March 2021

Telehealth Services for Our Government Programs Members

Below is general information on telehealth services during the COVID-19 Public Health Emergency (PHE) to help with claims coding and documentation for our government programs members. This includes our members with any of the following health benefit plans: Blue Cross Medicare Advantage^SM, Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM and Blue Cross Community Health Plans^SM (BCCHP^SM) members. This is consistent with information from the Centers for Medicare & Medicaid Services (CMS) and Illinois Department of Healthcare and Family Services (HFS).

Members’ telehealth benefits depend on the terms of their benefit plan. To verify telehealth coverage for our government programs members, call the appropriate Provider Services number to speak to a Customer Advocate: Medicare Advantage – 877-774-8592; MMAI – 877-723-7702; BCCHP – 877-860-2837. See the Additional Information for Government Programs section of our COVID-19 Preparedness FAQs for more details.

Topic	For Medicare Advantage and MMAI members:	For BCCHP members:
Audio-Plus-Visual Telehealth Services	Services may include: Office or other outpatient visits Annual Wellness Visits Telehealth consultations (emergency department, initial inpatient, skilled nursing facilities)	Services may include Medicaid-covered medically necessary and clinically appropriate telehealth and virtual care services.
Audio-Only Telehealth Services	Audio-only services don’t satisfy CMS’ face-to-face criteria for risk adjustment. CMS permits them during the PHE only in limited circumstances	Audio-only (telephone) evaluation and management (E/M) services to new or existing patients are permitted. Bill as a distant site telehealth visit if the care given meets the key components of a face-to-face visit Otherwise, bill using CPT code G2012 for virtual check-in services
Current Procedural Terminology (CPT^®)/Healthcare Common Procedure Coding System (HCPCS) Codes	CMS List of Telehealth Services	Illinois Medicaid COVID-19 Fee Schedule
Modifier/Place of Service (POS)	Report the POS code that would have been reported had the service been provided in person. Include CPT telehealth modifier 95 You can also report POS 02 with no modifier	All virtual health care/telehealth codes must be billed with POS 02 and GT modifier.
Documentation	During the PHE, CMS has revised its policy¹: To specify the office/outpatient E/M level selection for these services when furnished via telehealth can be based on medical decision making or time, with time defined as all of the time associated with the E/M on the day of the member visit; and To remove any requirements regarding documentation of history and/or physical exam in the medical record	The distant site provider and originating site provider eligible for a facility fee must maintain adequate documentation of the telehealth services provided.²
Technology*	Interactive audio and video telecommunications system that permits two-way, real-time communication,³ including: HIPAA-approved telehealth platforms Non-HIPAA-approved applications for the duration of the PHE	A brief communication technology-based service that uses audio-only real-time telephone interactions or synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.

*This information regards HIPAA-compliant remote technologies to meet risk adjustment criteria. Providers can find the latest guidance on acceptable HIPAA-compliant remote technologies issued by the U.S. Department of Health and Human Services’ Office for Civil Rights in Action. Also see BCBSIL’s COVID-19 Preparedness FAQs for more information.

¹ CMS interim final rule and comment period (IFC), 136, https://www.cms.gov/files/document/covid-final-ifc.pdf

² Illinois General Assembly, Joint Committee on Administrative Rules, http://www.ilga.gov/commission/jcar/admincode/089/089001400D04030R.html

³ CMS IFC, 49, https://www.cms.gov/files/document/covid-final-ifc.pdf

This material is for informational and educational purposes only. It is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. This material is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly.

The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. If you have any questions, call the number on the member’s ID card.