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For commercial members non-facility telemedicine claims must use POS 02 with the GT or 95 modifier. Fee schedules have been updated so claims with approved telemedicine CPT codes and modifiers with POS 02 will be reimbursed at the same rate as an equal office visit. For example, a telemedicine service 99213 GT with POS 02 will reimburse the same as a face-to-face in-office visit 99213. Facilities should continue to use their respective POS; CPTs and the telemedicine modifiers must be noted on the UB-04 form as the Rev Code will not be sufficient.
For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the 95 modifier indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate.
Reporting codes related to COVID-19 include:
ICD-10 Reporting Codes
Exposure to COVID-19
Lower Respiratory Infection
Aetna is complying with the CMS coding guidelines for COVID-19 lab testing. CMS adopted four CPT codes, (U0001), (U0002), (U0003) and (U0004) for COVID-19 diagnostic testing. Aetna will accept CPT code 87635 or HCPCS Level II U0002 for the COVID-19 diagnostic testing. The following codes should be used for COVID-19 testing for commercial and Medicare plans:
Providers should bill for the COVID-19 swab collection using one of these codes:
Telemedicine will be covered within the capitation agreement, similar to an in-office visit.
Aetna will cover appropriate evaluation and management codes with a wellness diagnosis for those aspects of the visit done via telehealth. Preventative visit codes should be reserved for such time when routine in-office visits resume and the remaining parts of the well visit can be completed. Both services will be fully reimbursed, and the patient will not incur a cost share.
In addition to the appropriate oral evaluation code, (for example D0140) one of the following codes should be reported:
The submission of D9995 or D9996 is purely informational. These codes indicate to us that the evaluation was performed via tele-dentistry, the way a code modifier is used on a medical claim. The code that will be reimbursed is the oral evaluation code.
For PPO plans: All emergency exams will be covered at 100% of the providers negotiated fee. Out-of-network services will be paid at the in-network level. Palliative treatment will be paid at the members benefit level.
For DMO plans: Will follow our standard DMO handling and normal protocols. Referrals are not required for emergency care. Tele-dentistry codes D9995 and D9996 will not be reimbursed. Those codes were not developed for reimbursement; they were created to be used as code modifiers, so that dentists have a way to report that an oral evaluation was performed via tele-dentistry.
If a dentist is seeing a patient in their office, they should submit their office address as they normally would. If the encounter is entirely virtual, then they should follow CMS guidance, which is to enter the place of service code, “02” (telehealth), into Box 38 on the ADA Dental Claim form.
In-network providers have a contracted fee schedule for all CDT codes including oral evaluations. There should not be a charge reported for codes D9995 and D9996. Those codes were not developed for reimbursement; they were created to be used as code modifiers, so that dentists have a way to report that an oral evaluation was performed via tele-dentistry.
We have not established an end date at this point but will reassess this policy as needed.
Any oral evaluation covered under Aetna dental plans and performed via tele-dentistry will be reimbursed the same as if it was performed in a traditional practice setting.
Aetna is suspending a 2% sequestration reduction in payments made to providers, to support them during the COVID-19 pandemic. This applies to claims reimbursements to providers in fee-for service arrangements in Aetna Medicare Advantage plans. The suspension aligns with the CARES Act legislation requiring all health plans to suspend the 2% sequestration reduction in payments from May 1, 2020 to December 31, 2020.
All claims that are based on Medicare payment (Medicare and Medicaid) with dates of service May 1, 2020 through December 31, 2020 will no longer apply the 2% reduction and will be in line with the CARES Act legislation.
The 2% reduction will automatically be removed for those claims where sequestration is applying.
We will evaluate any new legislation and make related policy decisions at the time it occurs.
We will pay providers according to the terms of their participation agreement. For providers who treat Medicare Advantage members and whose contracted reimbursement is based upon CMS IPPS reimbursement methodology, we will apply the increase, as appropriate, for discharges of individuals diagnosed with COVID-19 during the emergency period.
For out-of-network providers who treat Medicare Advantage members, we will comply with CMS requirements and apply the increase, as appropriate, for discharges of individuals diagnosed with COVID-19 during the emergency period. Providers are required to comply with CMS coding and billing requirements. For a provider who treats commercial or Medicaid members, we will pay for covered services in accordance with the member’s health plan benefits and applicable laws and regulations.
Effective dates for the COVID-19 add-in payment depend on the codes used and the date of patient discharge. Effective dates apply as follows:
Due to a delay in CMS releasing necessary information related to the increase in this weighting factor, and to accelerate payment to providers, we processed inpatient claims according to available information at the time. We will be automatically reprocessing the impacted claims. No action is required by providers to initiate the reprocessing.
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