Last updated 06/12/2023
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POLICY
DC Medicaid must reimburse for health care services through telehealth if the same service would be covered when delivered in person.
SOURCE: DC Code Sec. 31-3863 (Accessed June 2023).
The DC Medical Assistance Program will reimburse telemedicine services, if the Medicaid beneficiary meets the following conditions:
- Be enrolled in the DC Medicaid Program;
- Be physically present at the originating site at the time the telemedicine service is rendered; and
- Provide written or verbal consent to receive telemedicine services in lieu of in-person healthcare services, consistent with all applicable DC laws.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.5, Physicians Billing Manual. DC Medicaid. Apr. 2023, Sec. 15.2. P. 51 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2, Clinic Billing Manual (Apr. 2023) 15.2, P. 49; Behavioral Health Billing Manual (Apr. 2023) 14.2, p. 67. FQHC Billing Manual (Apr. 2023), 15.2, P 51. (Accessed June 2023).
ELIGIBLE SERVICES/SPECIALTIES
Medicaid shall cover and reimburse for healthcare services appropriately delivered through telehealth if the same services would be covered when delivered in person.
SOURCE: DC Code Sec. 31-3863 (Accessed June 2023)
Covered Services:
- Evaluation and management
- Consultation of an evaluation and management of a specific healthcare problem requested by an originating site provider
- Behavioral healthcare services including, but not limited to, psychiatric evaluation and treatment, psychotherapies, and counseling
- Speech therapy (Outpatient Hospital Billing Guide states: Rehabilitation services including speech therapy)
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.11 & Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.7. P. 53-54, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.7, P. 51-52. FQHC Billing Manual, DC Medicaid 15.6.1, P. 53-54. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.7, p. 69-70. & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5-6, Outpatient Hospital Billing Guide, 15.8.5, p. 75 (Apr. 2023), Inpatient Hospital Billing Guide, 11.7, p. 62-63 (Apr. 2023), Long-Term Care Billing Manual, 15.7, p. 53-54 (Apr. 2023). (Accessed June 2023).
The provider shall determine if the service can reasonably be delivered at the standard of care via telemedicine.
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6. Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.7. P. 54, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.7, P. 51-52. FQHC Billing Manual, DC Medicaid 15.6.1, P. 54. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.7, p. 70., Inpatient Hospital Billing Guide, 11.7, p. 63 (Apr. 2023), Long-Term Care Billing Manual, 15.7, p. 54 (Apr. 2023) (Accessed June 2023).
Distant site providers may only bill for the appropriate codes outlined.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.12.(Accessed June 2023).
Telemedicine listed as a covered service in the following manuals, but no other information is provided.
SOURCE: DC MMIS Provider Billing Manual (Dental) Apr. 10, 2023, 2.4, p. 12. DC MMIS Provider Billing Manual (Dialysis), 2.4, p. 11 (Apr. 12, 2023). DC MMIS Provider Billing Manual (DME/POS), 2.4, p. 12 (Apr. 12, 2023), DC MMIS Provider Billing Manual (EPSDT), 2.4, p. 12 (Apr. 12, 2023), DC MMIS Provider Billing Manual (Home Health), 2.4, p. 10-11. (Apr. 19, 2023), DC MMIS Provider Billing Manual (Hospice) 2.4, p. 10-11, (Apr. 12, 2023), DC MMIS Provider Billing Manual (Independent Lab & X-Ray), 2.4, p. 10-11 (Apr. 12, 2022), DC MMIS Provider Billing Manual (Podiatry), 2.4, p. 10-11 (Apr. 12, 2023), DC MMIS Provider Billing Manual (Residential Treatment Facilities), 2.4, p. 9-10 (Apr. 12, 2023), DC MMIS Provider Billing Manual (Transportation), 2.4, p. 10-11, (Apr. 12, 2023), DC MMIS Provider Billing Manual (Vision), 2.4, p. 10-11 (Apr. 12, 2023). (Accessed June 2023).
Education-Related Services
Office of the State Superintendent of Education shall only bill for distant site services that are allowable healthcare services to be delivered by the individual fee-for-service providers delivering Strong Start DC Early Intervention Program (DC EIP) services under them and can be delivered at the standard of care via telemedicine.
The following reimbursement parameters apply for services delivered under the Office of the State Superintendent of Education through the Strong Start DC Early Intervention Program:
- The LEA shall only bill for distant site services that are allowable healthcare services to be delivered at DCPS/DCPCS and can be delivered at the standard of care via telemedicine;
- The LEA shall provide an appropriate primary support professional to attend the medical encounter with the member at the originating site. In instances where it is clinically indicated, an appropriate healthcare professional shall attend the encounter with the member at the originating site.
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 5. Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.6. P. 53, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.6, P. 51. FQHC Billing Manual, DC Medicaid 15.6, P. 53. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.6, p. 69., Inpatient Hospital Billing Guide, 11.6, p. 62 (Apr. 2023), Long-Term Care Billing Manual, 15.6, p. 53 (Apr. 2023) (Accessed June 2023).
Excluded Services
The Program will not reimburse telemedicine providers for the following:
- Incomplete delivery of services via telemedicine, including technical interruptions that result in partial service delivery.
- When a provider is only assisting the beneficiary with technology and not delivering a clinical service.
- For a telemedicine transaction fee and/or facility fee.
- For store and forward and remote patient monitoring
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.8, p. 70. Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Apr. 2023), Inpatient Hospital Billing Guide, 11.8, p. 63 (Apr. 2023), Long-Term Care Billing Manual, 15.8, p. 54 (Apr. 2023) (Accessed June 2023).
Mental Health Rehabilitation Services Provider Certification Standards
Telemedicine/telehealth are included under reimbursable services. See rule for specific requirements.
SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3434. (Accessed June 2023).
Mental Health Crisis/Emergency Services
A Crisis/Emergency Service is an immediate response face-to-face or via telehealth in accordance with 29 DCMR § 910 to an emergency situation involving a consumer with mental illness or emotional disturbance that is available twenty-four (24) hours per day, seven (7) days per week.
SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3422. (Accessed June 2023).
Clinical Care Coordination (CCC)
CCC may be rendered by a qualified practitioner pursuant to § 3432.8 practicing within the scope of their license in person or through telehealth in accordance with 29 DCMR § 910.
Qualified practitioners providing CCC shall:
- Communicate treatment needs, assessments and treatment information to healthcare providers external to the consumer’s CSA or specialty provider;
- Facilitate appropriate linkages for the consumer with other healthcare professionals external to the consumer’s CSA or specialty provider; and
- Provide planning and Plan of Care implementation activities separate from the diagnostic assessment service when the clinician and consumer meet face-to-face or through telehealth pursuant to 29 DCMR § 910.
Providers must document CCC in an encounter note that meets the requirements of § 3413.19 and indicates the intended purpose of the service, the modality of communication, time spent reviewing or preparing records, the actions taken, and the result(s) achieved.
SOURCE: DC Municipal Regulation, Title 22, Ch. 34, Sec. 3432. (Accessed June 2023).
ELIGIBLE PROVIDERS
Telemedicine providers must comply with the following:
- Be an enrolled Medicaid provider and comply with requirements including having a completed, signed Medicaid Provider Agreement
- Comply with technical, programmatic and reporting requirements
- Be licensed; and
- Appropriately document the beneficiary’s written or verbal consent.
- Comply with any other applicable consent requirements under District laws, including but not limited to Section 3026 of Title 5-E of the District of Columbia Municipal Regulations if providing telemedicine services at a District of Columbia Public School (DCPS) or District of Columbia Public Charter School (DCPCS).
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.6. (Accessed June 2023)
D.C. Medicaid enrolled providers are eligible to deliver telemedicine services, using fee-for-service reimbursement, at the same rate as in-person consultations. All reimbursement rates for services delivered via telemedicine are consistent with the District’s Medical State Plan and implementing regulations.
The eligible distant site providers include but are not limited to the following:
- Hospital
- Nursing facility
- Federally Qualified Health Center
- Clinic
- Physician Group/Office
- Nurse Practitioner Group/Office
- DCPS
- DCPCS; and
- MHRS provider, ASARS provider and ASTEP provider certified by DBH and eligible to provide behavioral health services set forth under the State Plan
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.3, p. 68., Outpatient Hospital Billing Guide, 15.8.3, p. 74-75 (Apr. 2023), Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2023), Long-Term Care Billing Manual, 15.3, p. 52 (Apr. 2023) (Accessed June 2023).
At the discretion of the rendering provider, personnel delivering telemedicine services may work remotely, as long as all other requirements in the rule are met. See sections on technology, documentation in medical records, and confidentiality in guidance document for further specifications.
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 3-4. Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.3, p. 68, Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2023), Long-Term Care Billing Manual, 15.3, p. 52 (Apr. 2023) (Accessed June 2023).
When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.30. (Accessed June 2023).
Federally Qualified Health Center (FQHC) Reimbursement
In accordance with the District’s Prospective Payment System (PPS) or alternative payment methodology (APM) for FQHCs, the following reimbursement parameters apply:
- Originating Site: An FQHC provider must deliver an FQHC-eligible service in order to be reimbursed the appropriate PPS, APM, or fee-for-service (FFS) rate at the originating site;
- Distant Site: An FQHC provider must deliver an FQHC-eligible service that is listed in Appendix A in order to be reimbursed the appropriate PPS, APM, or FFS rate; and
- Originating and Distant Site: If both the originating and the distant site are FQHCs, for both to receive reimbursement, each site must deliver a different PPS or APM service (e.g. medical or behavioral). If both sites submit a claim for the same PPS or APM service (e.g. medical), then only the distance site will be eligible to receive reimbursement.
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 4-5.,Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.5. P. 53, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.5, P. 51. FQHC Billing Manual, DC Medicaid 15.5, P. 53. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.5, p. 69. Inpatient Hospital Billing Guide, 11.5, p. 62 (Apr. 2023), Long-Term Care Billing Manual, 15.5, p. 53 (Apr. 2023) (Accessed June 2023).
ELIGIBLE SITES
Eligible services can be delivered via telemedicine when the beneficiary is at the originating site, while the eligible “distant” provider renders services via the audio/video or audio-only connection.
When clinically indicated, an originating site provider or its designee shall be in attendance during the patient’s medical encounter with the distant site professional. An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. An originating site provider shall note their attendance status in the patient’s medical record.
To receive reimbursement, originating site providers must deliver an eligible service, distinct from the service delivered at the distant site, in order to receive reimbursement.
Telemedicine providers will submit claims in the same manner the provider uses for in person services.
When billing for services delivered via video-audio telemedicine, distant site providers shall enter the “GT” procedure modifier on the claim. When billing for any audio-only telemedicine services, distant site providers shall enter the “93” procedure modifier on the claim.
Additionally, the distant site provider must appropriately specify the place of service (POS) using the following POS codes:
- In the event the beneficiary’s home is the originating site, the distant site provider must specify the place of service “10” which is defined as “telehealth provided in patient’s home”.
- In the event a DCPS or a DCPCS is the originating site, the distant site provider must specific the place of service “03” which is defined as “school”.
- In the event the beneficiary is at any other eligible originating site (see section IV above), the distant site provider must specify the place of service “02” which is defined as “telehealth provided other than in patient’s home”. When utilizing place of service “02”, the distant site provider must also report the National Provider Identifier (NPI) of the originating site provider in the “referring provider” portion of the claim.
Services billed where telemedicine is the mode of service delivery, but the claim form and/or service documentation do not indicate telemedicine (using the appropriate procedure modifiers and appropriate POS codes) are subject to disallowances in the course of an audit.
The Program will implement this telemedicine service for both providers and participants in the Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs. All requirements stipulated in this provider guidance apply to all programs DHCF administers.
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 1-4. Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.4, p. 68-69., Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Apr. 2023), Long-Term Care Billing Manual, 15.4, p. 52-53 (Apr. 2023) (Accessed June 2023).
Effective March 1st, 2023, District health care providers rendering services to beneficiaries in Medicaid fee-for-service, Medicaid managed care, Health Care Alliance, and Immigrant Children’s programs must comply with these revised billing requirements. Refer to Transmittal #23-11 for additional information.
SOURCE: Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.4. P. 52-53, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.4, P. 50-51. FQHC Billing Manual, DC Medicaid 15.4, P. 52-53. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.4, p. 68-69., Inpatient Hospital Billing Guide, 11.4, p. 61-62 (Apr. 2023), Long-Term Care Billing Manual, 15.4, p. 52-53 (Apr. 2023) (Accessed June 2023).
The beneficiary’s home, or other settings authorized by DHCF, may serve as the originating site. When the originating site is the beneficiary’s home the distant site provider is responsible for ensuring that the technology in use meets the minimum requirements set forth in Subsection 910.13.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7 & 910.30. (Accessed June 2023).
DHCF defines “the definition of “the beneficiary’s home or other settings” to include temporary lodging, such as hotels and homeless shelters. Additionally, for circumstances where the patient, for privacy or other personal reasons, chooses to travel a short distance from the exact home location during a telehealth service, the service is still considered to be furnished” in the home of an individual.
SOURCE: Department of Health Care Finance. Telemedicine Provider Guidance Clarification “Beneficiary’s Home or Other Settings”. March 2023. (Accessed June 2023).
Must be an approved telemedicine provider. The following providers are considered an eligible originating site:
- Hospital
- Nursing facility
- Federally Qualified Health Center
- Clinic
- Physician Group/Office
- Nurse Practitioner Group/Office
- District of Columbia Public Schools (DCPS)
- District of Columbia Public Charter Schools (DCPCS)
- Mental Health Rehabilitation Service (MHRS) provider, Adult Substance Abuse Rehabilitation Service (ASARS) provider, and Adolescent Substance Abuse Treatment Expansion Program (ASTEP) provider certified by the Department of Behavioral Health (DBH) and eligible to provide behavioral health services set forth under the District of Columbia Medicaid State Plan (State Plan).
- The beneficiary’s home or other settings identified in guidance published on the DHCF website.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.7, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 2-3. Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.3. P. 52, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.3, P. 50. FQHC Billing Manual, DC Medicaid 15.3, P. 52. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.3, p. 68. Outpatient Hospital Billing Guide, 15.8.3, p. 74 (Apr. 2023), Inpatient Hospital Billing Guide, 11.3, p. 61 (Apr. 2023), Long-Term Care Billing Manual, 15.3, p. 52 (Apr. 2023) (Accessed June 2023).
When a beneficiary’s home is the originating site, the distant site provider shall ensure the technology in use meets the minimum requirements set forth in Subsection 910.13.
SOURCE: Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 7 (Accessed June 2023).
When DCPS or DCPCS is the originating site provider, a primary support professional (an individual designated by the school) shall be in attendance during the patient’s medical encounter.
An originating site provider shall not be required to be in attendance when the beneficiary prefers to be unaccompanied because the beneficiary feels the subject is sensitive. Sensitive topics may include counseling related to abuse, or other psychiatric matters. An originating site provider shall note their attendance status in the patient’s medical record.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.16-17. (Accessed June 2023).
GEOGRAPHIC LIMITS
No Reference Found
FACILITY/TRANSMISSION FEE
No transaction or facility fee.
SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.28, Department of Health Care Finance – Telemedicine Provider Guidance, Jan. 2023, pg. 6, Physicians Billing Manual. DC Medicaid. (Apr. 2023) Sec. 15.8. P. 54, Clinic Billing Manual, DC Medicaid (Apr. 2023), Sec. 15.8, P. 52. FQHC Billing Manual, DC Medicaid 15.6.2, P. 54. (Apr. 2023), Behavioral Health Billing Manual (Apr. 2023) 14.8, p. 70. Outpatient Hospital Billing Guide, 15.8.6, p. 75 (Apr. 2023), Inpatient Hospital Billing Guide, 11.8, p. 63 (Apr. 2023), Long-Term Care Billing Manual, 15.8, p. 54 (Apr. 2023) (Accessed June 2023).
