This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross and Blue Shield (Anthem).

 

Care providers are a trusted resource for members when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.

 

Some care providers may have seen a message on their provider Explanation of Benefits (EOB) stating that Anthem does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOB message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.

 

To aid in processing claims for the monkeypox and smallpox vaccine products, care providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:

 

1. Product code (90611 or 90622)
2. Applicable ICD-10-CM diagnosis code
3. Administration code

 

More detail on codes and cost-sharing

 

Providers are encouraged to use:

• Product code 90611 for smallpox and monkeypox vaccine.
• Product code 90622 for vaccinia (smallpox) virus vaccine.
• Code 87593 for laboratory testing.

 

When billing the monkeypox and smallpox vaccine products, care providers should submit those codes with a $0.01 charge.

 

Cost-sharing for the vaccine is waived.

 

If you have any questions, contact the Provider Service number on the back of the member’s ID card. You can read more information on monkeypox.

 

MULTI-BCBS-CRCM-008692-22-CPN8260

Effective January 1, 2022, Norfolk Healthcare Consortium* is offering health benefit plans from Anthem Blue Cross and Blue Shield and our affiliate HealthKeepers, Inc. The Norfolk Healthcare Consortium is comprised of Norfolk Public Schools, the City of Norfolk, and the Norfolk Redevelopment and Housing Authority with approximately 7,700 employees and 13,300 members in total.

 

For Norfolk Healthcare Consortium employees in Virginia, Anthem has issued two Anthem HealthKeepers Point of Service (POS) Open Access plans (Anthem HealthKeepers POS 1000 and Anthem HealthKeepers POS 750) as well as an Anthem HealthKeepers Health Savings Account (HSA) plan (Anthem HealthKeepers HSA 1500). Anthem has made available a PPO Out-of-Area plan (KeyCare PPO $750 Out-of-Area) for employees outside of Virginia. 

 

The prefix on member ID cards will be XHY for plans offered by Anthem and VQX for the PPO plan. The cards will also show customized benefit information and the group logo for the specific entity.

 

Providers should follow normal claims filing procedures.

 

ID cards

 

As always, Anthem encourages providers to ask patients to present their current ID cards. Many members were assigned new identification numbers effective January 1, 2022. New ID cards were provided digitally or mailed to all affected members in late December 2021. To ensure claims are processed appropriately, here is some helpful information.

 

Tips for success 

 

When Anthem members arrive at the office or facility, ask to see their current member identification card at each visit. Many Anthem members no longer receive a paper card, so they will present their digital card on their mobile device. Asking this will help:

• Identify the member’s product.
• Obtain health plan contact information.
• Speed claims processing.

 

Note: Claims providers submit with an incorrect ID number may be unable to be processed and may be returned for correction and resubmission with the correct ID.

 

* Norfolk Healthcare Consortium is an independent company providing comprehensive benefit packages on behalf of Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc.

 

VABCBS-CM-005292-22

 

 

The following services will be added to precertification for the effective dates listed below.

Precertification responsibility The ordering or rendering provider of service is responsible for completing the prior authorization process.   HMO plans: Services that require precertification will be denied if rendered without the appropriate prior authorization for in-network providers. HMO members may not have benefits for non-emergency services rendered outside of the network and are subject to review and may be denied.   PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.   EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/Urgent Care and authorized services.

To request precertification with the Virginia plan Access Availity* at https://www.availity.com for Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc., or call the number listed on the back of the member’s ID card.   For mental health and substance abuse precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

Add to Precertification

Criteria	Criteria description	Code	Effective date
LAB.00031	Advanced lipoprotein testing	0052U	Add 01/01/2023
MED.00118	Continuous monitoring of intraocular pressure	0329T	Add 01/01/2023
SURG.00150	Leadless pacemaker	33274	Add 01/01/2023
SURG.00150	Leadless pacemaker	33275	Add 01/01/2023
MED.00115	Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management	33289	Add 01/01/2023
SURG.00032	Patent foramen ovale and left atrial appendage closure devices for stroke prevention	33340	Add 01/01/2023
SURG.00121	Transcatheter heart valve procedures	33418	Add 01/01/2023
SURG.00116	High resolution anoscopy screening for anal intraepithelial neoplasia (AIN) and squamous cell cancer of the anus	46601	Add 01/01/2023
SURG.00116	High resolution anoscopy screening for anal intraepithelial neoplasia (AIN) and squamous cell cancer of the anus	46607	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53445	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53446	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53448	Add 01/01/2023
SURG.00010	Treatments for urinary incontinence	53449	Add 01/01/2023
SURG.00077	Uterine fibroid ablation: laparoscopic, percutaneous or transcervical image guided techniques	58674	Add 01/01/2023
SURG.00026	Deep brain, cortical, and cerebellar stimulation	61850	Add 01/01/2023
SURG.00026	Deep brain, cortical, and cerebellar stimulation	61860	Add 01/01/2023
SURG.00144	Occipital nerve block therapy for the treatment of headache and occipital neuralgia	64405	Add 01/01/2023
SURG.00140	Peripheral nerve blocks for treatment of neuropathic pain	64415	Add 01/01/2023
SURG.00140	Peripheral nerve blocks for treatment of neuropathic pain	64417	Add 01/01/2023
SURG.00140	Peripheral nerve blocks for treatment of neuropathic pain	64447	Add 01/01/2023
SURG.00140; SURG.00144	Peripheral nerve blocks for treatment of neuropathic pain; occipital nerve block therapy for the treatment of headache and occipital neuralgia	64450	Add 01/01/2023
SURG.00151	Balloon dilation of the eustachian tubes	69705	Add 01/01/2023
SURG.00151	Balloon dilation of the eustachian tubes	69706	Add 01/01/2023
CG-MED-51; RAD.00038	Three-dimensional (3-D) rendering of imaging studies; use of 3-D, 4-D or 5-D ultrasound in maternity care	76376	Add 01/01/2023
CG-MED-51; RAD.00038	Three-dimensional (3-D) rendering of imaging studies; use of 3-D, 4-D or 5-D ultrasound in maternity care	76377	Add 01/01/2023
LAB.00033	Protein biomarkers for the screening, detection and management of prostate cancer	81539	Add 01/01/2023
MED.00125	Biofeedback and neurofeedback	90875	Add 01/01/2023
MED.00125	Biofeedback and neurofeedback	90876	Add 01/01/2023
MED.00115	Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management	93264	Add 01/01/2023
RAD.00064	Myocardial sympathetic innervation imaging with or without single-photon emission computed tomography (SPECT)	A9582	Add 01/01/2023
MED.00115	Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management	C2624	Add 01/01/2023
DME.00037	Cooling devices and combined cooling/heating devices	E0218	Add 01/01/2023
MED.00125	Biofeedback and neurofeedback	E0746	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0558	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0561	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0690	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J0743	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J1267	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J1335	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J1956	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J2185	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J2280	Add 01/01/2023
MED.00013	Parenteral antibiotics for the treatment of Lyme disease	J2510	Add 01/01/2023

 

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

VABCBS-CM-006249-22

 

 

RETRACTION: Please refer to article published 8/1/22 - New patient evaluation and management services when reported for the same patient within the last three years

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

 

MULTI-BCBS-CM-006731-22

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 (select Virginia if needed.) 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

 

The following guideline was among those recently approved at the Medical Policy and Technology Assessment Committee meeting held August 11, 2022. Revisions have been made to the coding, which may result in services previously considered medically necessary to now be considered not medically necessary for dates of service on or after January 1, 2023.

 

This guideline impacts all our products — excluding Medicare Advantage, Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc., and the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program [FEP]).

 

The services addressed in this guideline will require authorization for all our products, excluding Medicare Advantage, and Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc. A predetermination can be requested for our PPO products. Please note that FEP is excluded from this requirement as well.

 

Guideline	Code
CG-GENE-13	81309

 

VABCBS-CM-006509-22

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion offered by HealthKeepers, Inc.

 

Managing illness can be a daunting task for Medallion and FAMIS members enrolled in HealthKeepers, Inc. It is not always easy to understand test results, to know how to obtain essential resources for treatment, or to know who to contact with questions and concerns.

 

HealthKeepers, Inc. is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, primary care physicians and caregivers. The complex case management process uses the experience and expertise of the Case Coordination team to educate and empower our members by increasing self-management skills. The Complex Case Management process can 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 Member Services number located on the back of their ID card. They will be transferred to a team member based on the immediate need. In addition, physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687. Case Management business hours are Monday through Friday from 8 a.m. to 6 p.m. ET.

 

VAHK-CD-003831-22-CPN3339

 

 

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

In line with our commitment to participating practitioners and members, HealthKeepers, Inc. 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/VA_CAID_ProviderManual.pdf?v=202110141650 

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.
 VAHK-CD-003853-22-CPN3784

Reimbursement Policy Retraction

Sexually Transmitted Infections Testing — Professional

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

 

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.

 

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 planned to retract this reimbursement policy.

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020, Anthem CCC Plus Provider Services at 855‑323‑4687, or visit the Contact Us page on our provider website (https://providers.anthem.com/va) for up-to-date contact information.

 

VAHK-CD-004020-22-CPN3670

Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.

 

Background

 

HealthKeepers, Inc. is carefully monitoring the recent outbreak of monkeypox infections in the U.S. and is 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 any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.

 

VAHK-CD-005160-22

Please continue to check our website https://providers.anthem.com/virginia-provider/home for the latest Medicaid information for members enrolled in HealthKeepers, Inc.’s Anthem HealthKeepers Plus and the Commonwealth Coordinated Care Plus (Anthem CCC Plus) benefit plans. Here are the topics we’re addressing in this edition:

 

• New specialty pharmacy medical step therapy requirements

• Prior authorization updates for medications billed under the medical benefit – effective December 1, 2022

 

• Prior authorization updates for medications billed under the medical benefit – effective November 1, 2022

 

• Private duty nursing reimbursement RETRACTION: October 14, 2022

  (Watch for the November 2022 edition of Provider News for further information.)

• Change to DME canes, crutches, and walkers benefit limits

 

• Change to DME traction equipment

This frequently asked questions (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, 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 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.

 

MULTI-BCBS-CARE-002053

Effective for dates of service on and after October 1, 2022, updated step criteria for immunoglobulins found in Clinical Criteria document ING-CC-0003 has been implemented. The preferred product list is being expanded. Please refer to the Clinical Criteria page for more information.

 

MULTI-BCBS-CR-003774-22-CPN3658

 

Reimbursement Policy Retraction

Sexually Transmitted Infections Testing — Professional

(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

Please continue to read news and updates at anthem.com/provider/medicare-advantage for the latest Medicare Advantage information, including:

 

• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list

 

• Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list – J3490, J3590 and J3299

• Consultation codes