Telemedicine
Telemedicine is the delivery of health care services using telecommunication technology to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care. This can include real-time (synchronous) interactions between patient and provider, asynchronous (capture, store, and forward) review of patient health information and/or remote patient monitoring.
As telecommunications, information and medical technologies advance, opportunities for patients to access health care services via non-traditional settings continue to develop, particularly allowing patients in underserved or remote locations to access medical expertise quickly, efficiently and without travel. Additionally, telemedicine has the potential to enhance doctor-patient relationships, support ongoing care and monitoring of eye health conditions, encourage office visits when needed, improve patient engagement in treatment plans for better health outcomes and reduce costs.
VSP® supports delivery of appropriate medical eye care services via telehealth channels to supplement access to quality vision care, including evaluating opportunities to further connect members and doctors and enable providers to practice to the full scope of their licensure, utilizing telehealth channels, when appropriate.
Patient Consent
Prior to rendering telemedicine service, inform the patient, obtain consent (verbal or written based on individual state requirements), and maintain appropriate documentation. Best practice is written consent and to inform the patient at the time of scheduling.
Be sure to allow and/or recommend alternate delivery options (e.g., ability to choose in-person or remote delivery), as appropriate, such as when history indicates a possible medical complication or active ocular pathology. Use your office standards and professional judgment for determining when remote exams are most appropriate.
Providing Telemedicine Services
Only offer telemedicine services in states where you are licensed and practice only when permissible by federal, state and local laws within your scope of licensure – you do not have to sign up with VSP for telemedicine for Billable Services outlined below. If you choose, you can designate your practice as offering telemedicine services using the Office Special Interest form on VSPOnline on eyefinity.com, which will display these services are available to members on the Find a Doctor Directory on vsp.com.
VSP reimburses providers for medical eye care services delivered via telehealth channels, including specific CPT codes covered under the Essential Medical Eye Care and Diabetic Eyecare Plus ProgramSM (only for appropriate conditions covered under the corresponding plan). Use your professional judgement to determine if a benefit or service is clinically appropriate to be provided via telehealth, subject to consent by the patient; allow or recommend alternate delivery options, when appropriate. Check with your liability insurance to verify if it covers telemedicine services, for your protection.
Billable Services
Please reference the VSP CPT codes and information in the following chart to continue providing appropriate medical eye care services to your patients via telemedicine channels. Complete CPT code details are available under the Essential Medical Eye Care and Diabetic Eyecare Plus Program detail pages.
Remember:
- All telemedicine services must have patient verbal or written consent (based on state) and documentation of their consent prior to rendering remote services.
- All images and/or videos used to make a diagnosis are required to be saved for future reference.
- Standard billing and documentation requirements must be followed for both remote and in-office services.
- Use the most appropriate CPT code that supports the service completed and appropriate modifier, when billing.
- The following services may be billed under Essential Medical Eye Care Plan and Diabetic Eyecare Plus Program when delivered remotely:
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CPT Code Range |
Brief Summary Description |
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92002, 92004 |
Ophthalmological services: medical examination and evaluation, new patient bill the CPT code with a GQ or 95 modifier, as appropriate |
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92012, 92014 |
Ophthalmological services: medical examination and evaluation, established patient bill the CPT code with a GQ or 95 modifier, as appropriate. |
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99202-99205 |
Office/outpatient visit, new patient evaluation and management service bill the CPT code with a GQ or 95 modifier, as appropriate. |
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99211-99215 |
Office/outpatient visit, established patient evaluation and management service bill the CPT code with a GQ or 95 modifier, as appropriate. |
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99421-99423 |
On-line digital evaluation and management service, for up to 7 days established patient, patient initiated only billable once per patient per seven-day period per chief complaint, cannot result in another evaluation and management service within 24 hours. |
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99446-99449, 99451 |
Interprofessional telephone/internet assessment, including health record assessment, by consulting provider or other qualified health care professional, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional. only billable once per patient per seven-day period, not allowed if you have seen the patient directly within past 14 days. |
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99452 |
Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician only billable once per patient per seven-day period. |
Copays
Copays, if required, apply to exams only (92002-92014, 99202-99205, 99211-99215, 99421-99423). You will receive your VSP payable fee for the service provided, less the copay.
Other Approved Services
For patients with Vision Therapy coverage, vision therapy sessions (CPT code 92065) can be billed when performed remotely. Be sure to refer to the Patient Record Report for coverage details.
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CPT Code Range |
Brief Summary Description |
|---|---|
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92065 |
Orthoptic and/or pleoptic training, with continuing medical direction and evaluation bill the CPT code with a GQ or 95 modifier, as appropriate. |
Eligibility & Submitting Claims
Telemedicine services may be billed under the Essential Medical Eyecare and Diabetic Eyecare Plus Program (only for appropriate conditions covered under the corresponding plan). Check the Patient Record Report to confirm if the patient has one of these plans.
- Enter the specific procedure code and related diagnosis code(s), when completing the claim online or manually on the CMS-1500 Claim Form.
- When applicable, bill the diagnosis code with the correct eye location: left, right or bilateral.
- Bill the CPT code with a modifier to indicate the modality it was rendered, 95 synchronous or GQ asynchronous, as appropriate.
Note:
VSP recognizes but does not currently support Place of Service (POS) code 02 for reporting telehealth services rendered from a distant site except when submitted on paper as a secondary for coordination of benefits. Additionally, VSP recognizes but does not currently support POS code 10 for reporting telehealth services provided in a patient’s home.
Note:
Modifiers GQ or 95 are used instead to identify telehealth services, as appropriate. Modifiers are used for information purposes only.
- Standard timely filing guidelines apply
- Patients choosing non-covered services should be informed of any out-of-pocket cost and asked to sign the Patient Responsibility Statement before receiving services. You can find the form under the Forms section of the Administration menu on VSPOnline on eyefinity.com.
Coordination of Benefits
Essential Medical Eye Care and Diabetic Eyecare Plus Program provide supplemental medical eye care coverage to VSP patients. These plans are secondary to other medical eye insurance coverage that may reimburse you, if you are a participating provider with the patient’s medical plan. Standard coordination of benefit guidelines apply. Please refer to Coordination of Benefits in this section for more information.
Reimbursement
Telemedicine services follow the appropriate payment guidelines of the benefit being billed, which include Essential Medical Eye Care, Diabetic Eyecare Plus Program and Vision Therapy.
Technology
Use your professional judgement when selecting the appropriate telemedicine equipment, platform and technology used, adhering to federal, state and local laws to ensure patient health, safety and privacy are protected.
- Be sure to document the technology used when performing remote care, including instances where the patient may be out of the office receiving medical eye care services via telehealth and doctor-remote eye exams.
- Providers must use equipment and data collection techniques consistent with or exceeding the accepted standards of care for in-person eye care services. (Equipment, platforms, and technology vendors used are up to the provider’s discretion, same as today for in-person equipment.)
- Systems/processes must meet regulatory compliance for confidentiality, protecting patients’ right to medical information and privacy using HIPAA/HITECH-secure channels.
- Providers (not VSP) determine the technology to enable two-way real-time communication between provider and patient.
- Provider (and/or technician/optician, where allowed) driven equipment during exam.
Doctor-Remote Eye Exam Guidelines
Virtual care (also referred to as telehealth) is an area of growing interest for consumers and an opportunity for providers to expand office hours, create access, and meet patient demand. New technologies are making it possible for private practices to expand patient capacity and increase revenue streams with solutions that support doctors in delivering in-office patient care virtually. Different forms of virtual care have emerged to facilitate patient/provider connections, including doctor-remote comprehensive eye exams – a doctor-directed, remote WellVision eye exam where the patient is in the office and the provider is remote using real-time two-way communication.
To meet the shifting demand for more remote eye care options, VSP is expanding opportunities for private practices to stay competitive in an evolving industry through a pilot to test offering doctor-remote eye exams. The following outlines VSP’s guidelines for providers who choose to offer doctor-remote eye exams.
All covered services must be rendered in a VSP-qualified office location. VSP follows American Medical Association (AMA) guidelines for exam requirements, as outlined in the Current Procedural Terminology (CPT) codes. Providers must continue to provide the most clinically appropriate care, regardless of whether delivered in person or remotely. Below, you’ll find guidelines, tests, condition considerations, and processes for doctor-remote eye exams (referred to as a WellVision eExamTM) as a covered member benefit.
Providing Doctor-Remote Exam Services
Practice Considerations
- You must be a licensed doctor to deliver the exam. You may perform services only in states where you are licensed, and practice only when permissible by federal, state, and local laws within your scope of licensure.
- As with in-person providers, remote providers must be credentialed and associated with each practice location to obtain eligibility and claim payment from VSP.
- When offering telemedicine services (medical or routine), use your professional judgment to determine when telemedicine is appropriate for your patient.
- Consultation and treatment recommendations must be held to the same standards of appropriate care for in-person eye care services.
- Follow existing office processes to support care coordination and referral, as needed, the same as if in-person.
- Follow existing processes for member complaints and grievances.
- Check with your liability insurance to verify if it covers telemedicine services, for your protection.
- Ensure you have a network doctor agreement for the originating site on file and approved by VSP.
- When conducting contact lens exam services, either new or existing contact lens wearers, use your professional judgement for determining when the doctor-remote exam model is appropriate.
- Bill the applicable CPT code for services performed, which must meet the corresponding criteria based on the level of service provided.
Clinical Guidelines
A comprehensive telemedicine eye examination includes at least the following procedures when professionally indicated, and providers must use equipment and data collection techniques consistent with or exceeding the same standards of appropriate care for in-person eye care services. Appropriate evaluation and recording of data in each area outlined below is required. See the Exam Documentation for these requirements. Please also refer to the Telemedicine section for further guidelines.
- Detailed case history, including but not limited to:
- Chief complaint
- Ocular and visual health history (patient and patient’s family, past and present)
- General health status and medical history
- Current medication and medication allergies
- Visual demands of work, school, and recreation
- Entrance Tests
- Visual acuity (monocular distance and near)
- Video extraocular motility (versions separate of binocular function testing)
- Pupillary reflexes/function assessment
- Visual field screening
- Tonometry
- Refractive component
- Lensometry, if applicable
- Keratometry, if applicable
- Auto-refraction
- Subjective refraction (distance and near) and document the best corrected visual acuity
- Ocular Health Assessment
- Biomicroscopy exam of the anterior segment by video and/or anterior photo documentation
- Wide field retinal imaging with interpretation and documentation of the posterior pole, including CD ratios, macula, retinal vasculature, and vitreous
Comprehensive or intermediate exams are permitted. Bill the applicable CPT code for services performed, which must meet the corresponding criteria based on the level of service provided.
Note:
VSP requires wide-field retinal imaging* as the minimum substitution for in-person evaluations that complete the WellVision exam criteria. VSP recognizes several methods to meet the wide-field criteria, including creating a montage image with a retina camera, using a special lens with a traditional fundus camera, using a specially designed wide-angle camera, or the use of ultra-wide-field imaging.
Retinal imaging/video used as a substitution for in-person evaluations to complete the minimum WellVision exam criteria is considered a bundled service; no balance billing allowed. Handle additional services performed that enhance the exam as you do today – bill VSP for covered services and the member for non-covered services.
*VSP considers wide-field retinal imaging as one that captures the mid periphery, which includes the retina extending from the vascular arcades to the posterior edge of the vortex vein ampulla.
Additional Testing
Additional testing typically available with an in-person eye examination, including but not limited to color vision, stereopsis, cover testing, and/or near point phorias, binocular testing, accommodative function, tear function/stability, etc., will be available from the provider, and performed and documented in the medical record, as needed.
Dilated Fundus Evaluation
A process must be in place to refer patient to the live Eye Care Professional in the same location, nearby location, or an established referral location to be performed in-person by a provider who is an Optometrist or Ophthalmologist following remote exam (or during remote exam by trained technician where permitted by state law) whenever clinically indicated or when requested by the patient within a reasonable timeframe (typically within seven days). Best practice is to document in the patient’s chart if completing fundus photography/videos when a dilation would otherwise have been performed due to a remote exam.
Diagnosis and Treatment Plan
Diagnosis codes and/or related descriptions, plus documentation of the diagnosis in the exam chart notes. Z01.00 and Z01.01 are not acceptable as the sole diagnosis after 10/1/15, and when there is another more appropriate refractive or medical diagnosis to use. Documentation of a treatment plan by the doctor is required in your patient’s chart notes.
Condition Considerations
Ideal Remote Exam Patient - Low Risk
An ideal remote eye exam patient would be one who is presenting for a routine annual exam, who has overall stable vision, and the primary reason for the visit is to update a spectacle or contact lens prescription, with no recent eye health or significant vision changes previously evaluated or diagnosed. If there are recent health changes but under the care of a provider for these issues, a remote exam could still be performed for their refractive needs.
Use Discretion for High-Risk Conditions
There may be instances where a patient is not a good candidate for a remote exam.
The main medical reason for a redirect to an in-person exam is that a remote Eye Care Professional cannot treat the patient due to certain limitations via the telemedicine modality. They will refer to the live Eye Care Professional in the same location, a nearby location, or an established referral location. However, if the patient is already under the care of an appropriate provider for that condition, use your discretion when choosing to continue with the exam and provide care for their refractive needs.
The following are some examples of conditions that may result in a referral to an in-person provider:
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As with on-site providers, the remote Eye Care Professional has a legal obligation to refer out when the patient has a condition beyond their ability to treat.
Eligibility & Claim Submission Requirements
Check the Patient Record Report to confirm if the patient is eligible for a routine WellVision exam.
- Enter the specific exam procedure code based on the level of service provided and related diagnosis code(s), when completing the claim online or manually on the CMS-1500 Claim Form.
- The following are billable services, which may vary by patient’s plan.
- Exams: 92002, 92004, 92012, 92014, 92015, S0620, S0621.
- Contact lens exam services: 92310-92313, 92326.
- Vision therapy sessions: 92065.
- Include modifier 95 (synchronous) to indicate the services were rendered remotely.
- Do not bill separately for the retinal imaging/video necessary to complete the minimum exam criteria.
- Medicaid covered services vary by state. Refer to your VSP Medicaid Manual for details, as needed.
Note:
VSP recognizes but does not currently support Place of Service (POS) code 02 for reporting telemedicine services except when submitted on paper for coordination of benefits or specific practice management systems. Modifier 95 is required to identify the telemedicine service, whether POS 11 or 02 is reported on the claim.
- Standard timely filing guidelines apply
- Patients choosing non-covered services should be informed of any out-of-pocket cost and asked to sign the Patient Responsibility Statement prior to receiving services. You can find the form under the Forms section of the Administration menu on VSPOnline at eyefinity.com.
- As with all services provided by VSP network providers, remote services are subject to audit review.
Reimbursement
VSP will reimburse you according to your contracted WellVision Exam fee (based on location, service billed, and patient’s coverage), less any copay.
Retinal imaging/video used as a substitution for in-person evaluations to complete the minimum WellVision exam criteria is considered a bundled service, no balance billing allowed, such as:
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- Wide field retinal imaging as a substitute for the retinal fundus evaluation for the posterior segment
- Video capabilities are used as a substitute for the anterior segment evaluation.
Handle additional services performed that enhance the exam as you do today – bill VSP for covered services and the member for non-covered services. Patients choosing non-covered services should be informed of any out-of-pocket costs in advance of the service being performed.
Refer to the Patient Record Report for the patient’s contact lens exam coverage.