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. Urgent Care Centers should continue to use POS 20. All other facilities should continue to use their respective POS; CPTs and the telemedicine modifiers must be noted on the UB-04 and HCFA 1500 forms 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. 

Aetna’s telemedicine policy is available to providers on the Availity portal.

Reporting codes related to COVID-19 include:

ICD-10 Reporting Codes

• Code U07.1, 2019-nCoV acute respiratory disease, will be implemented into ICD-10-CM with the update effective April 1, 2020. Until then, providers must use available ICD-10 codes and guidance.
  
  

Exposure to COVID-19

• Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out). Used for cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation.
• Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases). Used for cases where there is an actual exposure to someone who is confirmed to have COVID-19.
  

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:

• U0001 - 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when specimens are sent to the CDC and CDC-approved local/state health department laboratories.
• U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health department laboratories.
• U0003: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
• U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
• 87635 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.  Use of code 87635 will help the labs to efficiently report and track testing services related to SARS-CoV-2 and will streamline the reporting and reimbursement for this test in the US.
• 87426 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g. SARS-CoV, SARS-CoV-2 [COVID-19]).
• 0223U - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
• 86328 - Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 86769 - Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 0224U - Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed.

For more information and future updates, visit the CMS website and its recently issued FAQs. CMS has not set pricing for COVID-19 testing, but they are expected to soon. 

Providers should bill for the COVID-19 swab collection using one of these codes:

• Use code 99001 - Handling and/or conveyance of specimen for transfer from the patient in other than a physician’s office to a laboratory. (distance may be indicated).
• Use code 99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.
• Use code G2023 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
• Use code G2024 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source
• Use code C9803, Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19])

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.

Behavioral health codes are accessible on Aetna's website. 

In addition to the appropriate oral evaluation code, (for example D0140) one of the following codes should be reported:

• D9995 tele-dentistry – synchronous; real-time encounter. Reported in addition to other procedures (e.g. diagnostic) delivered to the patient on the date of service.
• D9996 tele-dentistry – asynchronous; information stored and forwarded to dentist for subsequent review. Reported in addition to other procedures (e.g. diagnostic) delivered to the patient on the date of service.

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. 

We will not require any additional proof of services. The claim should list the services performed using a valid CDT code.  Please reference ADA guidelines for more information.  

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.

Dentists can find all policies and clinical bulletins by visiting the Aetna Dental website. 

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. 
 

SEC. 3709. Adjustment of sequestration

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.