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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Wellmark Telehealth Policy PT and OT

Update: 4/19/2020

Wellmark has received many questions from providers regarding coverage of telehealth services amid the coronavirus (COVID-19) pandemic. As Iowa and South Dakota grapple with the COVID-19 pandemic, we know that virtual visits will play a vital role in preserving access to care and preventing the spread of the novel coronavirus.

Wellmark is taking these steps to increase access to virtual visits for all of our members during this time:

  1. Wellmark has made virtual visits available without any member cost-share to remove barriers to receiving care.
  2. Wellmark’s Iowa and South Dakota network providers will receive the same fee for virtual visits as an in-person visit. These changes apply to all appropriate medical and behavioral health virtual visits with any Wellmark in-network provider until June 16, 2020. Wellmark will reevaluate this date as the pandemic situation evolves.

While Wellmark’s preference is that providers conduct virtual visits via interactive audio-visual technology, we recognize that some of our members may not have a smart phone, tablet, or personal computer capable of engaging in an interactive audio-video visit. As such, Wellmark will allow telephonic visits through this period, when audio-visual capabilities aren’t accessible.

For claims to process accurately, providers must follow these billing guidelines:

  • Providers should bill the appropriate CPT codes for the services provided (see list below).
  • Use place of service 02 (telehealth) on the claim for interactive audio-video or telephonic visits.
  • Do NOT use a GT or 95 modifier or the claim will deny.
  • Providers conducting telephonic only visits with Wellmark’s members during this period must document in their medical records that the visit was conducted via telephone.
  • Benefit information on coverage of virtual visits for Wellmark’s members will not be updated on the Claims and Benefits Look-up tool on wellmark.com during this period, so please follow this guidance.

Providers must continue to check benefits for other Blue Cross Blue Shield members as their coverage of virtual visits may vary.

Therapeutic Services

CPT Code

Description

97110

THERAPEUTIC PROCEDURE

97112

NEUROMUSCULAR REEDUCATION OF MOVEMENT

97161

PT EVAL LOW COMPLEX 20 MIN

97162

PT EVAL MOD COMPLEX 30 MIN

97164

PT RE-EVAL EST PLAN CARE

97165

OT EVAL LOW COMPLEX 30 MIN

97166

OT EVAL MOD COMPLEX 45 MIN

97168

OT RE-EVAL EST PLAN CARE

97530

THERAPEUTIC ACTIVITIES

97535

SELF CARE/HOME MANAGEMENT TRAINING

92521

EVALUATION OF SPEECH FLUENCY

92522

EVALUATION OF SPEECH SOUND PRODUCTION

92523

EVALUATION OF LANGUAGE COMPREHENSION AND EXPRESSION

92524

BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND REASONANCE

92526

TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION

92507

TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER; INDIVIDUAL

97152

BEHAVIOR IDENTIFICATION-SUPPORTING ASSESSMENT, ADMINISTERED BY ONE TECHNICIAN UNDER THE DIRECTION OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PORFESSIONAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES.

97153

ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN UNDER THE DIRECTION OF A PHSYICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES.

97155

ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, WHICH MAY INCLUDE SIMULTANEOUS DIRECTION OF TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT, EACH 15 MINUTES.

97156

FAMILY ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (WITH OR WITHOUT THE PATIENT PRESENT), FACE-TO-FACE WITH GUARDIAN(S) / CAREGIVER(S), EACH 15 MINUTES.



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