Telehealth/Virtual Health Policy, Professional and Facility

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are

reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare

Community Plan reimbursement policies uses Current Procedural Terminology (CPT

*), Centers for Medicare and Medicaid

Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do

not imply any right to reimbursement.

This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed

on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design,

and other factors are considered in developing reimbursement policy.

This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s

reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation.

Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to

health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement

for health care services provided to UnitedHealthcare Community Plan enrollees.

Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors

include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts,

the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies.

Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems

used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare

Community Plan strives to minimize these variations.

UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the

policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication.

Medical Association.

Table of Contents

Application 1

Policy 1

Overview 2

Reimbursement Guidelines 2

Definitions 7

Questions and Answers 8

Attachments 9

Resources 11

History 11

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid.

This reimbursement policy applies to services reported using the UB-04 Form, the 1500 Health Insurance Claim Form

(a/k/a CMS-1500) or their electronic equivalents or their successor forms. This policy applies to all products, all network

and non-network providers, including, but not limited to, non-network authorized and percent of charge contract

hospitals, ambulatory surgical centers, physicians, and other qualified health care professionals.

Policy

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

Overview

This policy describes reimbursement for Telehealth/Telemedicine and virtual health services. For the purpose of

understanding the terms in this policy, Telehealth/Telemedicine and virtual health occur when the Physician or Other

Qualified Health Care Professional and the patient are not at the same site. Virtual health encompasses all

synchronous, asynchronous and Remote Physiologic Monitoring (RPM) care between health care professionals and

patients. This includes Telehealth/Telemedicine, Communication Technology-Based Services (CTBS), Electronic Visit

(E-visit), Virtual Check-Ins, interprofessional telephone/internet/electronic health record consultations, etc. Specifically,

Telehealth/Telemedicine services only includes live, interactive audio and visual transmissions of an encounter from

one site to another using telecommunications technology (synchronous only). The terms Telehealth and Telemedicine

are used interchangeably in this policy.

Reimbursement Guidelines

UnitedHealthcare Community Plan will consider for reimbursement Telehealth services which are recognized by The

Centers for Medicare and Medicaid Services (CMS) and appended with modifiers GQ or GT, or G0 (numeric zero, not

alpha O) for Telehealth services related to acute stroke, as well as services recognized by the American Medical

Association (AMA) included in Appendix P of CPT and appended with modifier 95.

In addition, UnitedHealthcare Community Plan recognizes certain additional services which can be effectively

performed via Telehealth/Telemedicine. These services will be considered for reimbursement when reported with

modifier GQ or GT:

• Medical genetics and genetic counseling services (code 96040)

• Education and training for patient self-management by a qualified, nonphysician health care professional using

a standardized curriculum (codes 98960-98962)

• Alcohol and/or substance abuse screening and brief intervention services (codes 99408-99409)

• Remote real-time interactive video-conferenced critical care evaluation and management (E/M) of the critically

ill or critically injured patient, use G0508 or G0509

UnitedHealthcare Community Plan requires one of the Telehealth-associated modifiers (GQ, GT, G0 or 95) to be

reported when performing a service via Telehealth to indicate the type of technology used and to identify the service as

Telehealth/virtual visits. UnitedHealthcare Community Plan will consider reimbursement for a procedure code/modifier

combination using these modifiers only when the modifier has been used appropriately. Coding relationships for

modifier GQ and modifier 95 are administered through the UnitedHealthcare Community Plan Procedure to Modifier

Policy.

(See the Attachments section below)

UnitedHealthcare Community Plan recognizes the CMS-designated Originating Sites considered eligible for furnishing

Telehealth services to a patient located in an Originating Site.

Claims for Originating Site services may be reported using HCPCS code Q3014 (Telehealth originating site facility fee)

on either a professional (CMS-1500) or a facility (UB-04) claim when a Telepresenter is present at an originating site

location other than the patient’s home. Q3014 is not reimbursable when the distant site claim is reported with a POS

10 indicating the patient is located at home and not receiving any Originating Site services from a Telepresenter.

Examples of Originating Sites are listed below:

• The office of a physician or practitioner

• A hospital (inpatient or outpatient)

• A critical access hospital (CAH)

• A rural health clinic (RHC)

• A federally qualified health center (FQHC)

• A hospital-based or critical access hospital-based renal dialysis center (including satellites); NOTE:

Independent renal dialysis facilities are not eligible Originating Sites

• A skilled nursing facility (SNF)

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

• A community mental health center (CMHC)

• Mobile Stroke Unit

• Patient home - only for monthly end stage renal, ESRD-related clinical assessments, and for purposes of

treatment of a substance use disorder or a co-occurring mental health disorder to an individual with a

substance use disorder diagnosis

UnitedHealthcare Community Plan recognizes the CMS-designated practitioners eligible to be reimbursed for

Telehealth services:

Examples of practitioners are listed below:

• Physician

• Nurse practitioner

• Physician assistant

• Nurse-midwife

• Clinical nurse specialist

• Registered dietitian or nutrition professional

• Clinical psychologist

• Clinical social worker

• Certified Registered Nurse Anesthetists

UnitedHealthcare Community Plan recognizes but does not require Place of Service (POS) code 02 or 10 for reporting

Telehealth services rendered by a physician or practitioner from a Distant Site. Modifiers GQ, GT or 95 are required

instead to identify Telehealth services.

UnitedHealthcare Community Plan recognizes federal and state mandates regarding Telehealth/virtual health.

Telehealth Transmission

UnitedHealthcare Community Plan follows CMS guidelines which do not allow reimbursement for Telehealth/virtual

health transmission, per minute, professional services bill separately reported with Healthcare Common procedure

Coding System (HCPCS) code T1014. They are non-reimbursable codes according to the CMS Physician Fee

Schedule (PFS) and are considered included in services.

Telephone Services

UnitedHealthcare Community Plan follows CMS guidelines which do not allow reimbursement for telephone services

which are non-face-to-face E/M services by a Physician or Other Qualified Health Care Professional reported with CPT

codes 98966-98968 or 99441-99443. They are non-reimbursable codes according to the CMS PFS and are considered

an integral part of other services provided.

On-Line Digital Evaluation and Management Services

UnitedHealthcare Community Plan aligns with CMS PFS guidelines and considers online digital E/M services (99421-

99423 and 98970-98972) eligible for reimbursement. These codes must be reported according to the guidelines as

outlined by the AMA in CPT.

Interprofessional Telephone/Internet/Electronic Health Record Consultations

UnitedHealthcare Community Plan follows CMS guidelines and considers interprofessional telephone/Internet

assessment and management services reported by consultative physicians with CPT codes 99446-99449 and 99451-

99452 eligible for reimbursement according to the CMS PFS.

Digitally Stored Data Services/Remote Physiologic Monitoring/Remote Physiologic Treatment Management

UnitedHealthcare Community Plan follows CMS guidelines and considers digitally stored data services Remote

Physiologic Monitoring services reported with CPT codes 99453, 99454, 99457, 99458, 99473 and 99091 eligible for

reimbursement according to the CMS PFS.

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

Remote Evaluation of Recorded Video and/or Images

UnitedHealthcare Community Plan follows CMS guidelines and considers remote evaluation of recorded video and/or

images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the

patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days

reported with HCPCS codes G2010 eligible for reimbursement according to the CMS PFS.

Brief Communication Technology-based Service

UnitedHealthcare Community Plan follows CMS guidelines and considers brief communication technology-based

service, e.g., Virtual Check-In, by a Physician or Other Qualified Health Care Professional who can report E/M services,

provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor

leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of

medical discussion reported with HCPCS code G2012 eligible for reimbursement according to the CMS PFS.

Opioid Use Disorder Treatment

UnitedHealthcare Community Plan follows CMS guidelines effective for services rendered on or after January 1, 2020

and considers office-based treatment for opioid use disorders, G2086-G2088, eligible for reimbursement according to

the CMS PFS.

State Exceptions

Arizona

AHCCCS has a State specific Telehealth/virtual health code list which allows a FQ, GT or GQ

modifier and the POS as the originating site. CPT codes 99441, 99442, 99443, 98966, 98967 and

98968 billed with modifier GT are reimbursable for Behavioral Health Providers.

Per state regulations procedure code Q3014 is not a covered code.

Arizona Medicaid does not deny Q3014 when the distant site claim is reported with a POS 10

California

• Please see Attachment section for California’s state specific list of Telehealth/virtual health

codes that are reimbursable when billed with modifier GQ and/or 95.

• Per state regulations, CPT 99451 is reimbursable when billed with modifier GQ.

Colorado

• Per Colorado Medicaid State regulations, Telehealth/virtual health policy will not apply as it

has no restriction for Telehealth/virtual health services.

Florida

Per state requirements, Florida Medicaid:

• Requires modifier GT be appended to all.

• Telehealth/virtual health codes with modifier 95 or GQ will deny.

• HCPCS codes H0001, H0031, H0046, H0047, H1000, H1001, H2000, H2010, H2019

and T1015 when billed with modifier GT are reimbursable for FLMMA.

• COVID vaccines are not payable in POS 02 or 10.

• 99382GT and 99392GT are not reimbursable for members ages 0-2years

Hawaii

During the COVID-19 PHE, use the POS that the service would have been rendered with the

applicable modifier 95, GQ, GT, when appropriate. Effective date is 3/1/2020 through the end of

the COVID-19 PHE. See the Attachment section for Hawaii’s state list.

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

Indiana

Indiana Medicaid has three separate state specific lists of codes:

• One allowed in a Telehealth place of service (02 or 10 with modifier 93)

• One allowed in a Telehealth place of service (02 with modifier 95)

• One allowed in a Telehealth place of service (02 or 10 with modifier 95)

The state of Indiana defines the following:

• Modifier GT is considered informational only and not required.

• The state considers “Telehealth” as a scheduled remote monitoring of clinical data

through technologic equipment in the member’s home.

• Any IHCP-covered service – aside from the exclusions listed by the state and speech,

occupational, and physical therapies – can be provided through audio-only, given that

the service can reasonably be provided through audio only communication.

Exclusions include surgical procedures, radiological services, laboratory services, anesthesia

services, audiological services, chiropractor services, care coordination without the member

present and durable medical equipment (DME)/home medical equipment (HME) providers.

Kansas

Per state requirements, Kansas Medicaid:

• Has two separate state specific lists of codes: One allowed in a Telehealth place of

service (02), and one allowed in a Telehealth place of service (10).

• HCPCS H0031 denies in Telehealth place of services when billed without modifier HO.

• HCPCS H0032 denies in Telehealth place of services when billed without modifier HA.

• Modifier GT is considered informational only and not required.

Kentucky

Kentucky Medicaid does not deny Q3014 when the distant site claim is reported with a POS 10

Maryland

Per State Regulations, the delivery of Telehealth/virtual health eligible services must be reported

with Modifier GT.

• Providers are required to bill the same place of service code that would be appropriate for a

non-Telehealth claim, based on the location of the provider rendering services.

• Telehealth/virtual health eligible services are reimbursable when delivered in a home

setting (POS 12).

• SBHC (School Based Health Centers) are required to use POS 03 (School) with Modifier

GT when reporting the delivery of Telehealth/virtual health eligible services.

• Maryland Medicaid does not recognize POS 02 or 10 (Telehealth) nor Telehealth/virtual

health Modifiers 95 or GQ and will deny if billed.

• CPT code 99600 with modifier GT is only payable in POS 12.

• CPT codes 99492, 99493, & 99494 billed with the GT modifier are reimbursable for

MDCAID.

Massachusetts

Per state requirements, COVID vaccines are not payable in POS 02 or 10.

Michigan

• MI Medicaid does not allow modifier GT for Telehealth/virtual health services.

• Please see Attachment section for Michigan’s state specific list of Telehealth/virtual

health codes that are reimbursable when billed with modifier 93 and 95.

• Place of service 02 and 10 are no longer allowed for Telehealth virtual communication.

Provider should now bill with the POS that they would have used if beneficiary was being

seen in person.

Minnesota

• Per Minnesota, all Telehealth/Virtual health services must be billed with a 93 modifier

along with POS 02 or 10.

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

Mississippi

• CPT code S9470 billed with the GT modifier is reimbursable for MSCAN.

• CPT code S9110 billed with the U9 modifier is reimbursable for MSCAN.

• Mississippi Medicaid has a state specific list of codes that are allowed with modifiers: G0,

GQ, and GT.

• MS Medicaid does not recognize modifier 95 for telehealth.

• MS Medicaid does not deny Q3014 when the distant site claim is reported with a POS 10

Missouri

• Missouri Medicaid has a state specific list of codes allowed in place of service 02.

Modifiers 95, G0, GQ, and GT are not allowed for billing purposes, except in POS 02

(Telehealth) and 03 (school). See the Attachment section for Missouri’s state list.

• MO Medicaid does not recognize POS 10.

New Mexico

Per state requirements, New Mexico Medicaid:

• Requires modifier GT to be used when reporting the delivery of (SBHC) School Based

Health Center.

Allows the home of an individual when an interactive audio and video telecommunication system

that permits real-time visit is used between the eligible provider and the MAP eligible recipient.

New Jersey

New Jersey Medicaid does not deny Q3014 when the distant site claim is reported with a POS

New York

Per state requirements, New York Medicaid:

• COVID vaccines are not payable in POS 02 or 10.

Nebraska

• Nebraska Medicaid has a state specified list of codes allowed in a Telehealth place of

service (02) & Place of service (10).

• All audio/visual telemedicine services must be billed with modifier 95.

• All audio-only telemedicine services must be billed with modifier 93.

• Nebraska Medicaid does not deny Q3014 when the distant site claim is reported with a

POS 10

North Carolina

According to State Regulations, North Carolina requires modifier GT for certain virtual health

services. Please see Attachment section for the North Carolina state specific list of Telehealth

codes that will allow a GT modifier. The following codes are not covered for Telehealth: G2010,

99451-99452, G2068-G2088, and 99091. NC Medicaid will allow codes 99441-99443, 99474,

G0071, and T1015 without a GT modifier. Q3014 submitted with a GT modifier is allowed.

State specialty limitations to include provider types listed within this policy as well as the

following:

• Licensed Professional Counselor

• Licensed Mental Health Counselor and other Master’s Level licensed types

• Licensed Clinical Alcohol and Drug Counselor

• Certified Applied Behavioral Analysis practitioner

• Licensed Marriage and Family Therapist

Telehealth, virtual communication, and remote patient monitoring claims should be filed with the

provider’s usual place of service code(s) and not place of service 02 (Telehealth); if billed, will deny.

• Exception: Hybrid telehealth with supporting home visits should be filed with place of service

12 (home).

Ohio

According to State Regulations, the following are reimbursable:

• GT modifier plus all codes in the “OH Telehealth Covered Codes” list.

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

• POS 02 and 10 plus all codes in the “OH Telehealth Covered Codes” list.

OH Medicaid has a state specific list of codes. See the Attachment section for Ohio’s state list.

OH Medicaid does not deny Q3014 when the distant site claim is reported with a POS 10

Pennsylvania

Per Pennsylvania Medicaid State regulations, Telehealth/virtual health policy will not apply as it has

no restriction for Telehealth/virtual health services.

COVID vaccines are not payable in POS 02 or 10.

Rhode Island

Per state regulations, RICAID allows code T1017, H0046, T1016, T1024, H2000, T1023, and

T1027, reimbursable when billed with modifier GT.

Per state requirements, COVID vaccines are not payable in POS 02 or 10.

Tennessee

Per TN Legislation, Telehealth is covered when delivered by any medical and behavioral health care

professional — with 2 exclusions:

• Pain Management Clinics

• Chronic nonmalignant pain treatment service

Texas

According to State Regulations, TX MMP allows codes:

• T1015, G2011, G8431, G8510, G9002, H0001, H0004, H0005, H0034, H0038, H0049,

H2011, H2017, and T1017.

TX Medicaid does not allow modifier GT for Telehealth/virtual health services. All telehealth/virtual

health services must be billed with modifier:

• 95

• 93 (audio only)

• FQ (audio only).

Please see Attachment section for the Texas state specific list of Telehealth/virtual health codes.

State specialty limitations apply.

• CPT code 99211 with modifier 93 is only billable during public state of emergencies.

• Per state requirements, COVID vaccines are not payable in POS 02 or 10.

• CPT code G9012 billed with the U2, U5, 95 modifier is reimbursable for comprehensive

visit (in person or synchronous audiovisual)

o CPT code G9012 billed with the TS, 93 modifier is reimbursable for follow-up visit

(in person or synchronous audiovisual)

• CPT code Q3014 billed with a 95 modifier is reimbursable for RHCs and FQHCs

• CPT codes: 99212, 99213, 99214, & 99215 are payable with an FQ modifier for established

patient services for mental health or substance use for synchronous telephone (audio-only).

• Texas Medicaid does not deny Q3014 when the distant site claim is reported with a POS

Virginia

• Virginia Medicaid (including CCC Plus) has a State specific Telehealth/virtual health code

list which allows a GT modifier. See the Attachment section for Virginia’s state list.

Washington

• Per Washington Medicaid State regulations, Telehealth/virtual health policy will not apply as

it has no restriction for Telehealth/virtual health services.

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

Washington DC

• Per District regulations, all Telehealth/Virtual health services must be billed with a GT

modifier.

Wisconsin

• Wisconsin Medicaid has a state specified list of codes allowed in a Telehealth place of

service (02, 10) and GT, FQ, FR, GQ, and 93 Modifier.

Definitions

Communication Technology-Based

Services (CTBS)

Services furnished via telecommunications technology and considered under

virtual care but not considered Telehealth services.

Distant Site

The location of a physician or other qualified health care professional at the

time the service being furnished via a telecommunications system occurs.

Electronic Visit (E-visit)

Communication between a patient and provider through an online patient

portal.

Originating Site

The location of a patient at the time the service being furnished via a

telecommunications system occurs.

Physician or Other Qualified Health

Care Professional

Per the CPT book, a Physician or Other Qualified Health Care Professional is

an individual who is qualified by education, training, licensure/regulation

(when applicable), and facility privileging (when applicable) who performs a

professional service within his/her scope of practice and independently

reports that professional service.

Remote Physiologic Monitoring

Collecting of vitals and physiologic information by the patient that is then sent

to the health care professional for interpretation and monitoring of the data.

Telehealth/Telemedicine

Telehealth services are live, interactive audio and visual transmissions of a

physician-patient encounter from one site to another using

telecommunications technology. They may include transmissions of real-time

telecommunications or those transmitted by store-and-forward technology.

Virtual Check-In

A brief check-in with the provider with an established patient-provider

relationship.

Questions and Answers

Q: How does UnitedHealthcare Community Plan reimburse for phone calls to patients that are not associated with

any other service? For example, a pediatrician receives a call from a mother at 2 A.M. regarding an asthmatic child

having difficulty breathing. The physician can handle the situation over the phone without requiring the child to be

seen in an emergency room. On what basis will the visit be denied?

A: UnitedHealthcare Community Plan will not reimburse for these services (99441-99443 or 98966-98968), as

they are considered included in the overall management of the patient.

Q: A physician makes daily telephone calls to an unstable diabetic patient to check on the status of his condition.

These services are in lieu of clinic visits. Will UnitedHealthcare Community Plan reimburse the physician for these

telephone services?

A: No, UnitedHealthcare Community Plan will not reimburse telephone services (99441-99443 or 98966-98968),

as they are considered included in the overall management of the patient.

Q: What is the difference between Telehealth services and telephone calls?

A: Telehealth services are live, interactive audio and visual transmissions of a physician-patient encounter from

one site to another using telecommunications technology. They may include transmissions of real-time

telecommunications or those transmitted by store-and-forward technology. Telephone calls, which are considered

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

audio transmissions, per the CPT definition, are non-face-to-face E/M services provided to a patient using the

telephone by a Physician or Other Qualified Health Care Professional, who may report E/Mt services.

Q: If a provider renders the professional component for a diagnostic service, at a Distant Site from the patient,

should modifier GT be reported?

A: No. Modifier GT indicates a face-to-face encounter utilizing interactive audio-visual communication technology.

Therefore, it is not appropriate to report modifier GT in this scenario since this does not represent a face-to-face

encounter. However, use of modifier 26 would be appropriate to designate that the professional component of the

diagnostic service was provided. Please refer to the Professional/Technical Component Policy for more

information.

Q: What are the documentation requirements for Telehealth visits?

A: A patient visit performed through Telehealth should be documented to the same extent as an in-person visit,

reflecting what occurred during the visit. The healthcare professionals should also document that the visit was

done through audio-video telecommunications.

Attachments

Codes Recognized with

Modifier GT, GQ or G0

A list of codes that UnitedHealthcare Community Plan codes recognized when

reported with modifier GT, GQ or G0

Codes Recognized with

Modifier 95

A list of codes that UnitedHealthcare Community Plan codes recognized when

reported with modifier 95

CALIFORNIA State

Telehealth Code List

California state specific list of codes recognized when reported with modifier GQ and

HAWAII State Telehealth

Code List

Hawaii state specific list of telehealth codes and modifiers.

Indiana State Medicaid

Modifier 93 with POS 02 or

Indiana state specific list of Telehealth codes allowed in POS 02 or 10 reported with

modifier 93

Indiana State Medicaid

Modifier 95 with POS 02

Indiana state specific list of Telehealth codes allowed in POS 02 reported with

modifier 95

Indiana State Medicaid

Modifier 95 in POS 02 or 10

Indiana state specific list of Telehealth codes allowed in POS 02 or 10 reported with

modifier 95

KANSAS State Telehealth

Code List POS 02

Kansas state specific list of telehealth codes allowed in POS 02

KANSAS State Telehealth

Code List POS 10

Kansas state specific list of telehealth codes allowed in POS 10

MICHIGAN State Telehealth

Code Modifier 93 List

Michigan state specific list of Telehealth codes allowed with modifier 93

MICHIGAN State Telehealth

Code Modifier 95 List

Michigan state specific list of Telehealth codes allowed with modifier 95

Mississippi State Telehealth

Code List

Mississippi state specific list of Telehealth codes allowed with modifier GT, G0, or GQ

MISSOURI State Telehealth

Code List

Missouri state specific list of telehealth codes allowed in POS 02

NEBRASKA State Telehealth

Code List Modifier 95 & 93

Nebraska state Medicaid specific list of Telehealth codes recognized with modifier 95

& 93.

NEBRASKA State Telehealth

Code List POS 02 & 10

Nebraska state Medicaid specific list of Telehealth codes recognized in POS 02 &10.

NORTH CAROLINA State

Telehealth Code List

North Carolina state specific list of codes allowed with modifier GT

Reimbursement Policy

CMS-1500 and UB04

Policy Number 2024R7133H

OHIO State Telehealth Code

List

Ohio state specific list of telehealth codes and recognized modifiers

TEXAS State Medicaid

Telehealth Code Audio Only

List

Texas state Medicaid specific list of Telehealth codes (audio-only) recognized with

modifier 93.

TEXAS State Medicaid

Telehealth Code List

Texas state specific list of telehealth codes recognized with modifier 95.

VIRGINIA State Telehealth

Code List

Virginia state specific list of codes recognized when reported with modifier GT

WISCONSIN State Telehealth

Code List

Wisconsin state specific list of telehealth codes

Resources

Individual state Medicaid regulations, manuals & fee schedules

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services.

Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services.

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release

and Code Sets.

Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS) Relative Value Files.

History

8/1/2024

Policy Version Change

State Exceptions: Arizona, Mississippi, Nebraska, New Jersey, Kentucky, Ohio & Texas

updated

7/14/2024

Policy Version Change

State Exceptions: Arizona updated

Attachment Section: KANSAS State Telehealth POS 02 Code List & KANSAS State

Telehealth POS 10 Code List updated.

6/30/2024

Policy Version Change

Attachment Section: KANSAS State Telehealth POS 02 Code List & KANSAS State

Telehealth POS 10 Code List updated.

6/17/2024

Policy Version Change

State Exceptions: New Mexico added.

6/16/2024

Policy Version Change

Attachment Section: Nebraska State Modifier 95 & 93 Telehealth Code List & Nebraska-State-

Telehealth-Code-List-POS-02-and-10 Policy Lists updated.

6/09/2024

Policy Version Change

Attachment Section: Mississippi-State-Telehealth-Code-List policy Lists updated.

5/26/2024

Policy Version Change

Attachment Section: Nebraska State Modifier 95 & 93 Telehealth Code List & Nebraska-State-

Telehealth-Code-List-POS-02-and-10 Policy Lists updated.

5/1/2024

Policy implemented by UnitedHealthcare Community & State