Last updated 07/13/2021
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, Nov. 15, 2020. (Accessed Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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. 4 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, Nov. 15, 2020 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 4 & 7-8, Jan. 1, 2021. (Accessed Jul. 2021).
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. 3-7, Nov. 15, 2020. (Accessed Jul. 2021).
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 awith 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. 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. 13-14, Nov. 15, 2020. (Accessed Jul. 2021).
See Attachment A of manual for billable codes (p. 12).
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. 6, 10 & 17-8, Nov. 15, 2020. (Accessed Jul. 2021).
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, Jan. 1, 2021. (Accessed Ju. 2021).
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.
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. 9, Dec. 1, 2020. (Accessed Jul. 2021).
Office Based Opioid Treatment (OBOT)
Telemedicine and telepsychiatry 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 telemedicine 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 telemedicine visit.
SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1A-41, Office-Based Opioid Treatment, p. 12-13, Dec. 12, 2019. (Accessed Jul. 2021).
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.
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, Amended July 1, 2021, pg. 3 & 47 (Accessed Jul. 2021).
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 June 1, 2021, pg. 4, 12 & 14, 43, 45 (Accessed Jul. 2021).
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, 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.
See Speech Language codes for eligible services via telehealth.
SOURCE: NC Div. of Medical Assistance, Independent Practitioners, Clinical Coverage Policy, Amended July 1, 2021, pg. 12 & 43-44 (Accessed Jul. 2021).
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).
SOURCE: NC Div. of Medical Assistance, Family Planning Services, Clinical Coverage Policy, Amended May 1, 2021, pg. 4, 22-24 (Accessed Jul. 2021).
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, Nov. 15, 2020 & NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 8C, Outpatient Behavioral Health Services, p. 12, Jan. 1, 2021. (Accessed Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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 Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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, Nov. 15, 2020. (Accessed Jul. 2021).
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 & 16, Nov. 15, 2020. (Accessed Jul. 2021).
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, Nov. 15, 2020, (Accessed Jul. 2021).
