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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.
For telephone only codes (99441-99443, 98966-98968, G2010, G2012) there are reimbursement rates in Aetna’s fee schedule that are not the same as E&M office visits 99201- 99215. Given those telephone only codes do not equate to an office visit, they will not result in an office visit reimbursement rate.
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.
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