RETRACTION: Please refer to article published 9/1/22 - Correction: New patient evaluation and management services when reported for the same patient within the last three years

The Centers for Medicare & Medicaid Services (CMS) routinely issues revisions to the average sales price (ASP) fee schedules regarding drug pricing. To that end, CMS is supplying the fourth-quarter fee schedule with an effective date of October 1, 2022. This will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on November 1, 2022. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice.

 

NVBCBS-CM-005673-22

Now open for learning!

Understanding how to use the many time saving applications on Availity Essentials* is important to working together digitally. Anthem Blue Cross and Blue Shield has developed a learning place just for that purpose — the Provider Learning Hub.

 

Using the Provider Learning Hub available from https://www.anthem.com/provider is the easiest and quickest way to access courses and learning guides about claim submission, attachments and status, eligibility and benefits, and more.

 

These new and improved learning experiences apply to Availity Essentials and electronic data interchange (EDI) transactions:

• Visit the Provider Learning Hub for short, easy-to-follow training videos with supporting resources — no username and password required.
• Handy filtering options make it easy to find what you are looking for.
• The Favorites folder lets you save courses for easy access later.
• Register once and on future visits your preferences are populated, eliminating the need for any additional logon information.

  

Get started today!

Access the Provider Learning Hub today using this link or from https://www.anthem.com/provider under Important Announcements on the home page.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

MULTI-BCBS-CM-007018-22

We are asking you to review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting www.anthem.com, select For Providers, then choose Go To Providers Overview, select Find Care.

 

Submit updates and corrections to your directory information using our online Provider Maintenance Form. Online update options include:

• Add/change an address location.
• Name change.
• Tax ID changes.
• Provider leaving a group or a single location.
• Phone/fax number changes.
• Closing a practice location.

Once you submit the form, we will send you an email acknowledging receipt of your request.

 

The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current.

 

 

MULTI-BCBS-CM-006813-22-CPN6767

The National Accounts 2023 Pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

 

MULTI-BCBS-CM-006731-22

Material adverse change

 

Anthem Blue Cross and Blue Shield (Anthem) and our subsidiary company, HMO Nevada are pleased to provide you with our updated and new medical policies. Anthem will also be implementing changes to our clinical utilization management (UM) guidelines that are adopted for Nevada. The clinical UM guidelines published on our website represent the clinical UM guidelines currently available to all plans for adoption throughout our organization. Because local practice patterns, claims systems, and benefit designs vary, a local plan may choose whether or not to implement a particular clinical UM guideline. The attached document can be used to confirm whether or not the local plan has adopted the clinical UM guideline(s) in question. Adoption lists are created and maintained solely by each local plan.

 

Open the attached document titled Nevada medical policy and clinical guideline updates to view the new and/or revised medical policies and clinical guidelines adopted by the MPTAC. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

 

Anthem medical policies and clinical UM guidelines are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes Anthem medical directors and representatives from practicing physician groups, meets quarterly to review current scientific data and clinical developments.

 

All coverage written or administered by Anthem excludes from coverage, services, or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s medical policies. Review procedures have been refined to facilitate claim investigation.

 

Anthem’s medical policies and clinical UM guidelines are available online

The complete list of our medical policies and clinical UM guidelines may be accessed on Anthem’s website at anthem.com/provider. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as your state. Select View Medical Policies & UM Guidelines. Either enter keyword or code or select the link for Full List page to search the policy for your inquiry.

 

To view the list of specific clinical UM guidelines adopted by Nevada, navigate to the View Medical Policies & UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem Blue Cross and Blue Shield in Nevada.

 

 

NVBCBS-CM-006557-22

Medicare

 

(Policy 21-001, effective 01/01/2022)

 

In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.

 

If you have any questions, contact your Provider Experience associate or visit the Contact Us page on our provider website (https://www.anthem.com/medicareprovider) for up-to-date contact information.

 

MULTI-BCBS-CR-004022-22-CPN3670

Medicaid

Please continue to check Medicaid Provider Communications & updates at anthem.com/nvmedicaiddoc for the latest Medicaid information.

Medicaid

 

Effective for dates of service on and after November 1, 2022, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of a national drug code on your medical claim is always required for claims processing.

 

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug name
ING-CC-0205	J9331	Fyarro (sirolimus albumin bound)
ING-CC-0206	J3490, J3590	BESREMi (ropeginterferon alfa-2b-njft)
ING-CC-0207	J9332	Vyvgart (efgartigimod alfa-fcab)
ING-CC-0208	J3490, C9399	Adbry (tralokinumab)
ING-CC-0209	J1306	Leqvio (inclisiran)

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Experience representative or call Provider Services at 844-396-2330.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

NVBCBS-CD-006178-22-CPN6053

Medicaid

 

Effective for dates of service on and after December 1, 2022, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

 

Please note, inclusion of a National Drug Code on your medical claim is necessary for claim processing.

 

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

 

Clinical Criteria	HCPCS or CPT® code(s)	Drug name
ING-CC-0202	J3490, J3590, C9086	Saphnelo (anifrolumab-fnia)
ING-CC-0203	J3490, J3590	Ryplazim (plasminogen, human-tvmh)

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local Provider Relations representative or call Provider Services at 844-396-2330.

 

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

 

NVBCBS-CD-005258-22-CPN5089

Medicaid

 

Background

We are carefully monitoring the recent outbreak of monkeypox infections in the U.S. and are working to support our members and our network care providers with information to help you respond appropriately in the context of your patient population.

 

The best source of up-to-date information is at the Centers for Disease Control and Prevention which has a dedicated monkeypox page for healthcare professionals.

 

In addition to resources for care providers, the CDC has developed educational materials for the public, available for free download online.

 

FAQs

How does monkeypox spread?

Monkeypox does not spread easily between people without close contact. Person-to-person transmission is possible by skin-to-skin contact with body fluids or monkeypox sores, or respiratory droplets during prolonged face-to-face contact, and less likely through contaminated items such as bedding, clothing, or towels. Patients are contagious until the scabs heal and are replaced by new skin.

 

How dangerous is the disease?

Monkeypox virus belongs to the poxvirus family and infection is rarely fatal. Patients whose immune system is compromised are most at risk for severe disease, along with children younger than 8 years old, pregnant and breastfeeding people, and people with a history of atopic dermatitis or other active skin conditions.

 

What are monkeypox symptoms?

Patients often have a characteristic rash (well-circumscribed, firm, or hard macules evolving to vesicles or pustules) on a single site on the body. Patients may also present with a fever and muscle aches. The rash may start in the genital and perianal areas. The lesions are painful when they initially emerge, but can become itchy as they heal, and then go away after two to four weeks. Symptoms can be similar or occur at the same time as sexually transmitted infections.

 

Is there a monkeypox vaccine?

Yes, although at the time of this writing, availability is limited. Smallpox and monkeypox vaccines are effective at protecting people against monkeypox when given before exposure to monkeypox, and vaccination after a monkeypox exposure may help prevent the disease or make it less severe. You can access the CDC’s vaccination updates online.

 

How can monkeypox be treated?

There are no treatments specifically for monkeypox virus infections. However, antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.

 

Do I need to report a case of suspected monkeypox?

Yes, contact your state health department if you have a patient with monkeypox. They can help with testing and exposure precautions. Find your state health plan department online.

 

What are the behavioral health impacts of monkeypox?

Studies reporting psychiatric symptoms have indicated that the presence of anxiety, depression, or low mood is common among hospitalized patients with monkeypox infection. Care providers can help by listening with compassion, understanding underlying behavioral health concerns that may be heightened during isolation, and refer patients to the appropriate level of support following a monkeypox diagnosis.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call Provider Services at 844-396-2330.

 

NVBCBS-CD-005152-22-CPN4845

Medicaid

 

Effective with claims with dates of service on or after July 1, 2021, provider type 12 (Hospital, Outpatient) may bill Current Procedural Terminology (CPT^®) code 99483 (Assessment of and Care Planning for Patient with Cognitive Impairment, typically 50 minutes) for recipients age 55 and older. No prior authorization is required unless the limitation of once per 180 days is exceeded.

 

For additional information please refer to: web_announcement_2611_20211018.pdf (nv.gov)

 

Attention Provider Types 20 (Physician, M.D., Osteopath, D.O.), 24 (Advanced Practice Registered Nurse) and 77 (Physician’s Assistant): Cognitive Assessment and Care Planning Procedure Code 99483 May Be Billed

 

Effective with claims with dates of service on or after July 1, 2021, provider types 20 (Physician, M.D., Osteopath, D.O.), 24 (Advanced Practice Registered Nurse) and 77 (Physician’s Assistant) may bill Current Procedural Terminology (CPT) code 99483 (Assessment of and Care Planning for Patient with Cognitive Impairment, typically 50 minutes) for recipients age 55 and older. No prior authorization is required unless the limitation of once per 180 days is exceeded.

 

For additional information please refer to: web_announcement_2554_20210805.pdf (nv.gov)

 

NVBCBS-CD-005109-22

Medicaid

Material adverse change (MAC)

 

Effective for dates of service on and after October 1, 2022, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of all drugs noted below.

 

The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.

 

Clinical Criteria	Status	Drug(s)	HCPCS codes
ING-CC-0107	Preferred	Mvasi	Q5107
ING-CC-0107	Non-preferred	Avastin	J9035
ING-CC-0107	Non-preferred	Zirabev	Q5118

 

NVBCBS-CD-005079-22-CPN4904

Medicaid

 

We are requesting your support to improve health data interoperability and data quality by participating in our state certified health information exchange, HealtHIE Nevada.* Our recent experience during this pandemic has shown that improving how we share patient and member clinical data is critical to our collective success. It is imperative to us that HealtHIE Nevada is a service we should all use to accomplish this.

 

Participation with HealtHIE Nevada will:

• Strengthen collaboration amongst payers, hospitals, providers, state public health agencies, and HealtHIE Nevada.
• Provide up-to-date patient information available at the time of care delivery and immediately afterwards.
• Become the source of truth for quality data that drives patient safety and improved quality outcomes.
• Help align performance expectations among providers and payers.
• Make it easier for providers to submit data and obtain accurate, on time evaluation of clinical performance.
• Reduce office burden for both payers and providers by eliminating or dramatically reducing manual data capture.
• Improve data collection that will allow reporting of quality measures and drivers of cost reduction.
• Allow managed care organizations (MCO) nurses to work to their license, helping providers improve workflow related to clinical care and capturing quality measures.
• Enhance end user experience with HealtHIE Nevada for both providers and payers.
• Improve quality scores across providers, payers, and the State of Nevada Medicaid division.
• Improve Nevada Health Outcomes for all Nevada locals by reducing morbidity and mortality rates.

Participation in HealtHIE Nevada is provided as a patient centered public service that benefits all participants. Please contact Chuck Dorman, Director of Outreach, at hiesupport@HealtHIEnevada.org to complete an interest form, and he will reach out to you to provide additional information on how HealtHIE Nevada can support your organization.

 

* HealthHIE Nevada is an independent company providing information exchange services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.

 

NVBCBS-CD-004825-22

Medicaid

 

In line with our commitment to participating practitioners and members, Anthem Blue Cross and Blue Shield Healthcare Solutions has a Members’ Rights and Responsibilities section located within the provider manual. The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Review this section in your provider manual here: https://providers.anthem.com/docs/gpp/NV_CAID_ProviderManual.pdf?v=202112161934

 

 

NVBCBS-CD-003850-22-CPN3784

Medicaid

 

Managing illness can be a daunting task for our members, your patients. It is not always easy to understand test results, how to obtain essential resources for treatment, or who to contact with questions and concerns. Our Complex Care Management program offers assistance.

 

Our care managers are part of an interdisciplinary team of clinicians and other resource professionals there to support members, families, PCPs, and caregivers. We leverage our experience and expertise of tour team to educate and empower our members by increasing self-management skills. We help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient healthcare.

 

Members or caregivers can refer themselves or family members by calling the Customer Service number located on their ID card. They will be transferred to a team member based on the immediate need. Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that members and caregivers are better prepared and informed about healthcare decisions and goals.

 

You can contact us by phone at 844-396-2330. Care Management business hours are Monday to Friday, from 8 a.m. to 5p.m. PT.

 

NVBCBS-CD-003828-22-CPN3339

Medicaid

 

Policy G- 06003), (Informational only)

 

The current Modifier 57: Decision for Surgery is retired and is combined with Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service for Anthem Blue Cross and Blue Shield Healthcare Solutions. The new combined policy title is Modifiers 25 and 57: Evaluation and Management with Global Procedures.

 

For additional information, please review the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy at https://providers.anthem.com/nv.

 

NVBCBS-CAID-002551-22-CPN2420

Medicaid

 

(Policy 21-001, effective 01/01/2022)

 

In the October 2021 edition of the provider newsletter, we announced that a new reimbursement policy titled Sexually Transmitted Infections Testing — Professional would be effective for dates of service on or after January 1, 2022. We have made a decision to retract this reimbursement policy.

 

If you have any questions, contact your Provider Experience associate or visit the Contact Us page on our provider website (https://providers.anthem.com/nv) for up-to-date contact information.

NVBCBS-CD-004015-22-CPN3670

Medicare Advantage

 

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information.

Medicare Advantage

 

Consultation codes will no longer be allowed for Anthem Blue Cross and Blue Shield for Medicare Advantage. This determination aligns with CMS guidance and does not allow reimbursement for inpatient (99251-99255) or outpatient (99241-99245) consultation codes and requires providers to bill the appropriate office visit evaluation and management (E/M) code for consultation services.

 

MULTI-BCBS-CR-005933-22-CPN5916

Medicare Advantage

Material adverse change (MAC)

 

 

Effective for dates of service on and after December 1, 2022, the specialty Medicare part B drug listed in the table below will be included in our precertification review process.

 

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

HCPCS or CPT® codes	Medicare part B drugs
J3490, J3590	Amvuttra (vutrisiran)
J3299	Xipere (triamcinolone acetonide injectable suspension)

 

 

MULTI-BCBS-CR-005197-22-CPN4920

Medicare

Material adverse change

 

Effective for dates of service on and after December 1, 2022, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

HCPCS or CPT® codes	Medicare Part B drugs
C9399, J3490, J3590, J9999	Alymsys (bevacizumab-maly)

 

 

MULTI-BCBS-CR-003521-22-CPN3371

Medicare Advantage

 

This FAQ communication is designed to provide general guidance for questions related to Medicare telehealth services during the Coronavirus (COVID-19) Public Health Emergency (PHE). The PHE is ongoing and ever evolving; therefore, Anthem Blue Cross and Blue Shield (Anthem) wants to support accurate and up-to-date information around legal and regulatory changes that may impact healthcare.

 

This FAQ is for informational purposes only and is intended to provide guidance regarding the changing landscape of Medicare telehealth. This guidance is not all-inclusive; it is intended to address frequently asked questions and common Medicare telehealth topics. The content included herein is not intended to be a substitute for the provisions of applicable statutes or regulations or other relevant guidance issued by CMS, as those items are subject to change from time-to-time.

 

General

 

Q. What virtual services are categorized as telehealth?

According to CMS, there are three main types of virtual services that physicians and other qualified healthcare providers can render to Medicare beneficiaries: (i) Medicare telehealth visit; (ii) virtual check-ins; and (iii) e-visits. Medicare telehealth visits are those facilitated by a telecommunication system between a provider and a patient. Virtual check-ins, which may or may not be face-to-face, are brief (5 to 10 minutes) interactions with an established patient and provider via telephone or other telecommunications platform and are used to determine whether an office visit or other service is needed. E-visits are non-face-to-face, patient-initiated communications between an established patient and their provider through an online patient portal. Please refer to the CMS Telemedicine Fact sheet for additional information.

 

Medicare Telehealth Services
Virtual Service	Description of Virtual Service	Medicare Covered	Eligible for Risk Adjustment Payment	Place of Service (POS)
Telehealth visits with real-time, interactive simultaneous audio and video	Medicare telehealth visits with real-time, interactive simultaneous audio and video are treated the same as an in-person visit and can be billed using the code for that service; POS 02 for telehealth provided at a location other than the patient’s home, or POS 10 for telehealth provided in the patient’s home; and telehealth CPT modifier 95 to indicate the services were performed via audio-visual telehealth	✓	✓	POS 02 or 10 (depending on location) and telehealth CPT modifier 95
Telehealth visits with audio only	Certain Medicare telehealth services may be conducted via an audio-only telecommunications system and can be billed using the code for that service; any applicable POS; and telehealth CPT modifier 93 to indicate the services were performed via audio only telehealth See CMS List of Telehealth Services	✓	X	Any applicable POS and telehealth CPT modifier 93
Virtual/brief check-ins	5-to-10-minute communication with an established patient to determine the need for an in-person visit	✓	X	Any applicable POS
E-visit	Communication between an established patient and their provider through an online patient portal	✓	X	Any applicable POS

 

 

Q. According to CMS, what types of services may be offered via telehealth?

As a result of the COVID-19 public health emergency (PHE), CMS has expanded the types of services that may be offered via telehealth. A complete list of Medicare telehealth services payable under the Medicare Physician Fee Schedule can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

 

Q. Who may perform telehealth services?

In accordance with the Social Security Act and CMS guidance, healthcare professionals such as physicians, nurse practitioners, physician assistants, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians may perform and bill for acceptable telehealth services within their scope of practice and consistent with federal and state requirements. For more information, please view the Social Security Act and the CMS List of Telehealth Services.

 

Q. Can telehealth services be rendered using FaceTime?

Yes, CMS has eased some Health Insurance Portability and Accountability Act (HIPAA) Privacy rules and currently permits the use of telecommunications systems that have audio and video capabilities that allow for simultaneous real-time, interactive communication between a healthcare provider and a patient. During the COVID-19 PHE, the Department of Health & Human Services (HHS) has waived penalties for HIPAA violations, allowing healthcare providers to serve patients using communications technologies, like FaceTime or Skype, when used in good faith. The Department of Health & Human Services (HHS) addresses telehealth remote communications in the Notification of Enforcement Discretion for Telehealth | HHS.gov.

 

Q. Can any of the services on the Medicare telehealth list be furnished and billed when rendered using audio-only technology, such as a telephone?

Currently, and throughout the duration of the PHE, eligible providers may furnish certain limited services using audio-only technology. These services are included on the Medicare telehealth list. Unless this list indicates that a service is acceptable for delivery through audio-only interaction, the Medicare telehealth service must be furnished simultaneously using, at a minimum, an interactive audio and video telecommunications system that permits real-time communication between the provider and patient.

 

Telephonic-only (in other words, telephone) evaluation and management (E/M) service provided by a physician or other qualified healthcare professional to an established patient, parent, or guardian (not originating from a related E/M services provided within the last seven days nor leading to an E/M service or procedure within the next 24 hours) should be billed with codes 99441-99443.

Q. Is occupational therapy considered a covered Medicare telehealth service?

Historically, therapy services, such as occupational therapy, have not been included on the list of approved Medicare telehealth services. However, in light of the public health emergency (PHE) associated with the COVID-19 pandemic, CMS offered additional clarification in the interim final rule and March 17, 2020 Medicare Provider FAQ. There, CMS acknowledged the need to mitigate exposure risks during the PHE by adding therapy services to the telehealth list as of March 1. Importantly, only eligible healthcare providers may render such services.

 

While practitioners such as physical therapists, occupational therapists, and speech-language pathologists are not among those identified under section 1842(b)(18)(C) of the Social Security Act as eligible to furnish and bill for Medicare telehealth services, such providers are permitted to offer virtual check-ins (G2010 and G2012) and remote evaluations

(in other words, e-visits (G2061-G2063)), and telephone E/M services (98966-98968), where appropriate.

 

Q. Does a healthcare provider have to be licensed in the state in which the patient is located at the time of service?

As a result of the COVID-19 PHE, many states have relaxed licensing requirements to support continuity of care and prevent impediments to accessing care during these unprecedented times. Further, on March 13, 2020, pursuant to the 1135-based waivers, CMS temporarily waived requirements that out-of-state healthcare providers must be licensed in the state in which they are providing services as well as the state in which they practice. More specifically, CMS will waive this licensing requirement when the following criteria is met: (i) provider is enrolled in the Medicare program; (ii) provider has a valid license to practice in the state associated with their Medicare enrollment; (iii) state in which provider is practicing – in addition to that associated with their Medicare enrollment – is affected by the COVID-19 PHE; and (iv) provider is not affirmatively barred from practice in the state in which they seek to render services or any other state that is part of the 1135 emergency area. Therefore, if the above criteria are met, providers may practice in states other than that in which they are licensed to practice if the state in which the provider wishes to practice via telehealth has – like CMS – waived its licensure requirements. Because licensure and scope of practice laws vary from state to state, it is important to check the applicable state-specific requirements and a member’s benefit agreement.

For additional information on the 1135 Waiver, please consult the Waiver or Modification of Requirements under Section 1135 of the Social Security Act from the US Department of Health and Human Services.

 

Billing and documentation guidance:

Q. What place of service (POS) code should be used for telehealth services rendered during the PHE?

To report telehealth E/M services to Anthem for a real-time, interactive simultaneous audio and video encounter, the applicable E/M CPT code, CPT Telehealth modifier 95, and either POS 02 or POS 10, depending on the location of the patient at the time of service should be used.

 

Importantly, CPT Telehealth modifier 95 must be used to indicate the encounter as an audio and video, real-time, interactive interaction between a provider and a patient. CPT Telehealth modifier 93 must be used to indicate the encounter as an audio only interaction between a provider and a patient.

 

Q. Is the originating site restriction still in place for Medicare telehealth visits?

No, under section 1834(m)(4)(C) of the Social Security Act, Medicare telehealth visits must meet strict originating site requirements (both geographic and site of service restrictions). Statutory originating sites include locations such as physician or practitioner office, hospital, skilled nursing facility, among other healthcare facilities. However, in the interim final rule, CMS lifted these restrictions for services beginning  March 6, 2020, and for the duration of the COVID-19 PHE. There, CMS authorized qualified healthcare providers to render telehealth services to patients wherever they are located, including the patient’s home.

 

Q. Are there specific documentation requirements for telehealth services during the PHE?

Healthcare providers should document services furnished via telehealth the same way a face-to-face encounter would be documented, except for the elements that require the presence of the patient, in other words, physical examination. Additionally, providers should document that the service was rendered via telehealth to reflect details of the encounter accurately and completely, specifically indicating whether the telehealth visit was with audio and video or whether it was audio only. See above regarding Q&A as to coding guidance, for example, E/M, POS, and CPT Telehealth modifier.

 

Q. Can an annual wellness visit (AWV) be conducted and billed for when rendered via telehealth even when vitals cannot be captured?

Yes, as of April 30, 2020, CMS expanded the list of acceptable Medicare telehealth services to include the AWV (G0438, Initial AWV and G0439, Subsequent AWV). Though several of the required elements of an AWV look and feel the same when completed via telehealth, some, like recording a patient’s vitals, necessitate adaptation. Healthcare providers should continue to document all information accurately and completely what they are able to collect during a telehealth encounter. Therefore, the provider can ask the patient if they have the ability to measure their height, weight, temperature, blood pressure, and/or heart rate. If so, the patient may be able to do so during the telehealth encounter. Alternatively, the patient may be able to self-report such information; self-reported information should be documented as such.

 

However, if vitals cannot be captured during a telehealth AWV, an AWV may still be conducted and billed when rendered in accordance with state and federal guidelines. In the interim final rule, CMS provided additional flexibility to providers during the COVID-19 PHE: on an interim basis, CMS removed requirements regarding documentation of history and/or physical exam in the medical record for office/outpatient evaluation and management (E/M) encounters provided via telehealth.

 

Medicare Risk Adjustment (MRA or risk adjustment)

Q. Is a diagnosis code reportable for risk adjustment purposes if documented by a provider based on a telehealth encounter?

As of the April 10, 2020, Memo, and as confirmed in the updated January 15, 2021, Memo, CMS authorizes Medicare Advantage organizations (MAOs) to submit diagnoses for risk adjustment from telehealth encounters, only when those encounters meet all criteria for risk adjustment data submission. More specifically, diagnoses submitted for risk adjustment purposes from a telehealth encounter must meet the following requirements:

• Encounter must be face-to-face, using interactive audio telecommunication simultaneously with video telecommunication to permit real-time communication between the provider and the member;
• Provider must use CPT Telehealth modifier 95;
• Provider must use POS 02 for telehealth provided at a location other than the patient’s home or POS 10 for telehealth provided in the patient’s home;
• Services rendered must be those which are allowable by CMS, included within the Anthem benefit package, and clinically appropriate to furnish via a face-to-face telehealth encounter;
• Provider must be an acceptable physician specialty/provider type, for example, physician (MD or DO), physician assistant (PA), or nurse practitioner (NP); and
• Encounter must meet all other criteria for risk adjustment eligibility, which include, but are not limited to, being from an allowable inpatient, outpatient, or professional service.

 

Q. How can the risk adjustment face-to-face requirement be met for services rendered via telehealth?

As a result of the COVID-19 PHE, CMS expanded the definition of face-to-face with regard to risk adjustment data submission criteria. Formerly, this requirement was met only when an in-person encounter between a patient and an acceptable provider type/physician specialty occurred. Under its April 10, 2020, guidance, CMS authorized satisfaction of this required element in a virtual setting via telehealth. To meet the risk adjustment face-to-face requirement for telehealth encounters, CMS requires the provider to simultaneously use an interactive audio and video telecommunications system that permits real-time communication between the provider and patient.

 

Q. Do telephone (audio-only) encounters between a provider and patient satisfy CMS criteria for risk adjustment payment?

No, an audio-only encounter, such as that facilitated using telephone audio-only, does not satisfy the criteria for risk adjustment data eligibility. To satisfy the criteria for risk adjustment data submission, diagnoses submitted based on a telehealth encounter must be derived from an eligible face-to-face interaction between a provider and patient. More specifically, the interaction must be conducted in real-time with simultaneous use of an interactive audio and video telecommunication system.

 

Q. How should a real-time, interactive audio and video telehealth encounter be reported?

To report telehealth Evaluation and Management (E/M) services to Anthem for an audio and video encounter, please use applicable E/M CPT code, CPT Telehealth modifier 95, and either POS 02 or POS 10 depending on the location of the patient at the time of service. CPT Telehealth modifier 95 in addition to the applicable POS must be used so Anthem can identify the encounter as an eligible face-to-face telehealth encounter, in other words, one that took place via real-time, simultaneous interactive audio and video telecommunications system. Providers should also document that the service was rendered via telehealth to reflect details of the encounter accurately and completely, specifically indicating that the telehealth visit was performed with audio and video.

 

Q. Would an encounter using Skype meet the CMS face-to-face requirement for risk adjustment data submission?

Yes, CMS currently permits the use of telecommunications systems with audio and video capabilities that allow for simultaneous, real-time, interactive communication between a healthcare provider and a patient. During the COVID-19 PHE, penalties for HIPAA violations have been waived. This waiver allows providers to serve patients using communications technologies like Skype or FaceTime when used in good faith. The department of Health and Human Services (HHS) addresses telehealth remote communications in the Notification of Enforcement Discretion for Telehealth | HHS.gov.

 

Q. To what dates of service (DOS) is the CMS guidance applicable with regard to eligible interactive audio and video telehealth encounters for risk adjustment payment?

During an April 29, 2020, stakeholder call, CMS clarified to what DOS its April 10, 2020, guidance regarding the applicability of diagnoses from telehealth services for risk adjustment data submission and payment applied. There, CMS stated that such guidance is applicable to eligible face-to-face telehealth encounters (in other words, those using real-time, interactive audio simultaneously with video) within open data submission periods, which as of the date of publication of this document include 2019 DOS, 2020 DOS, 2021 DOS, and 2022 DOS.

 

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