Billing Clarifications for Telehealth Services

This guidance applies for benefits billed as fee-for-service. Please contact the HMO or managed care organization for billing guidance from other payers. BadgerCare Plus and Medicaid SSI HMOs, as well as special managed care programs including Children Come First, Wraparound Milwaukee, and Care4Kids are expected to extend the same considerations to allowable telehealth services.

Temporarily Covered Telehealth Services

Services that can be delivered with functional equivalency to the face-to-face service via telehealth (interactive video and audio)

For services that are currently covered by ForwardHealth, the provider should submit claims with the procedure code, place of service (POS) code, and any required modifiers that would normally be appropriate for the face-to-face service. Distant site providers working remotely should use the POS code for the location that they are connecting to. For example, a provider working remotely from their clinic should use POS code 11 (Office).

Providers are encouraged to include modifier 95 for tracking purposes. Including modifier 95 will let ForwardHealth know that the service delivered via telehealth was functionally equivalent to a face-to-face visit. Examples of this could include a speech therapist providing therapy through video conferencing or a case manager communicating with a member through video conferencing.

Services that can be delivered with functional equivalency to the face-to-face service through audio only (phone) methods

Any services that are currently covered by ForwardHealth and delivered through audio-only methods (phone) should be billed the same way as interactive video services. That is, providers should bill with the POS code they would normally use for the face-to-face service and are encouraged to include modifier 95 for tracking purposes. Distant site providers working remotely should use the POS code for the location that they are connecting to. Including modifier 95 will let ForwardHealth know that the service delivered via audio-only methods (phone) was functionally equivalent to a face-to-face visit.

Dental Telehealth Services

Dental providers who can provide services via telehealth during the public health emergency that are functionally equivalent to the face-to-face service should review ForwardHealth Update 2020-15 for billing guidance. ForwardHealth does not follow American Dental Association guidance for billing procedure codes D9995 and D9996. For orthodontic services, providers may request a prior authorization amendment to extend the treatment plan timeframe. Additional information about billing dental telehealth services can be found in ForwardHealth Alert 017, titled “Billing Clarifications for Dental Telehealth Services.”

Permanently Covered Telehealth Services

Permanently covered telehealth services are found in the Telehealth topic (#510) of the Online Handbook and include the services added in Update 2020-09.

Allowable face-to-face services delivered via telehealth (interactive video and audio)

Distant site providers must use POS code 02 (Telehealth) and modifier GT to indicate the service was performed via telehealth (interactive video and audio) regardless of where the distant site provider is located at the time of the encounter.

Allowable video and audio services that are now allowed as audio only services in response to the state of emergency declared by the State of Wisconsin in Executive Order 72

The use of modifier 95 is encouraged for interactive services. When video and audio services listed as allowable in the Telehealth topic (#510) are provided as audio only (phone) services as allowed in response to the state of emergency declared by the State of Wisconsin in Executive Order 72, providers have three options:

• Report the service as instructed for temporary services with informational modifier 95 and the POS of where the distant site provider is located. Distant site providers working remotely should use the POS that they are connecting to. For example, a provider working remotely from their clinic should use POS code 11 (Office).
• Follow the billing policies in the Telehealth topic (#510), with modifier GT included and POS 02 (Telehealth), adding the informational modifier 95 after modifier GT.
• Follow the billing policies in the Telehealth topic (#510), with modifier GT included and POS 02. In the documentation of the visit, note that the service was performed with audio only as allowed by Executive Order 72.

New telehealth services delivered via audio only (phone) methods

ForwardHealth Update 2020-09 announced that ForwardHealth added coverage for audio only (phone) Evaluation and Management services. Providers should follow billing policies in the Telehealth topic (#510) and submit claims with modifier GT included and POS 02 (Telehealth).

Group services that are not allowable for an otherwise allowable provider and service delivered via visual and/or audio methods

Providers of psychosocial rehab, mental health, and substance abuse group services should bill with the POS code they would normally use for the face-to-face service. This applies specifically to the following:

• Comprehensive Community Service providers
• Community Support Programs
• Day treatment providers
• Outpatient mental health providers
• Outpatient substance abuse providers

Distant site providers working remotely should use the POS that they are connecting to. For example, a provider working remotely from their clinic should use POS code 11 (Office). Providers are encouraged to also include modifier 95 for tracking purposes. This will let ForwardHealth know that the service was delivered via interactive visual or audio (phone) methods as the functional equivalent of a face-to-face visit.

ForwardHealth is not expanding coverage policy or services allowable under the permanent telehealth coverage policy as outlined in the Telehealth topic (#510). Services not allowable by ForwardHealth in a face-to-face delivery method will remain not allowable in any delivery method.

Billing for Telehealth Services Flowchart