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Aetna Telemedicine Billing Information

March 18, 2020, 01:18 PM | by: David Williams | No Comments

Telemedicine and Direct Patient Contact

Policy Type:

Revised

Applies to: 

•   All Medical Products (including Commercial & Medicare)

•   All participating and nonparticipating physicians, facilities, and  other qualified health care professionals

Policy Implementation:

Date of Service

Policy Revision Date:

Click Here

Last Review:

December, 2019

Next Review

December, 2020

Our payment policies ensure that we pay providers based on the code that most accurately describes the procedure performed. We include CPT/HCPCS, CMS or other coding methodologies in our payment policies when appropriate. Unless noted otherwise, payment policies apply to all professionals who deliver health care services. When developing payment policies, we consider coding methodology, industry-standard payment logic, regulatory requirements, benefits design and other factors.

Overview

 This policy addresses our guidelines regarding payment for telehealth, telemedicine, direct patient contact, care plan oversight, concierge medicine, and missed appointments. 

Refer to Expanded Claim Edits for additional coding and reimbursement policies that may apply separately from the policy detailed below.

Definitions/Glossary

Asynchronous Telecommunication   

  • Telecommunication systems that store medical information such as diagnostic images or video and forward it from one site to another for the physician or health care practitioner to view in the future at a site different from the patient. This is a non-interactive telecommunication because the physician or health care practitioner views the medical information without the patient being present.

Synchronous Interactive Audio and Video Telecommunication Interactive Audio and Visual Transmissions Audio-Visual Communication Technology   

    • Real-time interactive video teleconferencing that involves communication between the patient and a distant physician or health care practitioner who is performing the medical service. The physician or health care practitioner sees the patient throughout the communication, so that two-way communication (sight and sound) can take place.

Telehealth       

    • Telehealth is broader than telemedicine and takes in all health care services that are provided via live, interactive audio and visual transmissions of a physician-patient encounter. These health care services include non-clinical services, such as provider training, administrative meetings and continuing medical education; in addition to clinical services. Telehealth may be provided via real-time telecommunications or transmitted by store-andforward technology.

Telemedicine

    • Telemedicine services involve the delivery of clinical medicine via real-time telecommunications such as telephone, the internet, or other communications networks or devices that do not involve in person direct patient contact.

Payment Guidelines

Two-way, Synchronous (i.e. real-time) Audiovisual Interactive Medical Service

            Modifiers GT, 95   

  • We pay for two-way, synchronous (i.e. real-time) audiovisual interactive medical services between the patient and the provider.
  • We consider services recognized by The Centers for Medicare and Medicaid Services (CMS) and appended with modifier GT, as well as services recognized by the AMA included in Appendix P of the CPT® Codebook and appended with modifier 95. 
  • A list of eligible CPT/HCPCS codes is available below. When a provider reports modifier GT or 95, it certifies the patient received services via an audiovisual telecommunications system.
    • GT: Telehealth service rendered via interactive audio and video telecommunications system
    • 95: Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system

Asynchronous Telecommunication

              Modifier GQ   

  • We don’t pay for asynchronous telemedicine services.
  • These services are considered incidental to the overall episode of care for the member.
  • When providers report modifier GQ it certifies the patient received services via an asynchronous method.

Tele-Stroke Services

              Modifier G0    

  • We pay for tele-stroke services when appended with modifier G0.
  • Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke

Telehealth Transmission Fees

HCPCS codes Q3014 and T1014

  • Charges for telehealth services or transmission fees aren’t eligible for payment. These services are incidental to the charges associated with the evaluation and management of the patient.

Direct Patient Contact

  • Other than two-way synchronous (i.e. real time) audio visual interactive medical services, and tele-stroke services, as above, we don’t pay for medical services that don’t include direct in-person patient contact. Payment for these services is considered incidental to the overall episode of care for the member. One example of time spent without direct patient contact is physician standby services.

We consider services payable only when provided in-person face-to- face.

Telemedicine for Medicare Members/Plans (as of March 18, 2020)

  • Until further notice, Aetna is also expanding coverage of telemedicine visits to its Aetna Medicare members, so they can receive the care they need from you without leaving their homes. With this change and new flexibilities announced by the Centers for Medicare and Medicaid Services to help combat the virus, Aetna Medicare members can now see their providers virtually via telephone or video.
  • Aetna is offering its Medicare Advantage brief virtual check-in and remote evaluation benefits to all Aetna Commercial members and waiving the co-pay.

Care Plan Oversight         

  • Care plan oversight is not eligible for payment. Care plan oversight is billed for physician supervision of patients under the care of home health agencies, hospice or nursing facilities. It includes the time spent reviewing reports on patient status and care conferences. We do not pay for time without direct patient contact.

Note: Care plan oversight is eligible for payment on case management exceptions authorized by Patient Management.

Concierge Medicine or Boutique Medicine  

  • Concierge medicine, also called boutique medicine is a fee charged for services a patient receives outside of direct patient contact. These services are considered above and beyond the usual, such as scheduling preference or return phone calls from the provider.
  • These services do not represent treatment of disease or injury. They are standard administrative services that are included in the evaluation & management service, we don’t allow separate payment.
  • No specific code exists for these services. Services may be billed with a written description, such as “Concierge Services” or “Administrative Services.”

Missed Appointments  We don’t cover missed appointments because no direct or indirect medical care was rendered to the patient. Charges due to a missed appointment are the responsibility of the member.

                             Eligible Code Description              Eligible CPT/HCPCS

Office or other outpatient visits or consults                 99201 – 99205,                                                                                    99211 – 99215,                                                                                    99241 – 9245      

Inpatient consult for a new or established patient       99251 – 99255

Prolonged service, inpatient or office                         99354, 99355,                                                                                      99356, 99357

Interactive complexity                                              90785

Follow-up inpatient Telehealth consultations

furnished to beneficiaries in hospitals

 or SNFs Subsequent hospital care services,

with the limitation of 1 Telehealth visit every 3 days   G0406*, G0407*, G0408*, 99231, 99232,  99233

Psychiatric diagnostic interview examination              90791, 90792

Individual psychotherapy                                          90832, 90833, 90834, 90836, 90837, 90838

Psychotherapy for crisis; first 60 minutes;

or each additional 30 minutes                                   90839, 90840

Psychoanalysis                                                         90845

Family or group psychotherapy                                  90846, 90847,                                                                                      90853

Pharmacologic management, including prescription

and review of medication, when performed

with psychotherapy services                                      90863

End-Stage renal disease (ESRD) related services         90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970

Remote imaging for detection of retinal disease           92227

External mobile cardiovascular

telemetry with ECG recording                                     93228, 93229

External patient and when performed auto

ECG rhythm derived event recording                           93268, 93270, 93271, 93272

Medical genetics and genetic counseling services          96040

Eligible Code Description                              Eligible CPT/HCPCS

Education and training for patient self-management by a qualified, non-physician health care professional                               98960, 98961,                                                                                     98962

Subsequent nursing facility care services, with the limitation of 1 Telehealth visit every 30 days                                    99307, 99308,                                                                                     99309, 99310

Individual and group medical nutrition therapy             97802, 97803,                                                                                      97804; G0270

Smoking and tobacco use cessation counseling visit      99406, 99407,                                                                                      G0436, G0437     

Alcohol and substance screen and intervention              99408, 99409

Transitional care management services                         99495, 99496

Administration of patient-focused health risk assessment instrument with scoring and documentation or for the benefit of the patient, per standardized instrument                                               96160, 96161

Neurobehavioral status examination                               96116

Advanced care planning                                                99497, 99498

Individual and group diabetes self-management training services                                                                                                G0108, G0109   Counseling visit to discuss need for lung cancer screening using low dose CT scan                                                                       G0296

Alcohol and/or substance abuse structured assessment                                                                                                              G0396, G0397 

Telehealth consultations, emergency department or initial inpatient                                                                                           G0425*,                                                                                               G0426*, G0427*             

Annual Wellness Visit, includes a personalized

prevention plan of service                                               G0438, G0439              

Alcohol misuse screening, counseling                               G0442, G0443              

Annual depression screening                                           G0444

High-intensity behavioral counseling to prevent

sexually transmitted infection; face-to-face,

individual, includes: education, skills

training and guidance on how to change

sexual behavior                                                             G0445

Eligible Code Description                                           Eligible CPT/HCPCS

Annual, face-to-face intensive behavioral therapy

for cardiovascular disease                                                   G0446

Face-to-face behavioral counseling for obesity                      G0447

Telehealth Pharmacologic Management                                G0459

Comprehensive assessment of and care planning for patients requiring chronic care management services                                                                                                                                                G0506

Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient via telehealth; subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth  

                                                                                         G0508*, G0509*

Prolonged preventive service                                                G0513, G0514

Opioid treatment                                                                  G2086, G2087, G2088

Questions and Answers

Beginning March 6, 2020, Aetna will offer zero co-pay telemedicine visits for any reason for 90 days. We will waive the cost share for all video visits through the Aetna-covered Teladoc offerings and in-network providers delivering synchronous virtual care (live video-conferencing) for all Commercial plan designs*. Self-insured plan sponsors can opt-out of this program at their discretion.

*We will also cover HCPCS G2010 and G2012 during the 90-day period.