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USFHP Coronavirus (COVID-19)
Please refer to the COVID 19 Testing, Treatment and Vaccination Reimbursement Policy for information regarding coding and reimbursement for COVID testing, treatment and vaccinations.
Effective September 20, 2021, ABA code 97156 is no longer covered as a telehealth visit for USFHP members. For details, please see the guidance in the Tricare Operations Manual Change 85 dated March 23, 2021.
Effective September 3, 2020, during the pandemic, USFHP waives the requirement for members to have a 3 day qualifying inpatient stay as a condition of approval for a Skilled Nursing Facility (SNF) level of care.
Effective December 15, 2021,USFHP does not cover a test done that's not primarily intended for diagnosis and/or treatment of COVID-19. This includes:
- Public health surveillance
- General workplace health and safety
- Return to school
- Mass transportation (e.g. bus, train, vanpool)
- Personal or leisure travel
- Curiosity or personal interest
Please see the applicable TRICARE Policy for details.
The following additional testing codes have been added:
- 86328: Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
- 86769: Antibody testing using multiple-step method; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
Effective April 14, 2020, during the Public Health Emergency:
- U0003: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
- U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
Effective March 1, 2020, during the Public Health Emergency:
- G2023: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source.
- G2024: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source. These codes are billable by clinical diagnostic laboratories.
Effective Feb. 4, 2020:
- Testing for COVID-19 is covered
- Members will have no copayments or other cost shares for items and services provided during an office visit (including in office or telehealth provider office visits, urgent care and emergency department visits) that results in the administration of a COVID-19 test or an order for such test, but only to the extent that the items and services relate to the COVID-19 test.
- Reimbursement for CMS codes: U0001 or U0002 and AMA code 87635.
- Prior authorizations waived for COVID-19 testing.
- Early refill restrictions waived on prescription for at least 30-day supplies.
Although our previous direction was for providers to use place of service (POS) 02 on all telemedicine claims, we recently received clarification from DHA that allows us to accept other POS codes. Moving forward, we ask providers to use the POS code that represents the location from which he/she rendered the telemedicine visit (for example, POS 11 if services are rendered from the provider’s office). CMS 1500 professional and UB04 telemedicine claims must still contain one of the telemedicine GT, GQ or 95 modifiers.
- Telemedicine is covered, originating site can be member’s home, provider can be at office or facility, including an Urgent Care Center. TRICARE® policy does not exclude the provider’s home as distant site. Unless State law prohibits the service from home via telehealth it would be covered. Telemedicine services include office visits, preventative health screenings, telemental health services (individual psychotherapy, psychiatric diagnostic interviews and exams and medication management) and services for End Stage Renal Disease.
- Continuing PT/OT can be covered when performed via telehealth. This benefit is only for continuing therapy, not initial therapy. Speech Therapy via telemedicine can be covered for initial evaluations and continuing therapy.
- Please see TRICARE Policy for details on Telemedicine as well as billing guidelines.
- Same authorization requirements apply for telemedicine as for face-to-face visits; special authorization not required because service being delivered via telemedicine.
- Coverage for audio visits
- Providers should use POS 02 with no modifier for an audio-only telephone visit, which is a temporary benefit during the pandemic.
- Waiving of copays for all covered telehealth visits
- Relaxing of professional licensing to allow interstate licensing if applicable federal and state law permits.
- G2025: For telehealth distant site services furnished between July 1, 2020, and the end of the COVID-19 Public Health Emergency, RHCs and FQHCs will use an RHC/FQHC specific G code, G2025, to identify services that were furnished via telehealth. Reimbursement $92.
DHA has authorized an exception to Autism Care Demonstration (ACD) policy regarding the use of telehealth (TH) to address the concerns of Applied Behavior Analysis (ABA) providers during the COVID-19 pandemic across the globe. The following paragraphs define the exception to policy requirements and the actions the managed care support contractors (MCSCs) must take to execute this provision.
- During the specific time period of COVID-19 impact (effective date of March 27, 2020 and ending when the President announces the end of the public health emergency period), TRICARE is permitting the unlimited use of only Current Procedural Terminology (CPT) code 97156 "Parent/Caregiver Guidance" via only synchronous TH services.
- CPT code 97156, in person or via TH, may be rendered by only Board Certified Behavior Analysts and assistant behavior analysts.
- CPT Codes 97151, 97153, and 97155 continue to be prohibited for delivery via TH.
- On any date of service, if the GT modifier is used for CPT code 97156, only 97151 and T1023 shall be payable in addition to 97156/GT. All other CPT codes filed on the same date of services as CPT code 97156/GT shall be denied reimbursement.
- On any date of services where CPT code 97156 is filed without the GT modifier, all CPT codes in the existing ABA authorization for that beneficiary shall be payable.
- No additional authorization is required, and no changes to the existing authorization, including expiration dates, will be required of the contractors. Maintaining the current authorization ensures that all submitted claims are tied to an existing authorization, therefore preventing any non-authorized ACD claims from being paid.
- Should the ABA provider render CPT code 97156 via TH, the claims filed must include the GT modifier and Place of Service (POS) code 02 or the claim shall be denied.
- Every session rendered via 97156 TH shall adhere to the same documentation standards set forth in TOM Chapter 18, Section 4, Paragraph 17.2. to include documenting Place of Services 02.
- All other criteria defined in TPM Chapter 7, Section 22.1 “Telemedicine” apply including the use of a HIPAA compliant platform, and compliance with all state/country licensing and privileging practice laws.
- For authorizations that expired during this specified window, the ABA provider may submit CPT code 97151 since much of that time is used for completing the treatment plan update via indirect services. All requirements of CPT code 97151 still apply.
- No extensions to the authorization timeline will be granted. For authorizations expiring during this period, and subsequent authorization requests, all relevant requirements (i.e., the PDDBI) are expected to be completed on time.
- No retro-authorizations will be authorized.
- No other ACD program requirements will be exempt.