Last updated 02/22/2023
Email, Phone & Fax
No reference found for email or fax.
Covered virtual communication services include: telephone conversations (audio only); virtual portal communications (secure messaging); and store and forward (transfer of data from beneficiary using a camera or similar device that records (stores) an image that is sent by telecommunication to another site for consultation).
Covered virtual communication services include telephone evaluation and management codes (audio only): 99441-99443 and G2012.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2 & 14, Oct. 1, 2022. (Accessed Feb. 2023).
A special COVID-19 Medicaid bulletin lists telephone E/M codes that have been made permanently eligible for reimbursement that have not yet been incorporated into the 1H Telehealth, Virtual Communication and Remote Patient Monitoring provider manual.
SOURCE: NC Medicaid Special Bulletin COVID-19 #237, Oct. 2022, (Accessed Feb. 2023).
Outpatient Behavioral Health
Telephonic services may be transmitted between a patient and provider in a manner that is consistent with the CPT code definition for those services. This service delivery method is reserved for circumstances when:
- The beneficiary’s physical or behavioral health status prevents them from participating in in-person or telehealth services; or
- Access issues (e.g., transportation, telehealth technology) prevent the beneficiary from participating in in-person or telehealth services.
Excluding psychotherapy for crisis services, Medicaid and NCHC shall require prior approval for services provided via the telephonic, audio-only communication method.
See Outpatient Behavioral Health manual for telephone-specific criteria, eligible providers, and covered codes.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4, 6-7, 10, 37-39, Sept. 1, 2021. (Accessed Feb. 2023).
FQHCs/RHCs
FQHCs and RHCs may conduct telephonic evaluation and management services using HCPCS code G0071. Eligible providers include physicians, nurse practitioners, psychiatric nurse practitioners, physician assistants, and certified nurse midwives.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 19, Dec. 1, 2020. (Accessed Feb. 2023).
Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)
Telephonic services my be transmitted between a patient and provider in a manner that is consistent with the CPT code and definition for those services.
This service delivery method is reserved for circumstances when:
- The caregiver’s physical or behavioral health status prevents them from participating in in-person or telehealth services; or
- Access issues (e.g., transportation, telehealth technology) prevent the caregiver from participating in in-person or telehealth services.
Refer to Subsection 3.2.5 for Telephonic-Specific Criteria ; Subsections 5.1 and 5.2 for Prior Approval requirements; and Subsection 7.1 for Compliance requirements.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), pgs. 6,9-10, 12 & 17, Amended Dec. 1, 2020, (Accessed Feb. 2023).
Peer Support Services
As outlined in Attachment A, select services within this clinical coverage policy may be provided via the telephonic, audio-only communication method. Telephonic services may be transmitted between a beneficiary and provider in a manner that is consistent with the CPT and HCPCS code definition for those services.
Refer to subsection 3.2.5.1 for Telephonic-Specific Criteria; and subsection 7.1 for Compliance requirements.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8G, Peer Support Services pgs. 5, 7 &17 & Attachment A, pgs. 20-21, Amended Aug. 15, 2022. (Accessed Feb. 2023).
Behavioral Health Providers
Triage and screening services provided to a beneficiary by a mobile crisis provider may be provided via telehealth or telephonically. Providers shall bill the MCM HCPCS with modifier GT for services provided via telehealth or modifier KX for services provided via telephonic, audio-only communication.
A mobile response is required if it is determined during triage that an in-person assessment is medically necessary. If an in-person assessment is required, this assessment must be delivered in the least restrictive environment and provided in or as close as possible to a beneficiary’s home, in the beneficiary’s natural setting, school, or work. This response must be mobile. The result of this assessment must identify the appropriate crisis stabilization intervention. Providers shall bill the MCM HCPCS with the HT modifier for mobile response services provided by:
- Two team members responding in-person to a beneficiary in crisis; OR
- One team member responding in-person to a beneficiary in crisis with an additional team member linked in via telehealth to assist with the crisis.
Providers may not bill separately for MCM team members responding to the same beneficiary or for team member(s) that linked in via telehealth. Documentation must indicate the two team members that provided crisis services to the beneficiary and specify team members that responded in-person or the team member that was linked in via telehealth.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8A, Enhanced Mental Health and Substance Abuse Services, Amended Feb. 15, 2023, pg. 33, pgs. 33, (Accessed Feb. 2023).
Last updated 02/22/2023
Live Video
POLICY
All telehealth services must be provided over a secure HIPAA compliant technology with live audio and video capabilities including (but not limited to) smart phones, tablets and computers.
The beneficiary must be enrolled in either the NC Medicaid program or the NC Health Choice Program. Provider(s) shall verify each Medicaid or NCHC beneficiary’s eligibility each time a service is rendered. The Medicaid beneficiary may have service restrictions due to their eligibility category that would make them ineligible for this service. For example, to participate in the NC Health Choice Program, a beneficiary must be between 6 and 18 years old.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3 & 8, Oct. 1, 2022. (Accessed Feb. 2023).
ELIGIBLE SERVICES/SPECIALTIES
A range of services may be delivered via telehealth, virtual communication, and remote patient monitoring to Medicaid and NCHC beneficiaries. All telehealth, virtual communication, and remote monitoring services must be delivered in a manner that is consistent with the quality of care provided in-person.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6, Oct. 1, 2022. (Accessed Feb. 2023).
A special COVID-19 Medicaid bulletin lists a variety of services that have been made permanently eligible for telehealth reimbursement that have not yet been incorporated into the 1H Telehealth, Virtual Communication and Remote Patient Monitoring provider manual.
SOURCE: NC Medicaid Special Bulletin COVID-19 #237, Oct. 2022, (Accessed Feb. 2023).
Medicaid or NCHC shall cover procedures, products, and services related to this policy when they are medically necessary, and:
- The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs;
- The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and
- The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.
Services NOT Covered
- The beneficiary does not meet the eligibility requirements;
- The beneficiary does not meet the criteria listed above;
- The procedure, product, or service duplicates another provider’s procedure, product, or service; or
- The procedure, product, or service is experimental, investigational, or part of a clinical trial.
See p. 5 of manual for specific criteria that must be met before a telehealth service can be rendered to a NC Medicaid beneficiary.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 5 & 7, Oct. 1, 2022 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4 & 7-8, Sept. 1, 2021. (Accessed Feb. 2023).
Additional Criteria not covered under NC Health Choice
Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under North Carolina Medicaid Program except for the following:
- No services for long-term care.
- No nonemergency medical transportation.
- No EPSDT.
- Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.
Unless otherwise required for a specific service, Medicaid and NCHC shall not require prior approval for 1H, Telehealth, Virtual Communications and Remote Patient Monitoring. Prior authorization or an initial in-person examination is not required in order to receive care via telehealth, virtual patient communication, or remote patient monitoring; however, when establishing a new relationship with a patient via these modalities, the provider shall meet the prevailing standard of care and complete all appropriate exam requirements and documentation dictated by relevant CPT or HCPCS coding guidelines.
Special provisions apply for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. See manual.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 3-8, Oct. 1, 2022. (Accessed Feb. 2023).
Telehealth, including:
- office or other outpatient services and office and inpatient consultation codes; and
- hybrid telehealth visit with supporting home visit codes.
Virtual communication, including:
- online digital evaluation and management codes;
- telephonic evaluation and management;
- telephonic evaluation and management and virtual communication codes; and
- interprofessional assessment and management codes.
Virtual patient communications must be transmitted between a patient and provider, or between two providers, in a manner that is consistent with the CPT code definition for those services. Provider(s) shall follow all applicable HIPAA rules.
Hybrid Telehealth with Supporting Home Visit (Hybrid Model)
Eligible providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients, for a range of scenarios including (but not limited to):
- Chronic Disease Management: Providers shall use the home visit codes in this policy with appropriate modifiers.
- Perinatal Care: Providers shall only use the home visit codes in this policy with appropriate modifiers if they are not billing the pregnancy global package codes. Providers billing the pregnancy global package codes shall refer to clinical coverage policy 1E-5, Obstetrical Services for billing guidance for this model.
Well-child services are not eligible to be delivered via the hybrid model. See manual for additional requirements.
FQHCs, FQHC-Lookalikes, and RHCs may utilize this hybrid model but shall not bill the home visit codes in table C.1.; FQHCs, FQHC-Lookalikes and RHCs may bill their core service code (T1015) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the beneficiary’s home. To be reimbursed for the originating site facility fee, all of the following requirements must be met for each home visit:
- The assistance delivered in the home must be given by an appropriately trained delegated staff person.
- The fee must be billed for the same day that the home visit is conducted.
- HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home.
- The core service code (T1015) must be billed separately from the originating site facility fee code (Q3014).
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 6 , 13 &14 Oct. 1, 2022. (Accessed Feb. 2023).
See Attachment A of manual for billable codes (pgs. 12-16).
When the GT modifier is appended to a code billed for professional services, the service is paid at the allowed amount of the fee schedule.
- For hospitals, this is a covered service for both inpatient and outpatient and is part of the normal hospital reimbursement methodology.
- Reimbursement for these services is subject to the same restrictions as face-to-face contacts (such as; place of service, allowable providers, multiple service limitations, prior authorization).
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 17-18, Oct. 1, 2022. (Accessed Feb. 2023).
Outpatient Behavioral Health
NC Medicaid covers a range of outpatient behavioral health services via audio-visual and audio-only modalities. See Outpatient Behavioral Health manual for criteria and covered services.
Medicaid and NCHC shall not cover Outpatient Behavioral Health Services for the following:
- sleep therapy for psychiatric disorders;
- when services are not provided in-person or in accordance with Attachment A.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4-8, Sept. 1, 2021. (Accessed Feb. 2023).
FQHCs/RHCs
Core Visit Services: Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth if the service is:
- Defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics; and,
- Covered as a telehealth-eligible core visit service in Attachment A, Section C.1.
Non-Core Visit Services: FQHCs and RHCs may also deliver a select set of services via telehealth, virtual patient communications, and remote patient monitoring that are not defined as a core visit service in Section 5.3 of Clinical Coverage Policy 1D-4: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics. FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring. See Attachment A, Section C.1 of this policy for further guidance for billing virtual patient communications and remote patient monitoring codes.
In addition, FQHC and RHC core service providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients and bill using HCPCS code T1015 (or T1015-HI, T1015-SC), for a range of scenarios including (but not limited to) chronic disease management and perinatal visits.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 8-9 & 19 Dec. 1, 2020. (Accessed Feb. 2023).
Office Based Opioid Treatment (OBOT)
Telehealth services may be used for the medical or counseling portions of OBOT services providing they are in accordance with NC Medicaid clinical coverage policy 1H, Telemedicine and Telepsychiatry. If telehealth is utilized for the medical management portion of OBOT services, the beneficiary shall be located at a facility where a physical exam can be conducted by a nurse practitioner, physician assistant, or MD at the time of the telehealth visit.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1A-41, Office-Based Opioid Treatment, p. 12, July 1, 2021. (Accessed Feb. 2023).
Independent Practitioners
As outlined in Attachment A and in Subsection 3.2.1.3.e, select services within this clinical coverage policy may be provided via telehealth.
A select set of speech and language evaluation and treatment interventions may be provided to a beneficiary using a telehealth delivery method as described in Clinical Coverage Policy 1-H. Telehealth delivery may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, access to transportation is inconsistent, or if their location is remote or underserved such that access to appropriately qualified providers is limited.
To ensure a beneficiary receives high quality care aligned with best practices, the following criteria must be considered when making decisions about providing care using a telehealth delivery method:
- Unless in-person care is contraindicated or unavailable, telehealth must be used as an adjunct to in-person care and not as a replacement.
- Telehealth must be used in the best interest of the beneficiary and not as a convenience for the therapist.
- Telehealth must never be used solely to increase therapist productivity.
Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual communications or remote patient monitoring
SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended Oct. 1, 2022, pg. 3, 12 & 44 (Accessed Feb. 2023).
Outpatient Specialized Therapies – Local Education Agencies
As outlined in Attachment A and in Subsections 3.5 and 3.8, select services within this clinical coverage policy may be provided via telehealth.
A select set of speech and language evaluation and treatment interventions as well as psychological and counseling treatment interventions may be billed by LEAs when provided to student beneficiaries using a telehealth delivery method as described in Clinical Coverage Policy 1-H. Telehealth delivery may be medically necessary when a student is medically homebound, during an extended school closure, or if their school is remote or underserved such that access to appropriately qualified providers is limited. See telehealth eligible service codes in manual.
Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.
SOURCE: NC Div. of Medical Assistance, Outpatient Specialized Therapies, Local Education Agencies, Clinical Coverage Policy, Amended Feb. 1, 2022, pg. 4, 12 & 14, 43, 45, & 46 (Accessed Feb. 2023).
Speech and Language Evaluation and Treatment
A select set of speech and language evaluation and treatment interventions may be provided to a beneficiary using a telehealth delivery method as described in Clinical Coverage Policy 1-H. Telehealth delivery may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, or if their location is remote or underserved such that access to appropriately qualified providers is limited.
To ensure a beneficiary receives high quality care aligned with best practices, the following criteria must be considered when making decisions about providing care using a telehealth delivery method:
- Unless in-person care is contraindicated or unavailable, telehealth must be used as an adjunct to in-person care and not as a replacement.
- Telehealth must be used in the best interest of the beneficiary and not as a convenience for the therapist.
- Telehealth must never be used solely to increase therapist productivity.
See Speech Language codes for eligible services via telehealth.
SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended Oct. 3, 2022, pg. 12 & 41 (Accessed Feb. 2023).
Family Planning Services
As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. See manual for approved codes.
Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.
Telehealth claims should be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth).
Six (6) inter-periodic visits are allowed per 365 calendar days. Each in-person or telehealth encounter will count as one of a beneficiary’s allotted six inter-periodic visits, per 365 days.
SOURCE: NC Div. of Medical Assistance, Family Planning Services, Clinical Coverage Policy, Amended Feb. 15, 2023, pg. 4, 27-28 & 31 (Accessed Feb. 2023).
Home Health Services
The use of telehealth is permitted for home health services. The physician shall provide a written attestation statement that face-to-face contact (including the use of telehealth), was made with the beneficiary within the last 90 days.
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies 3A Home Health Services, Amended Oct. 3, 2022, pg. 13, (Accessed Feb. 2023).
Dietary Evaluation and Counseling and Medical Lactation Services
Dialysis Services
Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy. Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual communications or remote patient monitoring.
See manual for service codes.
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dialysis Services Amended Dec. 1, 2020, pg. 17 (Accessed Feb. 2023).
Diabetes Outpatient Self-Management Education
Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy. Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual communications or remote patient monitoring.
See manual for service codes.
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Diabetes Outpatient Self-Management Education Amended Feb. 15, 2021, pg. 14, (Accessed Feb. 2023).
Independent Practitioners Respiratory Therapy Services
Services delivered via telehealth must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Communications, and Remote Patient Monitoring.
A select set of respiratory therapy treatment interventions may be provided to established patients using a telehealth delivery method as described in Clinical Coverage Policy 1-H. After necessary equipment and supplies have been delivered and assembled, delivery of treatment services via telehealth may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, or if their location is remote or underserved such that access to appropriately qualified providers is limited.
CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.
See manual for codes.
Respiratory Therapy treatment visits by the IPP must occur in the beneficiary’s primary private residence or via telehealth in accordance with Subsection 3.2.1 c., and focus on legal parent(s), legal guardian(s) or foster care provider(s) education. The IPP may provide two (2) respiratory therapy treatment visits of the allowed 15 treatment visits in either the school or other location (day care) during a six (6) consecutive month time frame to provide staff training.
The beneficiary shall be present and actively participating during each session.
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Independent Practitioners Respiratory Therapy Services Amended Jan. 1, 2021, pg. 7, 12 &14, (Accessed Feb. 2023).
Pregnancy Medical Home
Telehealth eligible services may be provided to new and established patients by the eligible providers listed within this policy. Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Telehealth, Pregnancy Medical Home, pg. 15, Feb. 15, 2023. (Accessed Feb. 2023).
Enhanced Mental Health and Substance Abuse Services
As outlined in Attachments A and D, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Enhanced Mental Health and Substance Abuse Services Amended Feb. 15, 2023, pg. 4 & Attachment A pgs 25028, Attachment D pgs. 32-36. (Accessed Feb. 2023).
Facility-Based Crisis Service for Children and Adolescents
As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8A-2, Facility-Based Crisis Service for Children and Adolescents pg. 7 & Attachment A pgs. 21-22, Amended May 15, 2022. (Accessed Feb. 2023).
Diagnostic Assessment
A diagnostic assessment is a direct periodic service that can be provided in any location. This service may be provided to the beneficiary in-person or via telehealth.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8A-5, Diagnostic Assessment, Amended April 15, 2023, pg. 5, (Accessed Feb. 2023).
Children’s Developmental Service Agencies (CDSAs)
As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8-J, Children’s Developmental Service Agencies (CDSAs) Amended Feb. 15, 2023, pg. 8 & Attachment A pgs. 18-20. (Accessed Feb. 2023).
North Carolina Innovations
As outlined in Attachment A, select services within this clinical coverage policy may be provided via telehealth. Services delivered via telehealth must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Patient Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.
Specialized Consultation Services
Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the beneficiary with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.
Activities covered include:
- Tele-consultation through use of two-way, real time-interactive audio and video to provide behavioral and psychological care when distance separates the care from the individual.
See manual for complete list of covered activities.
This service may be used for evaluations for adults when the State Plan limits have been exceeded.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8-P, North Carolina Innovations Amended May 1, 2022, pg. 10, Attachment A pgs. 38-43 & pg. 105, (Accessed Feb. 2023).
Behavioral Health Providers
Triage and screening services provided to a beneficiary by a mobile crisis provider may be provided via telehealth or telephonically. Providers shall bill the MCM HCPCS with modifier GT for services provided via telehealth or modifier KX for services provided via telephonic, audio-only communication.
A mobile response is required if it is determined during triage that an in-person assessment is medically necessary. If an in-person assessment is required, this assessment must be delivered in the least restrictive environment and provided in or as close as possible to a beneficiary’s home, in the beneficiary’s natural setting, school, or work. This response must be mobile. The result of this assessment must identify the appropriate crisis stabilization intervention. Providers shall bill the MCM HCPCS with the HT modifier for mobile response services provided by:
- Two team members responding in-person to a beneficiary in crisis; OR
- One team member responding in-person to a beneficiary in crisis with an additional team member linked in via telehealth to assist with the crisis.
Providers may not bill separately for MCM team members responding to the same beneficiary or for team member(s) that linked in via telehealth. Documentation must indicate the two team members that provided crisis services to the beneficiary and specify team members that responded in-person or the team member that was linked in via telehealth.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8A, Enhanced Mental Health and Substance Abuse Services, Amended Feb. 15, 2023, pg. 33, pgs. 33, (Accessed Feb. 2023).
ELIGIBLE PROVIDERS
To be eligible to bill for procedures, products, and services related to this policy, providers shall
- Meet Medicaid or NCHC qualifications for participation;
- Be currently Medicaid or NCHC enrolled; and
- Bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9, Oct. 1, 2022 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 13, Sept. 1, 2021. (Accessed Feb. 2023).
The distant site is the location from which the provider furnishes the telehealth, virtual communications, or remote patient monitoring services. There are no restrictions on distant sites. Distant sites may be wherever the provider may be located. Provider(s) shall ensure that beneficiary privacy is protected (such as taking calls from private, secure spaces; using headsets).
Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes and Rural Health Centers (RHCs) are considered eligible distant sites and shall follow the coding and billing guidelines (see Attachment A in the manual).
Eligible providers that can bill for telehealth services:
- Physicians;
- Nurse practitioners;
- Psychiatric Nurse Practitioner
- Certified nurse midwives;
- Physician’s assistants; and
- Clinical pharmacist practitioners
NC Medicaid permits all of the above provider types to bill for the hybrid telehealth with supporting home visits, most virtual communication services and remote patient monitoring, except clinical pharmacist practitioners. Physicians can only bill interprofessional assessment and management codes.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, 13-16, Oct. 1, 2022. (Accessed Feb. 2023).
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the beneficiary’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the beneficiary’s right to a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service, product or procedure:
- that is unsafe, ineffective, or experimental or investigational.
- that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 4, Oct. 1, 2022. (Accessed Feb. 2023).
Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) may bill for telehealth, virtual communication, and remote patient monitoring services if the service follows core service billing requirements as outlined in clinical coverage policy 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 12, Oct. 1, 2022. (Accessed Feb. 2023).
FQHCs/RHCs
Eligible providers include all core service providers as defined in Section 3.2.1 of the FQHC/RHC clinical policy, which includes physicians, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, licensed psychological associates, licensed clinical mental health counselors, licensed marriage and family therapists, advance practice nurse specialists, clinical nurse specialists, and licensed clinical addiction specialists.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, p. 19, Dec. 1, 2020. (Accessed Feb. 2023).
ELIGIBLE SITES
The Originating Site is the location in which the beneficiary is located, which may be health care facilities, schools, community sites, the home, or wherever the beneficiary may be at the time they receive services via telehealth, virtual communications, or remote patient monitoring. There are no restrictions on originating sites.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Oct. 1, 2022 (Accessed Feb. 2023).
When the originating site is a hospital, the originating site facility fee must be billed with RC780 and Q3014.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 17, Oct. 1, 2022. (Accessed Feb. 2023).
Dietary Evaluation
Dietary evaluation and counseling is provided in hospital outpatient clinics; public agencies such as health departments, federally qualified health centers, and rural health clinics; private agencies; physician or medical diagnostic clinics; and physician offices.
Telehealth claims should be filed with the provider’s usual place of service code(s).
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Dec. 1, 2020, pg. 19, (Accessed Feb. 2023).
Lactation Consultation Services
Services must be provided in hospital outpatient clinics; public agencies such as health departments, federally qualified health centers, and rural health clinics; private agencies; physician or medical diagnostic clinics; and physician offices.
Telehealth claims should be filed with the provider’s usual place of service code(s).
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Dec. 1, 2020, pg. 19, (Accessed Feb. 2023).
Dialysis Services
Telehealth claims should be filed with the provider’s usual place of services code(s).
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Dialysis Services Amended Dec. 1, 2020, pg. 18, (Accessed Feb. 2023).
Diabetes Outpatient Self-Management Education
Physician’s office, outpatient hospital department, physician diagnostic clinic, local health department, rural health clinic, federally qualified health center.
Telehealth claims should be filed with the provider’s usual place of service code(s).
SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Diabetes Outpatient Self-Management Education Amended Feb. 15, 2021, pg. 14, (Accessed Feb. 2023).
Independent Practitioners
Office, Home, School, through the Head Start program, and childcare (regular and developmental day care) settings.
Telehealth claims should be filed with the provider’s usual place of service code(s).
SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended Oct. 1, 2022, pg. 45 (Accessed Feb. 2023).
FQHCs/RHCs
Core Services
Core visit services delivered via telehealth are billed under the FQHC and RHC provider number using the HCPCS code T1015 (clinic visit/encounter, all-inclusive), T1015-HI (for behavioral health services), or T1015-SC (subsequent sick visit) and appended with the GT modifier. Eligible providers include all core service providers as defined in Section 3.2.1 of this policy, which includes physicians, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, licensed psychological associates, licensed clinical mental health counselors, licensed marriage and family therapists, advance practice nurse specialists, clinical nurse specialists, and licensed clinical addiction specialists.
Hybrid Telehealth with Supporting Home Visit
In addition, FQHC and RHC core service providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients and bill using HCPCS code T1015 (or T1015-HI, T1015-SC), for a range of scenarios including (but not limited to) chronic disease management and perinatal visits.
See manual for additional guidance.
Telehealth claims, except for hybrid telehealth with supporting home visits, should be filed with the provider’s usual place of service code(s).
Hybrid telehealth with supporting home visits should be filed with Place of Service (POS) 12 (home).
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pgs 19 & 20, Dec. 1, 2020. (Accessed Feb. 2023).
Pregnancy Medical Home
Telehealth claims should be filed with the provider’s usual place of service code(s).
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Telehealth, Pregnancy Medical Home, pg. 16, Feb. 15, 2023. (Accessed Feb. 2023).
GEOGRAPHIC LIMITS
There are no restrictions on the originating or distant sites.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, Oct. 1, 2022. (Accessed Feb. 2023).
FACILITY/TRANSMISSION FEE
Any Medicaid enrolled provider who provides a beneficiary with access to audio and visual equipment in order to complete a telehealth encounter may bill for a facility fee when their office or facility is the site at which the beneficiary is located when the service is provided and the distant site provider is at a different physical location. Skilled nursing facilities (SNF) shall not bill an originating site facility fee when the SNF Medical Director or a beneficiary’s attending physician is conducting a telehealth visit.
Providers must bill Q3014 for the originating site facility fee.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 9 & 17, Oct. 1, 2022. (Accessed Feb. 2023).
FQHCs, FQHC-Lookalikes and RHCs may bill their core service code (T1015) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the beneficiary’s home. To be reimbursed for the originating site facility fee, all of the following requirements must be met for each home visit:
- The assistance delivered in the home must be given by an appropriately trained delegated staff person.
- The fee must be billed for the same day that the home visit is conducted.
- HCPCS code Q3014 must be appended with the GT modifier and billed with a place of service ‘12’ to designate that the originating site was the home.
- The core service code (T1015) must be billed separately from the originating site facility fee code (Q3014).
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 14, Oct. 1, 2022, (Accessed Feb. 2023).
