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Guidance on coverage and billing for virtual health care visits
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Effective Sept. 1, 2020
Fully Insured Members
Wellmark has and will continue to provide benefits for telehealth (or virtual) visits for fully insured members. The $0 member cost-share for virtual visits will expire on Aug. 31 for fully insured members. This has been offered since the start of the pandemic to help the health care systems in Iowa and South Dakota by minimizing in-person visits to ERs or clinics as they prepared to potentially care for COVID-19 patients. After Aug. 31, a fully insured member will need to pay their standard cost-share for that benefit, which is no more for telehealth than an in-person visit.
Self-Funded Members
Some employers are self-funded, which means they make the decisions as to what benefits are offered on their plan. A few self-funded employer group plans do not provide coverage for or have limited telehealth benefits. Now that the health care systems have adapted and are able to serve more patients in-office, some of these self-funded plans are returning to our standard telehealth benefits. After Aug. 31, providers are encouraged to log into the Provider portal to check members' benefits prior to delivering telehealth services.
Telehealth Payment Parity - Updated Jan. 5, 2021
Wellmark will extend payment parity for appropriate medical and behavioral health virtual visits with an in-network provider in Iowa until June 30, 2021, and in South Dakota until further notice.
While Wellmark’s preference is that providers conduct virtual visits via interactive audio-visual technology, we recognize that some of our members may not have a smart phone, tablet, or personal computer capable of engaging in an interactive audio-video visit. As such, Wellmark will allow telephonic visits through this period, when audio-visual capabilities aren’t accessible. For claims to process accurately, providers must follow these billing guidelines:
- Providers should bill the appropriate CPT codes for the services provided (see list below).
- Use place of service 02 (telehealth) on the claim for interactive audio-video or telephonic visits.
- Do NOT use a GT or 95 modifier or the claim will deny.
- Providers conducting telephonic only visits with Wellmark’s members during this period must document in their medical records that the visit was conducted via telephone.
- Benefit information on coverage of virtual visits for Wellmark’s members will not be updated on the Claims and Benefits Look-up tool on wellmark.com during this period.
Providers must continue to check benefits for other Blue Cross Blue Shield members as their coverage of virtual visits may vary.
Mar. 16, 2020 - Aug. 31, 2020
Wellmark has received many questions from providers regarding coverage of telehealth services amid the coronavirus (COVID-19) pandemic. As Iowa and South Dakota grapple with the COVID-19 pandemic, we know that virtual visits will play a vital role in preserving access to care and preventing the spread of the novel coronavirus.
Wellmark is taking these steps to increase access to virtual visits for all of our members during this time:
- Wellmark’s Iowa and South Dakota network providers will receive the same fee for virtual visits as an in-person visit. These changes apply to all appropriate medical and behavioral health virtual visits with any Wellmark in-network provider until Aug. 31, 2020. Wellmark will reevaluate this date as the pandemic situation evolves.
- Wellmark has made virtual visits available without any member cost-share for fully-insured members to remove barriers to receiving care. In addition some self-funded clients have chosen to match Wellmark for their members. Effective June 17, other self-funded groups have elected to follow their current benefit structures (group numbers listed below):
While Wellmark’s preference is that providers conduct virtual visits via interactive audio-visual technology, we recognize that some of our members may not have a smart phone, tablet, or personal computer capable of engaging in an interactive audio-video visit. As such, Wellmark will allow telephonic visits through this period, when audio-visual capabilities aren’t accessible. For claims to process accurately, providers must follow these billing guidelines:
- Providers should bill the appropriate CPT codes for the services provided (see list below).
- Use place of service 02 (telehealth) on the claim for interactive audio-video or telephonic visits.
- Do NOT use a GT or 95 modifier or the claim will deny.
- Providers conducting telephonic only visits with Wellmark’s members during this period must document in their medical records that the visit was conducted via telephone.
- Benefit information on coverage of virtual visits for Wellmark’s members will not be updated on the Claims and Benefits Look-up tool on wellmark.com during this period.
Providers must continue to check benefits for other Blue Cross Blue Shield members as their coverage of virtual visits may vary.
Medically Appropriate codes for virtual visits
Based on input from physicians and other clinicians in our two states, Wellmark has established the following list of services that can be performed via a virtual visit (telehealth) and will be paid at the in-office fee from March 16 through Aug. 31:
Medical or Office Visits
CPT Code | Description |
99201 |
OFFICE/OUTPATIENT VISIT, NEW |
99202 |
OFFICE/OUTPATIENT VISIT, NEW |
99203 |
OFFICE/OUTPATIENT VISIT, NEW, 45 MINUTES |
99204 |
OFFICE/OUTPATIENT VISIT, NEW, 60 MINUTES |
99205 |
OFFICE/OUTPATIENT VISIT, NEW |
99211 |
OFFICE/OUTPATIENT VISIT, EST |
99212 |
OFFICE/OUTPATIENT VISIT, EST |
99213 |
OFFICE/OUTPATIENT VISIT, EST |
99214 |
OFFICE/OUTPATIENT VISIT, EST |
99215 |
OFFICE/OUTPATIENT VISIT, EST |
Behavioral Health Services
CPT Code | Description |
90785 |
PSYCHOTHERAPY COMPLEX INTERACTIVE |
90791 |
PSYCHIATRIC DIAGNOSTIC EVALUATION |
90792 |
PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES |
90832 |
PSYCHOTHERAPY PATIENT &/ FAMILY 30 MINUTES |
90833 |
PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 30 MIN |
90834 |
PSYCHOTHERAPY PATIENT &/ FAMILY 45 MINUTES |
90836 |
PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 45 MIN |
90837 |
PSYCHOTHERAPY PATIENT &/ FAMILY 60 MINUTES |
90838 |
PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 60 MIN |
90839 |
PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES |
90847 |
FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS |
96130 |
PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR |
96131 |
PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR |
96132 |
NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR |
96133 |
NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP EA ADDL HR |
96136 |
PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN |
96137 |
PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN |
99354 |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR |
99355 |
PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON ADDL 30 |
99356 |
PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR |
99357 |
PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN |
Therapeutic Services
CPT Code | Description |
92521 |
EVALUATION OF SPEECH FLUENCY |
92522 |
EVALUATION OF SPEECH SOUND PRODUCTION |
92523 |
EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION |
92524 |
BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND REASONANCE |
92526 |
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION |
92507 |
TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL |
92609 |
THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, INCLUDING PROGRAMMING AND MODIFICATION |
97110 |
THERAPEUTIC PROCEDURE |
97112 |
NEUROMUSCULAR REEDUCATION OF MOVEMENT |
97161 |
PT EVAL LOW COMPLEX 20 MIN |
97162 |
PT EVAL MOD COMPLEX 30 MIN |
97164 |
PT RE-EVAL EST PLAN CARE |
97165 |
OT EVAL LOW COMPLEX 30 MIN |
97166 |
OT EVAL MOD COMPLEX 45 MIN |
97168 |
OT RE-EVAL EST PLAN CARE |
97530 |
THERAPEUTIC ACTIVITIES |
97535 |
SELF CARE/HOME MANAGEMENT TRAINING |
97152 |
BEHAVIOR IDENTIFICATION-SUPPORTING ASSESSMENT, ADMINISTERED BY ONE TECHNICIAN UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PORFESSIONAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES. |
97153 |
ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN UNDER THE DIRECTION OF A PHSYICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES. |
97155 |
ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, WHICH MAY INCLUDE SIMULTANEOUS DIRECTION OF TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES. |
97156 |
FAMILY ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (WITH OR WITHOUT THE PATIENT PRESENT), FACE-TO-FACE WITH GUARDIAN(S) / CAREGIVER(S), EACH 15 MINUTES. |
Other codes will be evaluated if the need arises.
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