distant site services provided from January 27 to June 30, 2020, attach modifier 95 to the claim. For distant site services provided from July 1, 2020, through the end of the COVID-19 PHE, use HCPC G2025 to identify telehealth services. • Use Modifier GT for CAH Method II. • Use Modifer G0 for services for the diagnosis and treatment of an acute stroke. • When a patient receives telehealth services while in a healthcare facility, the facility is eligible to bill for the originating site facility fee, using HCPCS code Q3014. • Use time or MDM to determine the level for E/M selection. Typical times associated with each E/M can be found at: cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F

CTBS: Assessment and Management Services Telephone assessment and management services would take place only when telehealth services through video/audio are not available. *Risk adjustment: Diagnoses from telephone assessment and management services are not considered face-to-face and will not be accepted for HCC capture for MA or QHP patients under the CMS-HCC and HHS-HCC risk-adjustment models.

Communication Methods Synchronous communication by telephone is a valid method.

Patient Qualifications New and established patients, regardless of geographic location, are considered qualified patients.

Covered Services For qualified healthcare professionals who can report evaluation and management services: • 99441: Telephone assessment and management services (5-10 minutes). • 99442: Telephone assessment and management services (11-20 minutes). • 99443: Telephone assessment and management services (21-30 minutes). Covered Services For qualified nonphysician healthcare professional, such as physical therapists, occupational therapists, speech-language pathologists and clinical psychologists, etc.: • 98966: Telephone assessment and management services (5-10 minutes). • 98967: Telephone assessment and management services (11-20 minutes). • 98968: Telephone assessment and management services (21-30 minutes).

Billing Requirements • Occupational and physical therapists and speech-language pathologists must use therapy modifiers GO, GP or GN on CPT codes 98966-98968.

Special Considerations and Limitations: Telephone assessment and management services should only be used when telehealth services through video and audio are not available.

CTBS: Virtual Check-Ins Virtual check-ins are brief communications between the patient and provider (5-10 minutes of medical discussion), including the evaluation of or images submitted by the patient. *Risk adjustment: Diagnoses from virtual check-ins are not considered face-to-face and will not be accepted for HCC capture for MA and QHP patients under the CMS-HCC and HHS-HCC risk-adjustment models.

Communication Methods Synchronous and/or asynchronous communication through telephone, audio/visual, secure text messaging, email or patient portal are considered valid communication methods.

Qualified Providers Qualified healthcare professionals are those who can report evaluation and management services. Virtual check-ins have also been expanded for use by other practitioners, such as physical therapists, occupational therapists, speech-language pathologists, LCSWs and clinical psychologists (includes FQHCs/RHCs).

Patient Qualifications New and established patients, regardless of geographic location, are considered qualified patients.

Covered Services • G2012: Brief technology-based services with 5-10 minutes of medical discussion • G2010: Remote evaluation and interpretation of recorded video and/or images submitted by patient. • G0071: For FQHCs/RHCs use only. Services for G2012 and G2010 provided by an FQHC/RHC must be reported using the FQHCs/RHCs HCPCS code.

Considerations and Limitations • Services must be initiated by the patient. • Services cannot originate from a related E/M service within the previous seven days or lead to an E/M services/procedure within the next 24 hours.

CTBS: E-Visits E-visits are communications that occur between the provider and patient through an online patient portal over the course of up to seven days. *Risk adjustment: Only diagnoses for QHP patients from e-visits will be accepted for HCC capture under the HHS-HCC risk-adjustment model. Services are still subject to risk-adjustment requirements, such as provider type and diagnostic value. For MA patients, diagnoses from e-visits are not considered face-to-face and will not be accepted for HCC capture for MA patients under the CMS-HCC risk-adjustment model.

Communication Methods Asynchronous communication through an online patient portal is a valid communication method.

Patient Qualifications New and established patients, regardless of geographic location, are considered qualified patients.

Covered Services For qualified healthcare professionals who can report evaluation and management services: • 99421: Online digital E/M service, for up to seven days, cumulative time during the seven days (5-10 minutes). • 99422: Online digital E/M service, for up to seven days, cumulative time during the seven days (11-20 minutes). • 99423: Online digital E/M service, for up to seven days, cumulative time during the seven days (more than 21 minutes). • G0071: For FQHCs/RHCs use only. Services for 99421-99423 provided by an FQHC/RHC must be reported using this FQHCs/RHCs HCPCS code. Covered Services For qualified nonphysician healthcare professionals, such as physical therapists, occupational therapists, speech-language pathologists and clinical psychologists, etc: • G2061: Online assessment and management, for up to seven days (5-10 minutes). • G2062: Online assessment and management, for up to seven days (11-21 minutes). • G2063: Online assessment and management, for up to seven days (more than 21 minutes).

Billing Requirements • Occupational and physical therapists and speech-language pathologists need to attach therapy modifiers GO, GP or GN on CPT codes G2061-G2063.

Considerations and Limitations • Services cannot originate from a related E/M service within the previous seven days or lead to an E/M services/procedure within the next 24 hours. • Services must be initiated by the patient.

FAQs

Q: Are telehealth and CTBS services limited to patients with COVID-19 or suspected to have COVID- 19? A: No, services are not limited to patients with or suspected to have COVID-19. As with all other services, telehealth and CTBS services must be reasonable and medically necessary.

Q: How will telehealth and CTBS services be covered? A: All telehealth and CTBS services from in-network providers are temporarily covered with no member cost share through July 31, 2020 at the earliest, at which time we will reassess the situation and determine how to proceed.* Telehealth and CTBS services from out-of-network providers are subject to members’ out-of-network benefits. *Excludes self-funded commercial plans who have chosen to opt out.

Q: Will Blue Cross of Idaho accept verbal signatures for client care? A: Yes, we will accept verbal signatures. Providers must obtain physical or electronic signatures once normal business is reinstated.

Q: What fee schedules will be used to determine allowances for telehealth and CTBS services? A: Telehealth services will be allowed under current fee schedules.

Q: How will BlueCard claims be processed for telehealth and CTBS services? A: Providers must contact the member’s Blue Cross Blue Shield plan to verify benefits and coverage.

Q: Will Blue Cross of Idaho allow providers to perform telehealth and CTBS services from their home? A: Yes, so long as services are provided through the approved communication methods specified above.

Q: Is applied behavioral analysis (ABA) therapy covered through telehealth and CTBS services? A: Yes, services will be covered at no member cost share if services are billed with POS 02.

Q: Will telehealth and CTBS services (physical, occupational, speech and behavioral) billed on a UB04 claim form apply member cost share? A: Providers billing telehealth therapy services (physical, occupation, speech and behavioral) on a UB04 claim form with appropriate revenue codes, need to include either modifier GT or 95 on the procedure codes. Therapy services billed with either a GT or 95 modifiers will be processed with no member cost share up to the benefit limits.

Q: Are there specific documentation requirements for telehealth and CTBS services? A: Providers are required to develop and maintain documentation as required by PAP 107-Medical Record Standards. Clinical documentation requirements for telehealth visits are the same as those for in-office care. Documentation should also include: • Mode of communication (i.e., teleconference, telephone, online patient portal, etc.) • Written or verbal consent from patient for telehealth and/or CTBS services • Evidence of time, when using a code that is time-based

Q: What about the documenting elements that are integral to an in-office visit (i.e., vitals as part of the Medicare AWV) that cannot be obtained during the telehealth visit? A: Document each visit in the most detailed way possible. Special notations as to why elements (i.e., vitals) could not be obtained due to communication method are preferred. Please review PAP 107-Medical Record Standards for what elements should be included in the medical record.

Q: What should be stored as part of telehealth and CTBS services? A: Information exchanged asynchronously (videos, images, communications) must be retained according to state regulations. Synchronous audio/video visits are not required to be stored or retained.

Q: What resources are available to implement telehealth services at my clinic? A: CMS has published a Telehealth and Telemedicine Tool Kit, which includes a variety of helpful resources. You may access the tool kit at: cms.gov/files/document/general-telemedicine- toolkit.pdf

Q: Who is considered a qualified nonphysician healthcare professional? A: Individual healthcare providers who perform professional services within their scope of licensure according to federal and state regulations and can independently report such services (i.e., physical therapists, occupational therapists, speech-language pathologists and clinical psychologists, etc.).

Q: Can residents provide telehealth services? A: Yes, when services are provided under the direct supervision of the teaching physician. Direct supervision can be virtual, using real-time audio/video technology.

Q: In addition to the services described above, what else are you doing to ensure coverage for our members? A: 1) Blue Cross of Idaho is expanding our offering of MDLIVE to all our members with no cost share through July 31, 2020.

2) Blue Cross of Idaho has partnered with Episource to offer targeted high-risk members a virtual wellness assessment visit by licensed clinical health providers that is free of charge, completely voluntary and does not affect their healthcare coverage in anyway. These visits are traditionally provided in the members’ homes. However due to the public health mandates currently in place, we are transitioning to virtual visits as a way to safeguard everyone’s health. These visits are not meant to replace routine or specialized care the members receive from their regular physicians. All information obtained during these virtual visits will be shared with the members primary care physician.

If you have further questions on this program, please email [email protected].