COVERAGE AND REIMBURSEMENT OF EVISITS

IMPACTED PLANS: MEDICAID, HIV SNP and HARP

TO: MEDICAID PROVIDERS

(Retro) Effective October 1st, 2023, per New York State (NYS) Medicaid guidance update, MetroPlusHealth is allowing reimbursement of eVisits when aligned with below State billing guidelines.

eVisits are a type of Virtual Check-in involving patient-initiated communications with a medical provider through a text-based and Health Insurance Portability and Accountability Act (HIPAA)-compliant digital platform, such as a patient portal. eVisits occur through asynchronous communication; the exchange is neither real-time nor face-to-face.

NYS State Guidance Including Billing Codes and Reimbursement Criteria
To avoid inappropriate claims denials, please note the following DOH Guidelines including limitations:

  • eVisit CPT codes may be billed once per seven-day period (using the last date of communication within the seven-day period as the date of service).
    • To further clarify, the service time is cumulative up to a seven-day period. The (7) seven-day period starts upon the review of the initial patient communication by the provider.
    • The provider must begin their review within three business days of the patient inquiry. For example, if a patient initiates an eVisit on Monday, the provider must begin review on or before Thursday.
  • eVisits may not be billed if the patient inquiry is related to a visit within the previous seven days of the initial digital communication.
    • If the eVisit leads to an E&M visit, the eVisit should not be billed, but the time spent on the communication can be incorporated into the separately billed E&M visit.

Providers who can independently bill for Evaluation and Management (E&M), may bill using (CPT) codes “99421”, “99422”, and “99423”.

  • Examples of Provider types:
    • Physicians
    • Nurse Practitioners (NP)
    • Midwives
CPT CodeDescription
99421Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; five to 10 minutes.
99422Online digital evaluation and management service, for an established patient, for up to seven days cumulative time during the seven days; 11 to 20 minutes.
99423Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes.

Providers who may not independently bill for E&M procedure codes may bill using CPT codes “98970”, “98971”, and “98972”

  • Examples of Provider types:
    • licensed clinical social workers (LCSWs)
    • clinical psychologists
    • speech language pathologists (SLPs)
    • physical therapists (PTs)
    • occupational therapists (OTs)
CPT CodeDescription
98970Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; five to 10 minutes.
98971Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11 to 20 minutes.
98972Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes.

Other Provider Responsibilities:

  • Patient Rights and Consent:
    • Providers are required to obtain member verbal or written consent for communication-based technology services (CBTS) annually.
    • The informed consent for CBTS must be documented in the patient’s record prior to an occurrence of each eVisit.

If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].

> View & Download the Memo

last updated: February 5, 2025

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