Policy Updates - March 2025

MetroPlusHealth Reminds Medicaid Providers About eVisits Coverage and Reimbursement

(Retro) Effective Date: Oct. 1, 2023

MetroPlusHealth reminds providers about the reimbursement of eVisits for Medicaid providers, including those involved in HIV SNP and HARP plans. This aligns with New York State Medicaid guidelines and aims to enhance access to virtual healthcare services.

What Are eVisits?

eVisits are patient-initiated communications with medical providers through a HIPAA-compliant digital platform, such as a patient portal. These interactions occur asynchronously, meaning they do not take place in real-time or face-to-face, allowing patients to communicate with providers conveniently and securely.

Billing Codes and Reimbursement Criteria

To ensure accurate billing and avoid claim denials, providers should adhere to the following guidelines set forth by the New York State Department of Health (DOH):

CPT Codes Usage: eVisit CPT codes can be billed once per seven-day period, using the date of the last communication within that week as the service date.

Cumulative Time: The cumulative service time can span up to seven days, starting from when the provider reviews the initial patient communication.

Timeliness of Review: Providers must begin reviewing patient inquiries within three business days. For instance, if a patient starts an eVisit on a Monday, the review must commence by Thursday.

Limitations on Billing: eVisits cannot be billed if the patient’s inquiry pertains to a visit that occurred within the preceding seven days.

E&M Visits: If an eVisit transitions into an Evaluation and Management (E&M) visit, the eVisit should not be billed separately; however, the time spent on the eVisit can be included in the billed E&M visit.

CPT Codes for Providers

Providers who can independently bill for E&M services should use the following CPT codes:

99421: Online digital evaluation and management service for established patients; cumulative time of 5 to 10 minutes over seven days.

99422: Online digital evaluation and management service for established patients; cumulative time of 11 to 20 minutes over seven days.

99423: Online digital evaluation and management service for established patients; cumulative time of 21 or more minutes over seven days.

Providers who cannot independently bill for E&M services may use these CPT codes:

98970: Non-physician healthcare professional online assessment and management; cumulative time of 5 to 10 minutes over seven days.

98971: Non-physician healthcare professional online assessment and management; cumulative time of 11 to 20 minutes over seven days.

98972: Non-physician healthcare professional online assessment and management; cumulative time of 21 or more minutes over seven days.

Additional Provider Responsibilities

Patient Rights and Consent: Providers must obtain verbal or written consent from members for communication-based technology services (CBTS) annually. Informed consent should be documented in the patient’s record before each eVisit.

Source: Metroplus