North Carolina

Last updated 07/09/2024

Consent Requirements

Provider(s) shall obtain and document verbal or written consent. In extenuating circumstances when consent is unable to be obtained, this must be documented.

Outpatient Behavioral Health Services manual applies the same requirement to telephonic services specifically.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, Jun. 1, 2023 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, Nov. 1, 2023. (Accessed Jul. 2024).

Last updated 07/09/2024

Definitions

Telehealth is the use of two-way real-time interactive audio and video to provide and support health care services when participants are in different physical locations.

Virtual communications is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a beneficiary or a provider and another provider. As outlined in Attachment A and program-specific clinical coverage policies, 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).

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, June 1, 2023. (Accessed Jul. 2024).

Last updated 07/09/2024

Email, Phone & Fax

Virtual communications is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a beneficiary or a provider and another provider. As outlined in Attachment A and program specific clinical coverage policies, 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).

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.

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, June 1, 2023. (Accessed Jul. 2024).

Telephonic Claims: Modifier KX must be appended to the CPT or HCPCS code to indicate that a service has been provided via telephonic, audio-only communication.

Telehealth and telephonic 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. 8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), Amended Apr. 1, 2023.  (appears in multiple additional manuals), (Accessed Jul. 2024).

As outlined in Attachment A, select services within this clinical coverage policy can be provided via the telephonic, audio-only communication method. Telephonic services must be transmitted between a beneficiary 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:

• physical or behavioral health status prevent the beneficiary from participating in-person or telehealth services; or
• access issues (transportation, telehealth technology) prevent the beneficiary from participating in-person or telehealth services.

24-Hour Coverage for Behavioral Health Crises:  This coverage must incorporate the ability for the beneficiary to speak with the licensed clinician on call either in-person, via telehealth, or telephonically.

Specific criteria for services delivered telephonically are outlined in the manual.

Medicaid shall require prior approval for services provided via the telephonic, audio-only communication method.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, Nov. 1, 2023. (Accessed Jul. 2024).

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, Aug. 15, 2023. (Accessed Jul. 2024).

Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD)

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 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.

Telephonic-Specific Criteria

• Providers shall ensure that services can be safely and effectively delivered using telephonic, audio-only communication;
• Providers shall consider the caregiver’s abilities to participate in services provided using telephonic, audio-only communication;
• Delivery of services using telephonic, audio-only communication must conform to professional standards of care including but not limited to ethical practice, scope of practice, and other relevant federal, state and institutional policies and requirements including Practice Act and Licensing Board rules;
• Providers shall obtain and document verbal or written consent. In extenuating circumstances when consent is unable to be obtained, this should be documented;
• Providers shall verify the caregiver’s identity using two points of identification before initiating a telephonic, audio-only encounter; and
• Providers shall ensure that the beneficiary and caregivers’ privacy and confidentiality is protected.

Transition and discharge planning from a treatment program must document a written plan that specifies details for monitoring and follow-up as appropriate for the beneficiary and family or caregiver. The treatment plan is not to be used to provide respite, day care, or educational services and is not to be used to reimburse a parent for participating in a treatment program. The treatment or discharge plan must be available to a health plan upon request. A unit of service is defined according to the Current Procedural Terminology (CPT) approved code set unless otherwise specified.

See list of telephonic billable services on page 20-21.

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), Amended Apr. 1, 2023, (Accessed Jul. 2024). 

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.

The intent of the service is to be community-based rather than office-based. Service may be provided via telehealth or telephonic, audio-only communication. Telehealth or telephonic, audio-only communication time is supplemental rather than a replacement of in-person contacts and is limited to twenty (20) percent or less of total service time provided per beneficiary per fiscal year. Documentation of service rendered via telehealth or telephonic, audio-only communication with the beneficiary or collateral contacts (assisting beneficiary with rehabilitation goals) must be documented according to Subsection 5.5 of this policy.

Telehealth and telephonic, audio-only communication 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. 8G, Peer Support Services pgs. 5, 7 &17  & Attachment A, pgs. 20-21, Amended Apr. 15, 2023. (Accessed Jul. 2024).

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 and telephonically. Services delivered via telehealth and telephonically must follow the requirements and guidance in clinical coverage Policy 1-H, Telehealth, Virtual Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/.

Mobile Crisis Management (MHDDSA) – Mobile Crisis Management (MCM) services include immediate telephonic or telehealth response to assess the crisis and determine the risk, mental status, medical stability, and appropriate response.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Enhanced Mental Health and Substance Abuse Services Amended Mar. 1, 2024, (Accessed Jul. 2024).

Community Alternatives Program

Providers can utilize telephony and other automated systems to document the provision of CAP/C services as subject to NC Medicaid guidelines on telephony, telehealth, and the CAP/DA policy guidance on electronic engagement.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Community Alternatives Program for Children, Amended Apr. 1, 2023, and Community Alternatives Program for Disabled Adults, Apr. 1, 2023, (Accessed Jul. 2024).

Opioid Treatment Program

Necessary support systems within the OTP include: … 

• Behavioral health crisis response (de-escalation or coordination of care), when clinically appropriate, 24-hours a day, seven days a week telephonically or via telehealth.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8A-9, Opioid Treatment Program Services, Oct. 15, 2023. (Accessed Jul. 2024).

CPT 99401 can be billed at only one visit for each beneficiary per day, but there are no quantity limits for the number of times this education can be provided to an individual beneficiary. Counseling may be provided in person, through live audio/video (telehealth) or telephonically. Additionally, this service can be billed by multiple providers and can be billed multiple times on different days.

There is no requirement for a specific diagnosis code. The following coding criteria will apply:

• Requires 25 modifier if in addition to OV E&M, if applicable.
• Requires GT modifiers if provided via telehealth.
• Requires KX modifiers if provided telephonically.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update:  COVID-19 Vaccine and Reimbursement Guidelines for 2023-2024 for NC Medicaid, Dec. 14, 2023, (Accessed Jul. 2024).

Obstetrical Services

Note: Prenatal and postpartum visits conducted via telehealth (interactive audio and video) shall count as a visit within a global or package service. Telephone calls or online communications do not replace a telehealth or in person visit for prenatal care and do not count towards global or package services. The postpartum delivery period should not be confused with the twelve-month postpartum MPW coverage.

Billing Prenatal and Postpartum Services Via Telehealth – Eligible providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives may conduct antepartum and postpartum care visits via telehealth. These visits may not be conducted via virtual patient communication (for example, telephone conversations). To promote early initiation of prenatal care, providers shall conduct the initial antepartum visit and pregnancy risk screen via telehealth or in-person in the office or clinic setting. When the initial visit is conducted via telehealth, a follow-up visit must be conducted in person within the first trimester of pregnancy.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2024, (Accessed Jul. 2024).

Community Support Team

CST also contains telephone time with the beneficiary and collateral contact with persons who assist the beneficiary in meeting the beneficiary’s rehabilitation goals specified in the PCP.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8A-6, Community Support Team Amended Apr. 1, 2023, (Accessed Jul. 2024).

Inpatient Behavioral Health Services

Medically Managed Intensive Inpatient Services:  Medically Managed Intensive Inpatient Withdrawal Management Services are staffed by nonpsychiatric physicians and psychiatrists who are available 24 hours a day by telephone, conduct assessments within 24 hours of admission, and are active members of an interdisciplinary team of appropriately trained professionals, and who medically manage the care of the beneficiary.

A physician shall be available 24 hours a day by telehealth or telephone.

Inpatient Hospital Psychiatric Treatment (MH):  Inpatient Hospital Psychiatric Services are staffed by non-psychiatric physicians and psychiatrists, who are available 24 hours a day by telephone and who conduct assessments within 24 hours of admission.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8-B, Inpatient Behavioral Health Services Amended June 1, 2023, (Accessed Jul. 2024).

Dietary Evaluation and Counseling

For infant weight element for diagnostic lactation assessment, the weight cannot be conducted via telephone and audio/video.

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Aug. 15, 2023, pg.  18, (Accessed Jul. 2024).

Children’s Developmental Service Agencies (CDSAs)

See page 19-20 for telehealth eligible services.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8-J, Children’s Developmental Service Agencies (CDSAs) Amended Nov. 1, 2023, (Accessed Jul. 2024).

Last updated 07/09/2024

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POLICY

Medicaid shall cover the procedure, product, or service related to this policy when 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.

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.

General

• An eligible beneficiary shall be enrolled in the NC Medicaid Program (Medicaid is NC Medicaid program, unless context clearly indicates otherwise).
• Provider(s) shall verify each Medicaid 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.

Provider Provider(s) shall bill their usual and customary charges. For a schedule of rates, refer to: https://medicaid.ncdhhs.gov/

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).

Unless otherwise required for a specific service, Medicaid 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.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Jul. 2024).

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ELIGIBLE SERVICES/SPECIALTIES

Medicaid shall cover services delivered via telehealth, virtual communications, and remote patient monitoring services when the all the following additional criteria are followed before rendering services via telehealth, virtual communications, or remote patient monitoring:

• Provider(s) shall ensure that services can be safely and effectively delivered using telehealth, virtual communications, or remote patient monitoring.
• Provider(s) shall consider a beneficiary’s behavioral, physical and cognitive abilities to participate in services provided using telehealth, virtual communications, or remote patient monitoring.
• The beneficiary’s safety must be carefully considered for the complexity of the services provided.
• In situations where a caregiver or facilitator is necessary to assist with the delivery of services via telehealth, virtual communications, or remote patient monitoring, their ability to assist and their safety must also be considered.
• Delivery of services using telehealth, virtual communications, or remote patient monitoring must conform to professional standards of care: ethical practice, scope of practice, and other relevant federal, state and institutional policies and requirements, such as Practice Act and Licensing Board rules;
• Provider(s) shall obtain and document verbal or written consent. In extenuating circumstances when consent is unable to be obtained, this must be documented.
• Beneficiaries are not required to seek services through telehealth, virtual communications, or remote patient monitoring, and shall be allowed access to in-person services, if the beneficiary requests;
• Provider(s) shall verify the beneficiary’s identity using two points of identification before initiating service delivery via telehealth, virtual communications, or remote patient monitoring.
• Provider(s) shall ensure that beneficiary privacy and confidentiality is protected to the best of their ability.

A range of services may be delivered via telehealth, virtual communication, and remote patient monitoring to Medicaid 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.

Each set of eligible services has its own set of eligible provider(s) as defined in Attachment A of this policy or Refer to https://medicaid.ncdhhs.gov/ for the related coverage policies.

Telehealth, including:

• office or other outpatient services and office and inpatient consultation codes; and
• hybrid telehealth visit with supporting home visit codes.

In addition to the eligible services and providers listed in Attachment A of this policy, the policies listed under “Related Clinical Coverage Policies” at the top of this document also include telehealth coverage information, such as telehealth-eligible services and providers. Please refer to those policies for program-specific telehealth guidance.

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 should not be used for virtual patient communications (including telephonic evaluation and management services) or remote patient monitoring.

General Criteria Not Covered

Medicaid shall not cover the procedure, product, or service related to this policy when:

• the beneficiary does not meet the eligibility requirements listed in Section 2.0;
• the beneficiary does not meet the criteria listed in Section 3.0;
• 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.

List of eligible Office or Other Outpatient Service and Office and Inpatient Consultation Codes and Hybrid Telehealth Visit with Supporting Home Visit Codes provided on page 12 of Attachment A of the Telehealth, Virtual Communications and Remote Patient Monitoring manual.

* Family Planning beneficiaries are not eligible for new patient visit via telehealth.

Guidance: 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 at https://medicaid.ncdhhs.gov/ for billing guidance for this model.

Well-child services are not eligible to be delivered via the hybrid model.

Providers shall choose the most appropriate code based on the complexity of the services provided and document accordingly. If time is used as a determining factor, providers shall choose the code that corresponds with the length of the telehealth visit provided by the eligible provider (not the duration of the home visit performed by the delegated staff person).

The delegated staff person may perform vaccinations in the home as long as they comply with applicable vaccination requirements (e.g., staff person’s scope of practice), and may conduct other tests or screenings, as appropriate.

• Any vaccinations, tests or screenings conducted in the home should be billed as if they were delivered within the office, without modifiers.

Local Health Departments may also utilize the hybrid model when the telehealth visit is rendered by an eligible provider and may bill the home visit codes listed in table C.1.

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, June 1, 2023. (Accessed Jul. 2024).

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.

Note: Due to workforce shortages, we are delaying the implementation of these new requirements. The previous policies will be posted to our clinical coverage page and the previous requirements will continue effective Feb. 15, 2023, while we develop a path forward.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Policy Update for Behavioral Health Providers Effective Feb. 15, 2023 & Updated Version March 3, 2023, (Accessed Jul. 2024).

Telephonic Claims: Modifier KX must be appended to the CPT or HCPCS code to indicate that a service has been provided via telephonic, audio-only communication.

Telehealth and telephonic 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. 8F, Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), Amended Apr. 1, 2023.  (appears in multiple additional manuals), (Accessed Jul. 2024).

Telehealth Claims: 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 services provided via telephonic, audio-only communication [or virtual patient communication or remote patient monitoring – depending on manual].  Depending on which manual, a list of eligible codes may be provided.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, Nov. 1, 2023, (appears in multiple additional manuals), (Accessed Jul. 2024).

Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy.  See manual for eligible telehealth codes.

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dialysis Services Amended Aug. 15, 2023, (appears in multiple additional manuals), (Accessed Jul. 2024).

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, amended Apr. 1, 2023.  (appears in multiple additional manuals), (Accessed Jul. 2024).

Outpatient Behavioral Health

As outlined in Attachment A, select services within this clinical coverage policy can 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/.

24-Hour Coverage for Behavioral Health Crises:  This coverage must incorporate the ability for the beneficiary to speak with the licensed clinician on call either in-person, via telehealth, or telephonically.

See list of behavioral health codes provided in manual and whether or not its telehealth eligible on page 40.

Note: Please refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for utilization and billing guidance on virtual patient communication codes (e.g., online digital E&M, telephonic E&M, and interprofessional consultation) and remote patient monitoring codes (e.g., self-measured blood pressure and remote physiologic monitoring) billable by eligible psychiatric prescribers but which are not contained in Clinical Coverage Policy 8C.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, Nov. 1, 2023. (Accessed Jul. 2024).

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.

Use modifier SC to bill non–behavioral health visits that occur after the first encounter in which the beneficiary appears with, presents with, or suffers illness or injury requiring additional diagnosis or treatment.

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, Aug. 15, 2023. (Accessed Jul. 2024).

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, Telehealth, Virtual Communications and Remote Patient Monitoring. 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, Apr. 1, 2023. (Accessed Jul. 2024).

Opioid Treatment Program

Access to timely services within the OTP are the following:

• Clinical staff available five (5) days per week to offer and provide counseling, as needed (either in-person or telehealth)

Necessary support systems within the OTP include: …

• Behavioral health crisis response (de-escalation or coordination of care), when clinically appropriate, 24-hours a day, seven days a week telephonically or via telehealth.

All other physician medical services may be provided physically on-site or through telehealth, as medically appropriate.

Clinical services may be provided on-site or through telehealth based on beneficiary’s needs.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8A-9, Opioid Treatment Program Services, Oct. 15, 2023. (Accessed Jul. 2024).

Independent Practitioners

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.

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

See page 42 for list of eligible codes for telehealth services.

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended Apr. 1, 2023, (Accessed Jul. 2024).

Outpatient Specialized Therapies – Local Education Agencies

CPT codes that may be billed when service is furnished via telehealth are indicated in Attachment A, Section C: Codes.

A select set of speech and language evaluation and treatment interventions and 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, experiencing an acute crisis, during an extended school closure, or if their school is remote or underserved such that access to appropriately qualified providers is limited.

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 Apr. 1, 2023, (Accessed Jul. 2024).

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 1H Telehealth, Virtual Communications and Remote Patient Monitoring. 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.

Note: CPT codes that may be billed when service is furnished via telehealth are indicated in Clinical Coverage Policy 10B, Independent Practitioners Attachment A, Section C: Codes.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policy 10A: Outpatient Specialized Therapies, Amended June 15, 2024, (Accessed Jul. 2024).

Family Planning Services

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 set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Communications, and Remote Patient Monitoring.

List of eligible telehealth service codes provided page page 23.

Family planning services must be billed with the appropriate code using the FP modifier. All providers, except ambulatory surgical centers, must append modifier FP to the procedure code for family planning services.

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 Apr. 15, 2023, (Accessed Jul. 2024).

Home Health Services

Face to Face Encounter: 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 in accordance with Section 6407 of the Patient Protection and Affordable Care Act.

Telehealth may be implemented in accordance with 42 CFR 440.70 and clinical coverage policy 1H, Telehealth, Virtual Patient Communications and Remote Monitoring at https://medicaid.ncdhhs.gov/.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies 3A Home Health Services, Amended Apr. 1, 2023, (Accessed Jul. 2024).

Dietary Evaluation and Counseling and Medical Lactation Services 

Diabetes Outpatient Self-Management Education

See page 13 for eligible telehealth services.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Diabetes Outpatient Self-Management Education Amended June 1, 2023, (Accessed Jul. 2024).

Independent Practitioners Respiratory Therapy Services

Pregnancy Medical Home

See page 14 for list of telehealth eligible services.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1E-6, Pregnancy Management Program, Apr. 1, 2023. (Accessed Jul. 2024).

Enhanced Mental Health and Substance Abuse Services

List of telehealth eligible services provided on page 25-27, including for crisis management triage and screening.

As specified within this policy, components of certain service can be provided via telehealth by the physician. Due to this service containing other elements that are not permitted via telehealth, the GT modifier is not appended to the HCPCS code to indicate that a service component has been provided via telehealth.

Service Definition and Required Components Mobile Crisis Management (MCM) involves all support, services and treatments necessary to provide integrated crisis response, crisis stabilization interventions, and crisis prevention activities. Mobile Crisis Management services are available at all times, 24-hours-a-day, 7-days-a-week, 365-days-a-year. Crisis response provides an immediate evaluation, triage and access to acute mental health, intellectual/developmental disabilities, or substance abuse services, treatment, and supports to effect symptom reduction, harm reduction, or to safely transition persons in acute crises to appropriate crisis stabilization and detoxification supports or services. These services include immediate telephonic or telehealth response to assess the crisis and determine the risk, mental status, medical stability, and appropriate response.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Enhanced Mental Health and Substance Abuse Services Amended Mar. 1, 2024, (Accessed Jul. 2024).

Facility-Based Crisis Service for Children and Adolescents

Under certain circumstances, a beneficiary shall be seen by the psychiatrist in-person or via telehealth within 24 hours of their admission to the Facility-Based Crisis Service.

See page 20 for list of eligible telehealth codes.

Note: As specified within this policy, components of this service may be provided via telehealth by the psychiatrist. Due to this service containing other elements that are not permitted via telehealth, the GT modifier is not appended to the HCPCS code to indicate that a service component has been provided via telehealth.

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, amended Apr. 1, 2023. (Accessed Jul. 2024).

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 Jul. 2024).

Children’s Developmental Service Agencies (CDSAs)

See page 19-20 for telehealth eligible services.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8-J, Children’s Developmental Service Agencies (CDSAs) Amended Nov. 1, 2023, (Accessed Jul. 2024).

North Carolina Innovations

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ELIGIBLE PROVIDERS

The distant site is the location from which the provider furnishes 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 in Attachment A below.

A range of services may be delivered via telehealth, virtual communication, and remote patient monitoring to Medicaid 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.

Each set of eligible services has its own set of eligible provider(s) as defined in Attachment A of this policy or Refer to https://medicaid.ncdhhs.gov/ for the related coverage policies.

Up to three different consulting providers may be reimbursed for a separately identifiable telehealth service provided to a beneficiary per date of service.

To be eligible to bill for the procedure, product, or service related to this policy, the provider(s) shall:

• meet Medicaid qualifications for participation;
• have a current and signed Department of Health and Human Services (DHHS) Provider Administrative Participation Agreement; and
• bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity.

The following HCPCS code can be billed for the Telehealth originating site facility fee by the originating site (the site at which the beneficiary is located): Q3014

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, June 1, 2023. (Accessed Jul. 2024).

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.

List of eligible Office or Other Outpatient Service and Office and Inpatient Consultation Codes and Hybrid Telehealth Visit with Supporting Home Visit Codes provided on page 12 of Attachment A of the Telehealth, Virtual Communications and Remote Patient Monitoring manual.

* Family Planning beneficiaries are not eligible for new patient visit via telehealth.

Guidance: 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 at https://medicaid.ncdhhs.gov/ for billing guidance for this model.

Well-child services are not eligible to be delivered via the hybrid model.

Providers shall choose the most appropriate code based on the complexity of the services provided and document accordingly. If time is used as a determining factor, providers shall choose the code that corresponds with the length of the telehealth visit provided by the eligible provider (not the duration of the home visit performed by the delegated staff person).

The delegated staff person may perform vaccinations in the home as long as they comply with applicable vaccination requirements (e.g., staff person’s scope of practice), and may conduct other tests or screenings, as appropriate.

• Any vaccinations, tests or screenings conducted in the home should be billed as if they were delivered within the office, without modifiers.

Local Health Departments may also utilize the hybrid model when the telehealth visit is rendered by an eligible provider and may bill the home visit codes listed in table C.1.

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).

Eligible providers listed on Telehealth Services code charts include:

• Physicians;
• Nurse practitioners;
• Psychiatric Nurse Practitioner
• Certified nurse midwives;
• Physician’s assistants; and
• Clinical pharmacist practitioners

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, Attachment A, June 1, 2023. (Accessed Jul. 2024).

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. 6, June 1, 2023. (Accessed Jul. 2024).

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. 17-18, Aug. 15, 2023. (Accessed Jul. 2024).

Independent Practitioners

Telehealth eligible services may be provided to beneficiaries by the eligible providers listed within this policy.

SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy No: 10B, Amended Apr. 1, 2023, (Accessed Jul. 2024).

Teledentistry

Teledentistry eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

D9995 – Teledentistry – synchronous; real-time encounter

• Medicaid enrolled dentists may render provider to provider teledentistry services via synchronous, live audio and video transmission
• Dentist in the distant site must have enough information and evidence to make a diagnosis
• All services sites/providers must be Medicaid enrolled
• Enter “02” (Telehealth) as the place of treatment for teledentistry claims

SOURCE: NC Medicaid Clinical Coverage Policy 4A: Dental Services, Dec. 15, 2023, (Accessed Jul. 2024).

Obstetrical Services

Hybrid Telehealth Visit with Supporting Home Visit – Physicians, nurse practitioners, physician assistants and certified nurse midwives shall conduct antepartum or postpartum care via a telehealth visit, with a supporting visit to the beneficiary’s private residence made by an appropriately trained, delegated staff person, when medically necessary.

Individual Visit Billing- When OB services are provided and billed per visit (refer to Section 3.2.4 for billing individual prenatal visits) append GT modifier to each visit conducted via telehealth. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

Billing Prenatal and Postpartum Services Via Telehealth – Eligible providers, including physicians, nurse practitioners, physician assistants, and certified nurse midwives may conduct antepartum and postpartum care visits via telehealth. These visits may not be conducted via virtual patient communication (for example, telephone conversations). To promote early initiation of prenatal care, providers shall conduct the initial antepartum visit and pregnancy risk screen via telehealth or in-person in the office or clinic setting. When the initial visit is conducted via telehealth, a follow-up visit must be conducted in person within the first trimester of pregnancy.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2024, (Accessed Jul. 2024).

The psychiatrist shall conduct a psychiatric assessment of each beneficiary in person or via telehealth within 24 hours of admission. The psychiatrist shall provide consultation to and supervision of staff; this supervision must be available onsite whenever needed and must occur onsite no less than one day per week, averaged over each quarter.

A beneficiary shall be seen by the psychiatrist in-person or via telehealth within 24 hours of their admission to the Facility-Based Crisis Service.

Note: As specified within this policy, components of this service may be provided via telehealth by the psychiatrist. Due to this service containing other elements that are not permitted via telehealth, the GT modifier is not appended to the HCPCS code to indicate that a service component has been provided via telehealth.

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, amended Apr. 1, 2023. (Accessed Jul. 2024).

Peer Support Services

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/.

Note: Telehealth eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

The intent of the service is to be community-based rather than office-based. Service may be provided via telehealth or telephonic, audio-only communication. Telehealth or telephonic, audio-only communication time is supplemental rather than a replacement of in-person contacts and is limited to twenty (20) percent or less of total service time provided per beneficiary per fiscal year. Documentation of service rendered via telehealth or telephonic, audio-only communication with the beneficiary or collateral contacts (assisting beneficiary with rehabilitation goals) must be documented according to Subsection 5.5 of this policy.

Telehealth and telephonic, audio-only communication 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. 8G, Peer Support Services pgs. 5, 7 &17  & Attachment A, pgs. 20-21, Amended Apr. 15, 2023. (Accessed Jul. 2024).

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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.

Telehealth, virtual communication, and remote patient monitoring claims should be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth). Exception: 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: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring,  June 1, 2023. (Accessed Jul. 2024).

Guidance: Hybrid Telehealth with Supporting Home Visit (“Hybrid Model”)

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).

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, Attachment A, June 1, 2023. (Accessed Jul. 2024).

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).

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).

For infant weight element for diagnostic lactation assessment, the weight cannot be conducted via telephone and audio/video.

SOURCE:  NC Div. of Medical Assistance, Clinical Coverage Policies Dietary Evaluation and Counseling and Medical Lactation Services Amended Aug. 15, 2023, pg.  18, (Accessed Jul. 2024).

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, Aug. 15, 2023. (Accessed Jul. 2024).

Respiratory Therapy Services

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.

SOURCE: NC Div. of Medical Assistance, Clinical Coverage Policies Independent Practitioners Respiratory Therapy Services Amended Apr. 1, 2023, (Accessed Jul. 2024).

Teledentistry

Teledentistry eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

D9995 – Teledentistry – synchronous; real-time encounter

• The originating site is the facility in which the beneficiary is located
• All services sites/providers must be Medicaid enrolled
• Consultation must take place by an encrypted two-way real-time interactive audio and video telecommunications system

SOURCE: NC Medicaid Clinical Coverage Policy 4A: Dental Services, Dec. 15, 2023, (Accessed Jul. 2024).

Obstetrical Services

Telehealth Claims: Global/Package Billing – Append the GT modifier to the global or package code to indicate that one or more of the visits were conducted via telehealth under that package. This modifier is not appropriate for virtual patient communications or remote patient monitoring

Individual Visit Billing- When OB services are provided and billed per visit (refer to Section 3.2.4 for billing individual prenatal visits) append GT modifier to each visit conducted via telehealth. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

Telehealth claims shall be filed with the provider’s usual place of service code(s) and not place of service 02 (Telehealth).

Billing for Hybrid Telehealth Visit with a Supporting Home Visit – Providers Billing Global OB or Package Codes:

• To reflect the additional cost of the delegated staff person attending the patient’s home, eligible providers may bill a telehealth originating site facility fee for each telehealth visit conducted with a supporting visit. The originating site fee shall be billed in addition to the pregnancy global package codes.
• To be reimbursed for the originating site facility fee for this care model, all of the listed 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 with the date of service for which the home visit is conducted.
  • The telehealth originating site facility fee 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 antepartum or postpartum hybrid telehealth visit is included in the global or package code for the pregnancy. There is no separate evaluation and management code billing outside of the package or global code for the providers portion of the home visit.

Note: Refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for more information about originating site facility fees.

Providers Billing Individual Prenatal Visits:

• Providers shall bill the appropriate level Home Service evaluation and management code for each telehealth visit with a supporting home visit made by an appropriately trained delegated staff person.
• Providers should not bill the originating site facility fee.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2024, (Accessed Jul. 2024).

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.

The intent of the service is to be community-based rather than office-based. Service may be provided via telehealth or telephonic, audio-only communication. Telehealth or telephonic, audio-only communication time is supplemental rather than a replacement of in-person contacts and is limited to twenty (20) percent or less of total service time provided per beneficiary per fiscal year. Documentation of service rendered via telehealth or telephonic, audio-only communication with the beneficiary or collateral contacts (assisting beneficiary with rehabilitation goals) must be documented according to Subsection 5.5 of this policy.

Telehealth and telephonic, audio-only communication 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. 8G, Peer Support Services pgs. 5, 7 &17  & Attachment A, pgs. 20-21, Amended Apr. 15, 2023. (Accessed Jul. 2024).

Pregnancy Management Program

Non-Telehealth Claims: Providers shall follow applicable modifier guidelines.

Telehealth Claims: 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 eligible services may be provided to new and established patients by the eligible providers listed within this policy.

Telehealth claims must 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, Peer Support Services Amended Apr. 1, 2023. (Accessed Jul. 2024).

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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, June 1, 2023. (Accessed Jul. 2024).

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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.

The following HCPCS code can be billed for the Telehealth originating site facility fee by the originating site (the site at which the beneficiary is located): Q3014.

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, June 1, 2023. (Accessed Jul. 2024).

Guidance: Hybrid Telehealth with Supporting Home Visit (“Hybrid Model”)

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, Attachment A, June 1, 2023. (Accessed Jul. 2024).

Obstetrical Services

Billing for Hybrid Telehealth Visit with a Supporting Home Visit – Providers Billing Global OB or Package Codes:

• To reflect the additional cost of the delegated staff person attending the patient’s home, eligible providers may bill a telehealth originating site facility fee for each telehealth visit conducted with a supporting visit. The originating site fee shall be billed in addition to the pregnancy global package codes.
• To be reimbursed for the originating site facility fee for this care model, all of the listed 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 with the date of service for which the home visit is conducted.
  • The telehealth originating site facility fee 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 antepartum or postpartum hybrid telehealth visit is included in the global or package code for the pregnancy. There is no separate evaluation and management code billing outside of the package or global code for the providers portion of the home visit.

Note: Refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for more information about originating site facility fees.

Providers Billing Individual Prenatal Visits:

• Providers shall bill the appropriate level Home Service evaluation and management code for each telehealth visit with a supporting home visit made by an appropriately trained delegated staff person.
• Providers should not bill the originating site facility fee.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended June 15, 2025, (Accessed Jul. 2024).

Last updated 07/09/2024

Miscellaneous

Unless otherwise required for a specific service, Medicaid 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.

Provider(s) shall comply with the following in effect at the time the service is rendered:

• All applicable agreements, federal, state and local laws and regulations including the Health Insurance Portability and Accountability Act (HIPAA) and record retention requirements; and
• All NC Medicaid’s clinical (medical) coverage policies, guidelines, policies, provider manuals, implementation updates, and bulletins published by the Centers for Medicare and Medicaid Services (CMS), DHHS, DHHS division(s) or fiscal contractor(s).

Provider(s) are expected to send documentation of any telehealth services rendered to a beneficiary’s identified primary care provider or medical home within 48 hours of the encounter for medical services (including behavioral health medication management), obtaining required consent when necessary (as per 42 CFR Part 2 for relevant substance use disorder related disclosures). Documentation can be sent by any HIPAA-compliant secure means.

Claims for all telehealth, virtual communication, and remote patient monitoring services must be billed according to the guidance in Attachment A below.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 7, June 1, 2023. (Accessed Jul. 2024).

Last updated 07/09/2024

Out of State Providers

No Reference Found

Last updated 07/09/2024

Overview

NC Medicaid reimburses for medically necessary telehealth services via live video, remote patient monitoring, audio-only and other virtual communications modalities outlined in its updated telehealth clinical coverage policies.

Last updated 07/09/2024

Remote Patient Monitoring

POLICY

Remote Patient Monitoring is the use of digital devices to measure and transmit personal health information from a beneficiary in one location to a provider in a different location. Remote patient monitoring enables providers to collect and analyze information such as vital signs (blood pressure, heart rate, weight, blood oxygen levels) in order to make treatment recommendations. There are two types of remote patient monitoring addressed within this policy:

• Self-Measured and Reported Monitoring: When a beneficiary uses a digital device to measure and record their own vital signs, then transmits the data to a provider for evaluation.
• Remote Physiologic Monitoring: When a beneficiary’s physiologic data is wirelessly synced from a beneficiary’s digital device where it can be evaluated immediately or at a later time by a provider.

Remote patient monitoring, including:

• self-measured blood pressure monitoring; and
• remote physiologic monitoring.

List of eligible Remote Patient Monitoring Services provided on page 14 of Attachment A of the Telehealth, Virtual Communications and Remote Patient Monitoring manual.  FQHCs, FQHC Lookalikes and RHCs are allowed to bill for RPM codes.

Guidance: Self-Measured Blood Pressure Monitoring (SMBPM)

SMBPM is a beneficiary’s regular use of a personal blood pressure monitoring device to assess and record blood pressure across different points in time outside of a clinical setting, typically at home. This service is available for new or established patients. SMBPM require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

Guidance: Remote Physiologic Monitoring (RPM)

RPM is the collection and interpretation of an established beneficiary’s physiologic data digitally transmitted to the eligible provider. Codes 99453 and 99454 are used for device set-up, training and supply – the following guidance applies to both of these codes:

• 99453 and 99454 can be used for blood pressure RPM if the device used to measure blood pressure meets RPM requirements. If the beneficiary self-reports blood pressure readings, the provider should instead bill SMBPM codes 99473/99474.
• 99453 and 99454 cannot be reported if monitoring is less than 16 days in duration.
• Providers should not report codes 99453 or 99454 if the services are included in any other codes covered by NC Medicaid for the duration of time of the RPM (for example, continuous glucose monitoring that is covered under code 95250).

RPM treatment management services are the use of the RPM results by the eligible provider to manage an established patient’s treatment plan. Codes 99457 and 99458 are used to report RPM treatment management services – the following guidance applies to both of these codes.

• Codes 99457 and 99458 require a live, interactive communication between the beneficiary or caregiver.
• Providers may not bill code 99457 or 99458 for interactions of less than 20 minutes.

For all RPM and RPM treatment management service codes in table C.3: If the services described by codes 99453, 99454, 99457 or 99458 are provided on the same day a beneficiary presents for an evaluation and management service to the same provider (whether by telehealth or in-person), these services should be considered part of the E/M service and not billed under the RPM code.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Jul. 2024).

North Carolina Innovations – Supported Living

The Supported Living provider shall be responsible for providing an individualized level of supports determined during the assessment process, including risk assessment, and identified and approved in the Individual Support Plan (ISP) and have 24 hour per day availability, including back-up and relief staff and in the case of emergency or crisis. Some beneficiaries receiving Supported Living services may be able to have unsupervised periods of time based on the assessment process. In these situations, a specific plan for addressing health and safety needs must be included in the ISP and the Supported Living provider shall have staffing available in the case of emergency or crisis. Requirements for the beneficiary’s safety in the absence of a staff person must be addressed and may include use of tele care options. When assessed to be appropriate Assistive Technology elements may be utilized in lieu of direct care staff.

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CONDITIONS

Phase II Outpatient Cardiac Rehabilitation Programs

Telemetry monitoring is available for at risk patients.  See manual for details.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs, June 1, 2023. (Accessed Jul. 2024).

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PROVIDER LIMITATIONS

Providers that may bill NC Medicaid for remote patient monitoring include physicians, nurse practitioners; psychiatric nurse practitioner; certified nurse midwives; and physician’s assistants.

FQHCs, FQHC Lookalikes and RHCs are allowed to bill for RPM codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Jul. 2024).

Electrocardiography, Echocardiography, and Intravascular Ultrasound

Holter monitoring is not covered for less than a 24-hour monitored period.

Home-based telemetry systems are not covered by N.C. Medicaid.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound, November 1, 2023. (Accessed Jul. 2024).

Federally Qualified Health Centers & 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.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics ID-4 Aug. 15, 2023.  (Accessed Jul. 2024).

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OTHER RESTRICTIONS

Remote patient monitoring requires use of a device that is defined by the FDA as a medical device and is in real-time and transmittable. Some forms of remote patient monitoring, such as remote physiologic monitoring (detailed below), require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Jul. 2024).

 

Last updated 07/09/2024

Store and Forward

POLICY

Virtual communications is the use of technologies other than video to enable remote evaluation and consultation support between a provider and a beneficiary or a provider and another provider. As outlined in Attachment A and program specific clinical coverage policies, 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).

Virtual Patient Communication – 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.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Jul. 2024).

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ELIGIBLE SERVICES/SPECIALTIES

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.

List of eligible Virtual Communication Services provided on page 13 of Attachment A of the Telehealth, Virtual Communications and Remote Patient Monitoring manual.  FQHCs, FQHC Lookalikes and RHCs are only allowed to bill for Online Digital Evaluation and Management Codes (not Telephonic Evaluation and Management and Virtual Communication Codes OR 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, June 1, 2023. (Accessed Jul. 2024).

Teledentistry

Teledentistry eligible services may be provided to both new and established patients by the eligible providers listed within this policy.

D9996 – Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

• Medicaid enrolled dentists may render provider to provider teledentistry services via asynchronous, store and forward or eConsults
• Dentist in the distant site must have enough information and evidence to make a diagnosis
• Must be billed with oral evaluation codes D0140 or D0170
• Reported in addition to other procedures delivered on the same date of service
• Dental treatment rendered through teledentistry must be documented in the beneficiary record including the date/time/duration of encounter, reasons for the encounter, technology used, records reviewed, diagnosis, and treatment recommendations
• Limited to once per recipient, per provider for a one-week period
• Limited to four teledentistry services (D9995 or D9996) in a six-month period
• The originating site is the facility in which the beneficiary is located
• The distant site is the facility from which the provider furnishes the teledentistry service
• All services sites/providers must be Medicaid enrolled
• Consultation must take place by an encrypted telecommunications system
• Enter “02” (Telehealth) as the place of treatment for teledentistry claims

SOURCE: NC Medicaid Clinical Coverage Policy 4A: Dental Services, Dec. 15, 2023, (Accessed Jul. 2024).

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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, June 1, 2023. (Accessed Jul. 2024).

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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. 

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, June 1, 2023. (Accessed Jul. 2024).