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Guidance on coverage and billing for virtual health care visits

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:

  1. 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.
  2. 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): 
    Group Number
    XA001
    56794

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 CodeDescription
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 CodeDescription
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 CodeDescription
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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