Aetna Telemedicine Billing InformationMarch 18, 2020, 01:18 PM | by: David Williams | No Comments
Telemedicine and Direct Patient Contact
• All Medical Products (including Commercial & Medicare)
• All participating and nonparticipating physicians, facilities, and other qualified health care professionals
Date of Service
Policy Revision Date:
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.
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.
- 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 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 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.
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
- 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.
- 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
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
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.