Anthem Blue Cross Blue Shield of Georgia policy
Allowed Virtual Services in Addition to CPT Appendix P
Allowed Virtual Services in Addition to CPT Appendix P is a public Anthem Blue Cross Blue Shield of Georgia policy (policy MULTI-BCBS-CM-050974-24, effective Feb 17, 2024). It lists 96 CPT or HCPCS codes, 28 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- MULTI-BCBS-CM-050974-24
- Effective
- Feb 17, 2024
- Line of business
- Commercial
- States
- CO, CT, GA, IN, KY, MO, NV, OH, WI
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| 0362T | On the list | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Policies naming 0362T |
| 0373T | On the list | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Policies naming 0373T |
| 90853 | Not listed | Policies naming 90853 | |
| 90887 | Not listed | Policies naming 90887 | |
| 96127 | Not listed | Policies naming 96127 | |
| 96130 | Not listed | Policies naming 96130 | |
| 96131 | Not listed | Policies naming 96131 | |
| 96132 | Not listed | Policies naming 96132 | |
| 96133 | Not listed | Policies naming 96133 | |
| 96136 | Not listed | Policies naming 96136 | |
| 96137 | Not listed | Policies naming 96137 | |
| 96138 | Not listed | Policies naming 96138 | |
| 96139 | Not listed | Policies naming 96139 | |
| 96146 | Not listed | Policies naming 96146 | |
| 97151 | On the list | Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face- to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan | Policies naming 97151 |
| 97152 | On the list | Behavior identification-supporting assessment, administered by one technician under the direction of a physician or other qualified health care professional, face-to-face with the patient, each 15 minutes | Policies naming 97152 |
| 97153 | On the list | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes | Policies naming 97153 |
| 97154 | On the list | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes | Policies naming 97154 |
| 97155 | On the list | 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 | Policies naming 97155 |
| 97156 | On the list | 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 | Policies naming 97156 |
| 97157 | On the list | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes | Policies naming 97157 |
| 97158 | On the list | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes | Policies naming 97158 |
| 97163 | On the list | Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. | Policies naming 97163 |
| 97164 | On the list | Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. | Policies naming 97164 |
| 97167 | On the list | Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. | Policies naming 97167 |
| 97168 | On the list | Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to- face with the patient and/or family. | Policies naming 97168 |
| 97542 | On the list | Wheelchair management (eg, assessment, fitting, training), each 15 minutes | Policies naming 97542 |
| 98966 | Not listed | Policies naming 98966 | |
| 98967 | Not listed | Policies naming 98967 | |
| 98968 | Not listed | Policies naming 98968 | |
| 98970 | Not listed | Policies naming 98970 | |
| 98971 | Not listed | Policies naming 98971 | |
| 98972 | Not listed | Policies naming 98972 | |
| 99205 | Not listed | Policies naming 99205 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99358 | Not listed | Policies naming 99358 | |
| 99359 | Not listed | Policies naming 99359 | |
| 99381 | Not listed | Policies naming 99381 | |
| 99382 | Not listed | Policies naming 99382 | |
| 99383 | Not listed | Policies naming 99383 | |
| 99384 | Not listed | Policies naming 99384 | |
| 99385 | Not listed | Policies naming 99385 | |
| 99386 | Not listed | Policies naming 99386 | |
| 99387 | Not listed | Policies naming 99387 | |
| 99391 | Not listed | Policies naming 99391 | |
| 99392 | Not listed | Policies naming 99392 | |
| 99393 | Not listed | Policies naming 99393 | |
| 99394 | Not listed | Policies naming 99394 | |
| 99395 | Not listed | Policies naming 99395 | |
| 99396 | Not listed | Policies naming 99396 | |
| 99397 | Not listed | Policies naming 99397 | |
| 99401 | Not listed | Policies naming 99401 | |
| 99402 | Not listed | Policies naming 99402 | |
| 99403 | Not listed | Policies naming 99403 | |
| 99404 | Not listed | Policies naming 99404 | |
| 99415 | Not listed | Policies naming 99415 | |
| 99416 | Not listed | Policies naming 99416 | |
| 99421 | Not listed | Policies naming 99421 | |
| 99422 | Not listed | Policies naming 99422 | |
| 99423 | Not listed | Policies naming 99423 | |
| 99441 | Not listed | Policies naming 99441 | |
| 99442 | Not listed | Policies naming 99442 | |
| 99443 | Not listed | Policies naming 99443 | |
| 99446 | Not listed | Policies naming 99446 | |
| 99447 | Not listed | Policies naming 99447 | |
| 99448 | Not listed | Policies naming 99448 | |
| 99449 | Not listed | Policies naming 99449 | |
| 99451 | Not listed | Policies naming 99451 | |
| 99452 | Not listed | Policies naming 99452 | |
| 99453 | Not listed | Policies naming 99453 | |
| 99454 | Not listed | Policies naming 99454 | |
| 99457 | Not listed | Policies naming 99457 | |
| 99458 | Not listed | Policies naming 99458 | |
| 99483 | Not listed | Policies naming 99483 | |
| G0270 | Not listed | Policies naming G0270 | |
| G0271 | Not listed | Policies naming G0271 | |
| G2010 | Not listed | Policies naming G2010 | |
| G2012 | Not listed | Policies naming G2012 | |
| G2212 | Not listed | Policies naming G2212 | |
| H0001 | Not listed | Policies naming H0001 | |
| H0004 | On the list | Behavioral health counseling and therapy, per 15 minutes | Policies naming H0004 |
| H0005 | Not listed | Policies naming H0005 | |
| H0006 | On the list | Alcohol and/or drug services; case management | Policies naming H0006 |
| H0015 | On the list | Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education | Policies naming H0015 |
| H0021 | Not listed | Policies naming H0021 | |
| H0023 | On the list | Behavioral health outreach service (planned approach to reach a targeted population) | Policies naming H0023 |
| H0031 | On the list | Mental health assessment, by nonphysician | Policies naming H0031 |
| H0035 | On the list | Mental health partial hospitalization, treatment, less than 24 hours | Policies naming H0035 |
| H0036 | On the list | Community psychiatric supportive treatment, face- to-face, per 15 minutes | Policies naming H0036 |
| H0038 | On the list | Self-help/peer services, per 15 minutes | Policies naming H0038 |
| H0039 | On the list | Assertive community treatment, face-to-face, per 15 minutes | Policies naming H0039 |
| H0040 | On the list | Assertive community treatment program, per diem | Policies naming H0040 |
| H2021 | On the list | Community-based wrap-around services, per 15 minutes | Policies naming H2021 |
| H2035 | Not listed | Policies naming H2035 | |
| S0201 | On the list | Partial Hospitalization Services, Less Than 24 Hours, Per Diem | Policies naming S0201 |
| S9480 | On the list | Intensive Outpatient Psychia | Policies naming S9480 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list