California

Last updated 01/17/2022

Consent Requirements

Providers must inform the patient about the use of telehealth and obtain verbal or written consent from patients before utilizing telehealth.  If a healthcare provider at the originating or distant site maintains a general consent agreement that addresses the use of telehealth that is sufficient for documentation of patient consent and must be kept in the patient’s medical file.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Oct. 2021), Pg. 5. (Accessed Jan. 2022).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Refer to fee-for-service policy.  All consent for homeless, homebound or migratory or seasonal workers (HHMS) must be documented.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 11.  (Accessed Jan. 2022). 

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refer to fee-for-service policy. All consent for homeless patients must be documented.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 8.  (Accessed Jan. 2022).  

Vision Care

Providers must include a record of the written or verbal request for the consultation by the referring provider or other source in the medical record.   Verbal and written informed consent from the patient or the patient’s legal representative is required if the consulting provider has ultimate authority over the care or primary diagnosis of the patient.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual.  (Aug. 2020), Pg. 5.  (Accessed Jan. 2022). 

Local Education Agency Services

Oral consent must be obtained for the student’s parent or guardian.  The student’s written consent to telehealth is not required.

If oral consent from the student’s parent or legal guardian is received, the health care provider must document oral consent in the student’s medical record, including the following:

• A description of the risks, benefits and consequences of telehealth
• The student’s parent or legal guardian retains the right to withdraw the student from services via telehealth at any time
• All existing confidentiality protections apply, including HIPAA requirements
• The student’s parent or legal guardian has access to all transmitted medical information
• No dissemination of any student images or information to other entities without further written consent››

SOURCE:  CA Department of Health Care Services (DHCS).  Local Education Agency (LEA) Telehealth.  Aug. 2021. Pg. 4.  (Accessed Jan. 2022).

Last updated 01/17/2022

Definitions

“Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care.  Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store-and-forward transfers.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 1. (Accessed Jan. 2022).

Last updated 01/17/2022

Email, Phone & Fax

E-Consult includes interprofessional telephone/internet/electronic health record assessment and management services.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual.  Telehealth.  (Aug. 2020), Pg. 9. (Accessed Jan. 2022).

Telehealth services, telephonic services and other specified services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds. The Department is required to issue guidance for entities to facilitate reimbursement for telehealth or telephonic services in emergency situations by July 1, 2020.

SOURCE: Welfare and Institutions Code Sec. 14132.723 & 724 (AB 1494 – 2019 Legislative Session). (Accessed Jan. 2022).

The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program, including audio-only. The department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.

For purposes of informing the 2022–23 proposed Governor’s Budget, released in January 2022, the department shall convene an advisory group consisting of consultants, subject matter experts, and other affected stakeholders to provide recommendations to inform the department in establishing and adopting billing and utilization management protocols for telehealth modalities to increase access and equity and reduce disparities in the Medi-Cal program. The advisory group shall analyze the impact of telehealth in increased access for patients, changes in health quality outcomes and utilization, best practices for the appropriate mix of in-person visits and telehealth, and the benefits or liabilities of any practice or care model changes that have resulted from telephonic visits.

SOURCE: AB 133, Sec. 380 (2021 Session). Accessed Jan. 2022.

Vision Services

Asynchronous telecommunications system (store and forward telehealth) in single media format does not include telephone calls, images transmitted via facsimile machine, and text messages without visualization of the patient (electronic mail).

SOURCE: CA Department of Health Care Services. Medi-Cal Professional Services Manual. Page 6. (Aug. 2020). Accessed Jan. 2022.

LEA Services

Medi-Cal does not reimburse for telephone calls, electronic mail messages or facsimile transmissions.

SOURCE: CA Department of Health Care Services. Medi-Cal Local Educational Agency (LEA) Telehealth Manual. Page 3. (Aug. 2021). Accessed Jan. 2022.

Last updated 01/17/2022

Live Video

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jan. 2022). 

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 6. (Accessed Jan. 2022).

Family PACT

Family PACT telehealth policy mirrors the fee-for-service policy.

SOURCE:  CA Department of Health Care Services.  Family Planning, Access, Care and Treatment Program.  Benefits Manual.  Aug. 2020, Pg. 6. (Accessed. Jan. 2022).

Managed Care

Existing Medi-Cal covered services may be provided via a telehealth modality (includes live video) if certain conditions are met (as outlined in fee-for-service manual).

SOURCE: CA Department of Health Care Services (DHCS).  All Plan Letter 19-009:  Telehealth Services Policy.  Oct. 16, 2019. (Accessed Jan. 2022).  

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Services rendered via telehealth must be FQHC or RHC covered services.  Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Jan. 2022).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services rendered via telehealth must be IHS-MOA covered services.

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 8.  (Accessed Jan. 2022). 

Local Education Agency: Speech Therapy

For dates of service on July 1, 2016 up to March 1, 2020, LEAs may only bill for covered speech therapy services provided via telehealth under the LEA Medi-Cal Billing Option Program. Speech therapy services are reimbursable when performed according to telemedicine guidelines and billed with modifier 95 and the appropriate CPT code.

For dates of service on or after March 1, 2020, until the termination of the COVID-19 PHE, all LEA services covered under the LEA Medi-Cal Billing Option Program may be billed by participating LEAs when performed via telehealth, except for services, such as specialized medical transportation services, that preclude a telehealth modality. For dates of service on or after July 1, 2021, allowable services delivered via telehealth must be billed with modifier 95 (synchronous telehealth service rendered via a real-time interactive audio and video telecommunications system) and the appropriate CPT code.

For all dates, a telemedicine service must use interactive audio, video or data communication to qualify for reimbursement. The qualified service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the student and health care provider.

Upon termination of the COVID-19 PHE, DHCS will provide guidance to LEAs on the permanent telehealth policy by which LEAs will be reimbursed for services delivered via telehealth.

SOURCE:  CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021. Pg. 2-3, 5-7.  (Accessed Jan. 2022). 

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (including live video) as an alternative modality for the provision of select dental services when the beneficiary requests it or if the health care provider believes the service is clinically appropriate.

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day.

SOURCE:  CA Department of Health Care Services (DHCS).  Dental Provider Handbook.  Jan. 2022. Pg. 4-21 – 4-24 (Accessed Jan. 2022). 

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

SOURCE: Sec. 14132.72 of the Welfare and Institutions Code.  (Accessed Jan. 2022).

ELIGIBLE SERVICES/SPECIALTIES

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Certain types of benefits or services that would not be expected to be appropriately delivered via telehealth include, but are not limited to, benefits or services that are performed in an operating room or while the patient is under anesthesia, require direct visualization or instrumentation of bodily structures, involve sampling of tissue or insertion/removal of medical devices and/or otherwise require the in-person presence of the patient for any reason.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 6. (Accessed Jan. 2022).  

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE:  CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jan. 2022).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Jan. 2022). 

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 8.  (Accessed Jan. 2022). 

Dental Services

Synchronous live transmissions are covered.  Live transmissions are limited to 90 minutes per beneficiary per provider, per day.  They may be provided at the beneficiary’s request or if the health care provider believes the service is clinically appropriate.  All dental information transmitted during the delivery of services become part of the patient’s dental record maintained by the Medi-Cal provider at the distant site.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual.  Jan. 2022. Pg. 4-21 – 4-24.  (Accessed Jan. 2022).  

Home Health & Durable Medical Equipment

Live video telehealth may be used to deliver a face-to-face encounter related to the primary reason a recipient requires home health services or a durable medical equipment item.

SOURCE: Department of Health Care Services. Home Health Agencies (HHA) Provider Handbook. (Feb. 2021), Pg. 3. & Department of Health Care Services. Durable Medical Equipment (DME): An Overview. (July 2021), Pg. 6. (Accessed Jan. 2022).

CA Children’s Services (CCS)

CA Children’s Services Program lists eligible CPT/HCPCS codes in Numbered Letters 16-1217 & 09-0718.  Codes specifically include tele-speech, tele-auditory verbal therapy, tele-auditory habilitation and tele-auditory rehabilitation services in the home, with the parent or guardian working with the speech therapist at the distant site.

SOURCE:  Department of Health Care Services.  Numbered letter 16-1217 to the CA Children’s Services Program and Genetically Handicapped Persons Program (GHPP).  Dec. 22, 2017.  & Number Letter 09-0718 to CA Children’s Services Program.  Jul. 10, 2018.  (Accessed Jan. 2022). 

Drug Medi-Cal certified providers may receive reimbursement for individual counseling provided through telehealth. However, implementation is dependent on the extent of federal participation and federal approval. The Department of Health Care Services must adopt regulations by July 1, 2022 to implement this section in accordance with the Administrative Procedure Act.

SOURCE: Sec. 14132.731 of the Welfare and Institutions Code. (Accessed Jan. 2022).

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 43. Dec. 2021. Accessed Jan. 2022.

ELIGIBLE PROVIDERS

Providers must meet all of the following criteria:

• The provider rendering covered benefits or services must meet the requirements of B&P 2290.5(a)(3) or equivalent requirements under California law in which the provider is considered licensed (ex: Behavior Analyst Certification Board).
• Provider must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group.
• The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

For purposes of telehealth [the distant site] can be different from the administrative location.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2-3. (Accessed Jan. 2022). 

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Billable providers are eligible to deliver covered FQHC/RHC services.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 11-12.  (Accessed Jan. 2022).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Billable providers are eligible to deliver available services offered under IHS-MOA services.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 7-8.  (Accessed Jan. 2022). 

Dental Services

For Medi-Cal dental benefits or services, Medi-Cal enrolled dentists and allied dental professionals (under the supervision of a dentist) may render limited services via synchronous/live transmission teledentistry, so long as such services are within their scope of practice, when billed using CDT code D9995 for dates of service on or after May 16, 2020.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual. Jan. 2022. Pg. 4-23.  (Accessed Jan. 2022). 

Psychiatrists may bill for services delivered through telehealth in accordance with the Medicaid state plan.

SOURCE: Sec. 14132.73 of the Welfare and Institutions Code. (Accessed Jan. 2022).

ELIGIBLE SITES

For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [WIC] Section 14132.72(e)). This may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jan. 2022).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Refers to fee-for-service policy for the definition of an ‘originating site’.  See manual for examples.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 13.  (Accessed Jan. 2022).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refers to fee-for-service policy for the definition of an ‘originating site’.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 10.  (Accessed Jan. 2022).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The originating site facility fee is reimbursable only to the originating site when billed with HCPCS code Q3014 (telehealth originating site facility fee).  Transmission costs incurred from providing telehealth services via audio/video communication is reimbursable when billed with HCPCS code T1014 (telehealth transmission, per minute, professional services bill separately).

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 11. (Accessed Jan. 2022). 

FQHC & RHC/IHS-MOA

These sites are not eligible for the facility or transmission fee.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Jan. 2022).

Local Education Agency:  Speech Therapy

The facility and transmission fee are not covered.

SOURCE:  CA Department of Health Care Services (DHCS).  Local Education Agency (LEA) Telehealth.  Aug. 2021. Pg. 5,7  (Accessed Jan. 2022).

Every Woman Counts Program

Effective retroactively for dates of service on or after November 1, 2013, HCPCS codes Q3014 (telehealth originating site facility fee) and T1014 (telehealth transmission, per minute, professional services bill separately) are benefits of the Every Woman Counts (EWC) program.

SOURCE: Department of Health Care Services. Every Woman Counts Program Manual. Pgs. 34-35. July 2021. Accessed Jan. 2022.

Last updated 01/17/2022

Miscellaneous

Specific documentation requirements apply to substantiate the corresponding technical and professional components of billed CPT or HCPCS codes.  Providers are not required to document a barrier to in-person visit for Med-Cal coverage or to document the cost effectiveness of telehealth or store-and-forward. Providers at the distant site are not required to document cost effectiveness of telehealth to be reimbursed for telehealth or store-and-forward services.  The distant site provider is, however, responsible for billing Medi-Cal for the covered services and supplying the appropriate supporting documentation.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Aug. 2020), Pg. 4. (Accessed Jan. 2022).

Health care providers must inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services. If a health care provider, whether at the originating site or distant site, maintains a general consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file. The consent shall be documented in the patient’s medical file (B&P Code, Section 2290.5(b)) and be available to the Department of Health Care Services (DHCS) upon request.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Aug. 2021), Pg. 5. (Accessed Jan. 2022).

Telehealth services and supports are among the services and supports authorized to be included by individual program plans developed for disabled individuals by regional centers that contract with the State Department of Developmental Disabilities.

SOURCE: Welfare and Institutions Code Sec. 4512. (Accessed Jan. 2022).

Medicaid must ensure that all managed care covered services are available and accessible to enrollees of Medicaid managed care plans in a timely manner. Telehealth can be used as a means to meet time and distance standards in some circumstances. See statute for details.

SOURCE: CA Welfare and Institutions Code Sec. 14197. (Accessed Aug. 2021). & CA Department of Health Care Services (DHCS).  All Plan Letter 20-003:  Telehealth Services Policy.  Feb. 27, 2020. (Accessed Jan. 2022).

Telehealth services, telephonic services and other specified services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds. The Department is required to issue guidance for entities to facilitate reimbursement for telehealth or telephonic services in emergency situations by July 1, 2020.

SOURCE: Welfare and Institutions Code Sec. 14132.723 & 724 (AB 1494 – 2019 Legislative Session). (Accessed Jan. 2022).

Issues of privileges and credentialing for distant physicians to care for patients via telehealth are determined by the policies of the originating hospital. Hospitals can accept the privileges and credentials for providers at distant hospitals.

SOURCE: Telehealth FAQs, Providers. March 2021. Accessed Jan. 2022.

The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program. Subject to subdivision (e), the department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

For purposes of informing the 2022–23 proposed Governor’s Budget, released in January 2022, the department shall convene an advisory group consisting of consultants, subject matter experts, and other affected stakeholders to provide recommendations to inform the department in establishing and adopting billing and utilization management protocols for telehealth modalities to increase access and equity and reduce disparities in the Medi-Cal program. The advisory group shall analyze the impact of telehealth in increased access for patients, changes in health quality outcomes and utilization, best practices for the appropriate mix of in-person visits and telehealth, and the benefits or liabilities of any practice or care model changes that have resulted from telephonic visits.

SOURCE: AB 133, Sec. 380 (2021 Session). Accessed Jan. 2022.

Last updated 01/17/2022

Out of State Providers

Provider must be licensed in CA, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Aug. 2020), Pg. 3. (Accessed Jan. 2022).

Last updated 01/17/2022

Overview

Medi-Cal allows providers to decide what modality, live video or store-and-forward, will be used to deliver eligible services to a Medi-Cal enrollee as long as the service is covered by Medi-Cal and meets all other Medi-Cal guidelines, policies, can be properly provided via telehealth, and meets the procedural and definition components of the appropriate CPT or HCPCS code.  Additional requirements apply for specific programs (such as FQHCs/RHCS and Indian Health Services).  Medi-Cal also reimburses for one specific e-consult code.

Last updated 02/16/2022

Remote Patient Monitoring

POLICY

Medi-Cal has not adopted reimbursement policies for remote patient monitoring.

SOURCE: DHCS Telehealth FAQs, Coverage Questions. March 2021. Accessed Feb. 2022.

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

SOURCE: Sec. 14124.12 (f)(1)(B) of the Welfare and Institutions Code. As amended by AB 133, Sec. 380 (2021 Session). Accessed Feb. 2022.

Remote Physiologic Monitoring

Medi-Cal reimburses for 5 remote physiologic monitoring codes (99091, 99453, 99454, 99457, 99458). It is possible Medi-Cal is considering these codes Communication Technology Based Services (CTBS) consistent with Medicare.

SOURCE: Medi-Cal Rates Information. Feb. 2022. Accessed Feb. 2022.

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services are reimbursable when ordered by and billed by physicians or other qualified health professionals (QHP). RPM services may be delivered by auxiliary personnel including contracted employees, when under the supervision of the billing physician or qualified health professional.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 37. Dec. 2021. Accessed Feb. 2022.

OTHER RESTRICTIONS

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services are reimbursable for established patients ages 21 and older.

CPT code 99453 is reimbursable once per episode of care but cannot be used for monitoring fewer than 16 days during a 30-day billing period.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 37. Dec. 2021. Accessed Feb. 2022.

Last updated 01/17/2022

Store and Forward

POLICY

“Asynchronous store-and-forward” means the transmission of a patient’s medical information from an originating site to the health care provider at a distant site.  Consultations via asynchronous electronic transmission initiated directly by patients, including through mobile phone applications, are not covered under this policy.

“E-consults” fall under the auspice of store-and-forward.  E-consults are asynchronous health record consultation services that provide an assessment and management service in which the patient’s treating health care practitioner (attending or primary) requests the opinion and/or treatment advice of another health care practitioner (consultant) with specific specialty expertise to assist in the diagnosis and/or management of the patient’s health care needs without patient face-to-face contact with the consultant.  E-consults between health care providers are designed to offer coordinated multidisciplinary case reviews, advisory opinions and recommendations of care.  E-consults are permissible only between health care providers.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 1. (Accessed Jan. 2022).

Family PACT

Family PACT telehealth policy mirrors the fee-for-service policy.

SOURCE:  CA Department of Health Care Services.  Family Planning, Access, Care and Treatment Program.  Benefits Manual.  Aug. 2020, Pg. 6. (Accessed. Jan. 2022).  

Managed Care

Existing Medi-Cal covered services may be provided via a telehealth modality (includes store-and-forward) if certain conditions are met (as outlined in fee-for-service manual).

SOURCE: CA Department of Health Care Services (DHCS).  All Plan Letter 19-009:  Telehealth Services Policy.  Oct. 16, 2019. (Accessed Jan. 2022).  

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Store-and-forward covered for specific specialties for established patients, with the exception of a homeless, homebound or a migratory or seasonal worker (HHMS).  E-consult is not covered.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 11-12.  (Accessed Jan. 2022).  

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Store-and-forward covered for specific specialties for established patients, with the exception of a homeless patient.  E-consult is not covered.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 9.  (Accessed Jan. 2022). 

Local Education Agency:  Speech Therapy

A telehealth service must use interactive audio, video or data communication to qualify for reimbursement, billed with modifier 95 and the appropriate CPT code.

SOURCE:  CA Department of Health Care Services (DHCS).  Local Education Agency (LEA) Telehealth.  Aug. 2021. Pg. 3.  (Accessed Jan. 2022). 

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (includes store-and-forward) as an alternative modality for the provision of select dental services.

SOURCE:  CA Department of Health Care Services (DHCS).  Medi-Cal Dental Provider Handbook.  Jan. 2022. Pg. 4-21 – 4-23.  (Accessed Jan. 2022). 

ELIGIBLE SERVICES/SPECIALTIES

Modifier GQ must be used for Medi-Cal covered benefits or services, including, but not limited to, teleophthalmology, teledermatology, teledentistry and teleradiology, delivered via asynchronous store and forward telecommunications systems, including through e-consult. Only the service(s) rendered from the distant site must be billed with modifier GQ.

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality if all of the following are satisfied:

• The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
• The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
• The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Certain types of benefits or services that would not be expected to be appropriately delivered via telehealth include, but are not limited to, benefits or services that are performed in an operating room or while the patient is under anesthesia, require direct visualization or instrumentation of bodily structures, involve sampling of tissue or insertion/removal of medical devices and/or otherwise require the in-person presence of the patient for any reason.

E-consult code 99451 in conjunction with the GQ modifier (indicating store-and-forward) is reimbursed. For e-consult the following requirements must be met for distant and originating site providers:

• Originating Site Providers must create and maintain the following:
  • A record that the e-consult is the result of patient care that has occurred or will occur and relates to ongoing patient management; and
  • A record of a request for an e-consult by the health care provider at the originating site
• Distant Site providers must create and maintain the following:
  • A record of the review and analysis of the transmitted medical information with written documentation of the date of service and time spent; and
  • A written report of case findings and recommendations with conveyance to the originating site.

See manual for instances when e-consult is not reimbursable.

If more than one contact or encounter is required to complete the e-consult request, the entirety of the service and cumulative discussion and review time should be reported only once using CPT code 99451.  E-consults are not applicable for FQHCs, RHCs, or IHS-MOA clinics.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (May 2021), Pg. 6, 8, 9-10. (Accessed Jan. 2022).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal. A Treatment Authorization Request is required.  See manual for applicable codes.

SOURCE:  CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Jan. 2022).

Managed Care

MCP providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered via telehealth, including asynchronous store and forward telecommunications. Consultations via asynchronous electronic transmission cannot be initiated directly by patients. Electronic consultations (e-consults) are permissible using CPT-4 code 99451, modifier(s), and medical record documentation as defined in the Medi-Cal Provider Manual. E-consults are permissible only between health care providers.

SOURCE: CA Department of Health Care Services (DHCS).  All Plan Letter 19-009:  Telehealth Services Policy.  Oct. 16, 2019. (Accessed Jan. 2022). 

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Reimbursement is permitted for established patients for teleophthalmology, teledermatology and teledentistry, when it is furnished by a billable provider at the distant site.

Asynchronous store-and-forward reimbursement may not be used to “establish” a patient, with the exception of a homeless, homebound or a migratory or seasonal worker (HHMS).  E-consult is not a reimbursable telehealth service of FQHCs/RHCs.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Jan. 2022). 

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Reimbursement is permitted for established patients for teleophthalmology, teledermatology and teledentistry, when it is furnished by a billable provider at the distant site.

Asynchronous store-and-forward reimbursement may not be used to “establish” a patient, with the exception of a homeless patient.  E-consult is not a reimbursable telehealth service of IHS-MOA clinics.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 8-9.  (Accessed Jan. 2022).  

Vision Care

Teleophthalmology by store-and-forward is covered for three specific CPT codes.  Information can be reviewed by a physician or optometrist at a distant site.   If the reviewing optometrist identifies a disease or condition requiring consultation or referral pursuant to Section 3041 of the Business and Professions Code, a referral must be made with an appropriate physician and surgeon or ophthalmologist, as required. Teleophthalmology services by store and forward must be billed with modifier GQ (service rendered by store and forward telecommunications system). Only the portion(s) rendered from the distant site (hub) are billed with modifier GQ. The use of modifier GQ does not alter reimbursement for the CPT or HCPCS code billed.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual.  (Aug. 2020), Pg. 5-6.  (Accessed Jan. 2022).

Dental Services

Reimburses for specific teledentistry codes via store-and-forward (see manual).

SOURCE:  CA Department of Health Care Services (DHCS).  Medi-Cal Dental Provider Manual.  Aug. 2021. Pg. 4-22 – 4-23.  (Accessed Jan. 2022).

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 43. Dec. 2021. (Accessed Jan. 2022).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

The originating site is eligible for a facility fee with HCPCS code Q3014.  A transmission fee is only reimbursed for live video; therefore, store-and-forward is not eligible.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual.  Telehealth.  (Aug. 2020), Pg. 11. (Accessed Jan. 2022).  

FQHC & RHC/IHS-MOA

These sites are not eligible for the facility or transmission fee.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 8 & Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Jan. 2022).  

Vision Care

The facility fee is reimbursable to the originating site when billed with HCPCS code Q3014.  Transmission costs incurred from providing telehealth services via audio/video communication is also reimbursable for the original site and the consulting provider when billed with HCPCS code T1014.  Expenses involving telehealth equipment and telecommunications and transmission costs by Internet service providers will not be reimbursed by Medi-Cal.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual.  (Aug. 2020), Pg. 5.  (Accessed Jan. 2022).

Dental Care

Transmission costs associated with store-and-forward are not reimbursable.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual. Aug. 2021. Pg.4-23.  (Accessed Jan. 2022).