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Guidance on coverage and billing for virtual health care visits

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, 2020, providers are encouraged to log into the Provider portal to check members' benefits prior to delivering telehealth services.

 

Telehealth Payment Parity - Updated May 11, 2021

Wellmark will extend payment parity for appropriate medical and behavioral health virtual visits with an in-network provider in Iowa until Oct. 31, 2021, and in South Dakota until further notice.

 

Virtual Visit Billing – Updated 7/20/21

As providers are aware, the telehealth provisions in the Iowa Governor’s COVID-19 Public Health Disaster Proclamation expired on June 30, 2021, which had included both coverage for audio-only telehealth and waiver of professional scope of practice limitations on audio-only telehealth. Providers are responsible for knowing and complying with their own professional scope of practice. For providers whose ordinary professional scope of practice does not prevent audio-only telehealth services, such providers may continue billing telephonic (audio-only) visits in accordance with COVID-19 billing guidance using the same codes they would use if the services were provided in person and place of service “02” on a transitional basis until September 1, 2021. Effective September 1, 2021, Wellmark will no longer allow telephonic (audio-only) visits for telehealth services for any provider, and all providers will be required to comply with Wellmark’s Provider Guide for billing services performed by telehealth.

 

Refer to the “Payment Policies and Reports” section of the Wellmark Provider Guide found on Wellmark.com (Provider > Communications and Resources > Provider Guide) for billing services performed by telehealth.

 

**This update is for telephonic (audio-only) only telehealth and does not impact payment parity.

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 through Oct. 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
99417 PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN
G2212 PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN

 

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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