North Carolina

Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

At A Glance
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MEDICAID REIMBURSEMENT

  • Live Video: Yes
  • Store-and-Forward: Yes*
  • Remote Patient Monitoring: Yes
  • Audio Only: Yes

PRIVATE PAYER LAW

  • Law Exists: No
  • Payment Parity: No

PROFESSIONAL REQUIREMENTS

  • Licensure Compacts: ASLP-IC, CC, NLC, OT, PSY, PTC
  • Consent Requirements: Yes

STATE RESOURCES

  1. Medicaid Program: North Carolina Medicaid
  2. Administrator: NC Medicaid Division of Health Benefits
  3. Regional Telehealth Resource Center: Mid-Atlantic Telehealth Resource Center
Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

Last updated 03/17/2024

Definitions

No reference found.

Last updated 03/17/2024

Parity

SERVICE PARITY

No Reference Found


PAYMENT PARITY

No Reference Found

Last updated 03/17/2024

Requirements

No Reference Found

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 03/17/2024

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 Mar. 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 Mar. 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.

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 Mar. 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 Mar. 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 Mar. 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.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No. 8G, Peer Support Services pgs. 5, 7 &17  & Attachment A, pgs. 20-21, Amended Aug. 15, 2022. (Accessed Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 2024).

Last updated 03/17/2024

Live Video

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).

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 Mar. 2024).


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 Mar. 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 Mar. 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 Mar. 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].

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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 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 Mar. 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. 1, 2023, (Accessed Mar. 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 Mar. 2024).

Dietary Evaluation and Counseling and Medical Lactation Services 

Non-Telehealth Claims:  Providers who bill for Medical Lactation services with codes 96156, 96158, and 96159 must append the SC modifier to denote Medical Lactation Services.

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

Diabetes Outpatient Self-Management Education

See page 15 for eligible telehealth services.

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

Independent Practitioners Respiratory Therapy Services

A select set of respiratory therapy treatment interventions may be provided to established patients using a telehealth delivery method as described in Clinical Coverage Policy 1-H. After necessary equipment and supplies have been delivered and assembled, delivery of treatment services via telehealth may be medically necessary when a beneficiary’s medical condition is such that exposure to others should be avoided, or if their location is remote or underserved such that access to appropriately qualified providers is limited.

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

See page 22 of the manual for list of eligible telehealth services.

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

Pregnancy Medical Home

See page 14 for list of telehealth eligible services.

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

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

North Carolina Innovations

In addition to telehealth criteria specified in clinical coverage Policy 1-H, Telehealth, Virtual Patient Communications, and Remote Patient Monitoring, at https://medicaid.ncdhhs.gov/. The provision of NC Innovations waiver services using telehealth may only occur when it is clinically indicated for the beneficiary and the beneficiary needs only verbal cueing or prompting to complete tasks

See page 38 for list of telehealth billable services.

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, Outpatient Behavioral Health Services Provided by Direct-Enrolled Providers, https://medicaid.ncdhhs.gov/.

Specialized Consultation Services

Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the beneficiary with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.

Activities covered include:

  • Tele-consultation through use of two-way, real time-interactive audio and video to provide behavioral and psychological care when distance separates the care from the individual.

See manual for complete list of covered activities.

This service may be used for evaluations for adults when the State Plan limits have been exceeded.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8-P, North Carolina Innovations Amended Apr. 1, 2023, (Accessed Mar. 2024).

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

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

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 8F.

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 Mar. 2024).

Acute Inpatient Hospital Services

Refer to clinical coverage policy 1H, Telemedicine and Telepsychiatry, at https://medicaid.ncdhhs.gov/, for billing instructions and coverage criteria.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 2A-1, Acute Inpatient Hospital Services Amended Jun. 1, 2023, (Accessed Mar. 2024).

Childbirth Education

HCPCS Code S9442 is eligible for telehealth service.

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

Maximum beneficiaries (excluding partners) in both telehealth and non-telehealth group classes is limited to 10.

For telehealth group classes, the provider is responsible for making the beneficiary aware of the public nature of online classes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1M-2, Childbirth Education Amended Aug. 15, 2023 (Accessed Mar. 2024).

Health and Behavior Intervention

CPT codes 96158 and 96159 are eligible for telehealth service.

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

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1M-3, Health and Behavior Intervention Amended Aug. 15, 2023, (Accessed Mar. 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.

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 home visit made by an appropriately trained, delegated staff person when medically necessary. Reimbursement for this care model is open to both new and established patients. The supporting delegated staff person may perform vaccinations in the home, subject to compliance with all applicable requirements for vaccinations (it is within delegated staff person’s scope of practice to administer vaccinations) and may conduct other tests or screenings, as appropriate. Refer to Attachment B, Letter E for billing guidance.

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 3.2.2 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.

See manual for list of eligible CPT codes

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 (e.g., telephone conversations). In order 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 should be conducted in person within the first trimester of pregnancy.

Providers Billing Global OB or Package Codes:

  • The following table of Global and Package CPT codes contains services that may be rendered via telehealth. A limited number of services may be offered via telehealth and billed for new and established patients.
  • The code billed must be appended with the GT modifier to indicate that at least one visit was conducted via telehealth. This modifier is not appropriate for services performed telephonically or through patient portal. In addition, 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.

Note: FQHCs, FQHC Look-Alikes and RHCs that bill T1015 for perinatal services may render some of these services via telehealth.

See manual for instructions on billing hybrid telehealth visit with a supporting home visit.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 1E-5, Obstetrical Services Amended Apr. 1, 2023, (Accessed Mar. 2024).

Office-Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone 

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 1A-41, Office-Based Opioid Treatment: Use of Buprenorphine and Buprenorphine-Naloxone , Amended Apr. 1, 2023, (Accessed Mar. 2024).

1915(c) TBI Waiver

NC Medicaid has submitted a 1915(c) TBI Waiver amendment to (CMS) to make the following Appendix K flexibilities permanent: …

  • Allow real time two-way interactive audio and video telehealth for Life Skills Training, Cognitive Rehabilitation, Day Support, Supported Employment; Supported Living and Community Networking to be delivered via telehealth.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update:  TBI Waiver 1915 (c) and Appendix K Flexibilities, Nov. 3, 2023, (Accessed Mar. 2024).

Traumatic Brain Injury Appendix K

The following telehealth policies will be implemented Mar. 1, 2024:

  • Waiver members may access Life Skills Training, Cognitive Rehabilitation, Day Supports, Supported Employment, Supported Living, Community Networking via telehealth.
  • Telehealth is not intended to supplant a full meaningful day, but rather to complement it. Services that support community integration are not eligible for 100% telehealth delivery.
  • The provider shall document that any platforms used to conduct telehealth activities are in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
  • The use of telehealth shall not exceed 25% of the authorized service hours per week (i.e. if an individual is authorized 40 hours a week, the individual may use the real time two-way interactive audio and video telehealth 10 hours week).

Effective March 1, 2024, monthly and quarterly care coordination/waiver member meetings for individuals receiving residential supports or new to waiver shall occur face-to-face.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update:  NC Medicaid Guidance on Sunsetting of Traumatic Brain Injury Appendix K Flexibilities, Jan. 30 2024, (Accessed Mar. 2024).

Innovations Waiver

NC Medicaid submitted a 1915(c) Innovations Waiver amendment to (CMS) to make the following Appendix K flexibilities permanent:

  • Allow real time, two-way interactive audio and video telehealth for Community Living Support; Day Support, Supported Employment; Supported Living and Community Networking to be delivered via telehealth.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update:  Innovation Waiver 1915 (c) and Appendix K Flexibilities, Nov. 3, 2023, (Accessed Mar. 2024).

COVID-19 Counseling Code 99401 may be used for counseling families on the availability of the new RSV monoclonal antibody for children 0-19 months until Sept. 30, 2024. Counseling may be provided in person, through live audio/video (telehealth) or telephonically. Additionally, this service may be billed by multiple providers and may be billed multiple times on different days. Different than for COVID-19 counseling, use of this code for Beyfortis counseling is limited to beneficiaries 0 to 20 months of age and during the 2023-2024 RSV season.

SOURCE: NCDHHS NC Medicaid Division of Health Benefits, Update:  NC Medicaid Respiratory Syncytial Virus (RSV) Guidelines for 2023-2024, Nov. 3, 2023, (Accessed Mar. 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 Mar. 2024).

Individual Placement and Support (IPS) – Mental Health & Substance Use

The IPS Team shall have weekly vocational unit meetings inclusive of all IPS staff to review caseloads, share beneficiaries’ progress, successes, and needs, job leads, and other issues. In-person meetings are preferred. IPS teams can use a virtual telehealth platform that is Health Insurance Portability and Accountability Act (HIPAA) compliant for vocational unit meetings for no more than three meetings a month. It is recommended that cameras are used during this meeting. Telephonic participation in the vocational unit meetings is not allowed.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8H-2, Individual Placement and Support (IPS) – Mental Health & Substance Use, Amended Nov. 1, 2023, (Accessed Mar. 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
  • 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 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 two-way real-time interactive audio and video 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 Mar. 2024).


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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 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 Mar. 2024).


ELIGIBLE SITES

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 Mar. 2024).

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, p. 2, June 1, 2023. (Accessed Mar. 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 Mar. 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.

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.

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


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 Mar. 2024).


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 Mar. 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 Mar. 2024).

Last updated 03/17/2024

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 Mar. 2024).

Last updated 03/17/2024

Out of State Providers

No Reference Found

Last updated 03/17/2024

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 03/17/2024

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 Mar. 2024).


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 Mar. 2024).


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 Mar. 2024).


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 Mar. 2024).

Last updated 03/17/2024

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 Mar. 2024).


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 Mar. 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 Mar. 2024).


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 Mar. 2024).


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 Mar. 2024).

Last updated 03/17/2024

Cross State Licensing

The Board may approve a dental hygienist licensed in this State or any other state or territory to provide local anesthesia upon the dental hygienist meeting all of the following criteria:

  • Produces satisfactory evidence of the required education, training, and clinical qualifications to provide local anesthesia.
  • Has been practicing dental hygiene, as defined in G.S. 90-221, under the supervision of a licensed dentist for a minimum of two years immediately preceding the date of the application.
  • Has successfully completed a course of study on local anesthetics offered through a school or college approved by the United States Department of Education or a Board-approved continuing education provider that includes all of the following:
      • A minimum of 16 lecture hours on pharmacology, physiology, equipment, block and infiltration techniques, legal issues, and medical emergencies, including systemic complications.
      • A minimum of eight clinical hours of instruction and experience in administering local anesthesia injections.
      • Completion of at least 12 block and 12 infiltration injections under the direct supervision of a licensed dentist who must certify the applicant’s competency.

SOURCE: NC General Statutes Sec. 90-225.3. (Accessed Mar. 2024).

Dietetics, Nutritionists

Any person, whether residing in this State or not, who by use of electronic or other medium performs any of the acts described as the practice of medical nutrition therapy with a client or patient located in this State, but is not licensed pursuant to Article 25 of Chapter 90 of the General Statutes shall be deemed by the Board as being engaged in the practice of medical nutrition therapy and subject to the enforcement provisions available to the Board. Among other remedies, the Board shall report violations of this Rule to any occupational licensing board having issued an occupational license to a person who violates this Rule. This Rule does not apply to persons licensed pursuant to, or exempt from licensure pursuant to, Article 25 of G.S. 90.

SOURCE: 21 NCAC 17.0403, (Accessed Mar. 2024).

Last updated 03/17/2024

Definitions

Maternal and Child Health and Women’s Health

Telemedicine is the use of audio and video between places of lesser and greater medical capability or expertise to provide and support health care when distance separates participants who are in different geographical locations.

SOURCE: NC General Statute 130A-125(b2)(1). (Accessed Mar. 2024).

Involuntary Commitments

“Telehealth” means the use of two-way, real-time interactive audio and video where the respondent and commitment examiner can hear and see each other.

SOURCE: NC General Statute Sec. 122C-263, (Accessed Mar. 2024).

Practice of teledentistry

The provision of dental services by use of any electronic or other digital means, as authorized in G.S. 90-29(b)(11) and provided for in subsection (b) of this section.

A person shall be deemed to be practicing dentistry in this State who does, undertakes or attempts to do, or claims the ability to do any one or more of the following acts or things which, for the purposes of this Article, constitute the practice of dentistry:

  • Administers an anesthetic of any kind in the treatment of dental or oral diseases or physical conditions, or in preparation for or incident to any operation within the oral cavity; provided, however, that this subsection shall not apply to a lawfully qualified nurse anesthetist who administers such anesthetic under the supervision and direction of a licensed dentist or physician; physician, or to a registered dental hygienist qualified to administer local anesthetics.
  • Owns, manages, supervises, controls or conducts, either himself or himself, by and through another person or other persons, or by use of any electronic or other digital means, any enterprise wherein any one or more of the acts or practices set forth in subdivisions (1) through (10) above are done, attempted to be done, or represented to be done.

SOURCE: NC General Statutes Sec. 90-29 & 90-30.2 (Accessed Mar. 2024).

Veterinary Telemedicine

“Veterinary Telemedicine” or “telemedicine” means the use of electronic or telecommunication technologies to remotely provide medical information regarding a patient’s clinical health status and to deliver veterinary medical services to a patient that resides in or is located in the State. The delivery of veterinary medical services through telemedicine is the practice of veterinary medicine.

SOURCE:  21 NCAC 66 .0211  & NC Veterinary Board of Medicine. (Accessed Mar. 2024).

Occupational Therapy Compact

Telehealth – The application of telecommunication technology to deliver occupational therapy services for assessment, intervention, or consultation.

SOURCE: NC General Statute Sec. 90-270.181, (Accessed Mar. 2024).

Interstate Compact For Audiology And Speech Pathology

Telehealth – The application of telecommunication technology to deliver audiology or speech-language pathology services at a distance for assessment, intervention, and/or consultation.

SOURCE: NC General Statute Sec. 90-312.2. (Accessed Mar. 2024).

Professional Counseling

Telehealth. – The application of telecommunication technology to deliver professional counseling services remotely to assess, diagnose, and treat behavioral health conditions.

SOURCE: NC General Statute Sec. 90-349.2, (Accessed Mar. 2024).

Last updated 03/17/2024

Licensure Compacts

Member of the Physical Therapy Compact.

SOURCE: PT Compact. Compact Map, (Accessed Mar. 2024).

Member of the Nurses Licensure Compact.

SOURCE:  Current NLC States & Status.  Nurse Licensure Compact.  (Accessed Mar. 2024).

Member of Psychology Interjurisdictional Compact.

SOURCE: PSYPACT. Compact Map, (Accessed Mar. 2024).

Member of the Audiology and Speech-Language Pathology Interstate Compact

SOURCE: Audiology and Speech-Language Pathology Interstate Compact. Compact Map, (Accessed Mar. 2024).

Member of Occupational Therapy Interstate Compact

SOURCE: OT Compact Map. (Accessed Mar. 2024).

Member of the Counseling Compact.

SOURCE: Counseling Compact Map. (Accessed Mar. 2024).

* See Compact websites for implementation and license issuing status and other related requirements.

Last updated 03/17/2024

Miscellaneous

Telemedicine may be utilized for neonatal or infant echocardiograms.

SOURCE: 10A N.C.A.C. 43K.0102(c)(3). (Accessed Mar. 2024).

Telehealth may be used to perform the initial examination for purposes of involuntary commitment.

SOURCE: N.C. Gen. Stat. § 122C-263(c), (Accessed Mar. 2024).

The Commission is required to address follow-up protocols to ensure early treatment for newborn infants diagnosed with congenital heart defects, including by means of telemedicine (live video).

SOURCE: NC General Statute 130A-125(b2)(1). (Accessed Mar. 2024).

Audiology Assistants may utilize telehealth to extend access to clinical care.

SOURCE: 21 NCAC 64 .1104(a)(7). (Accessed Mar. 2024).

Teledentistry

The licensee shall ensure that any electronic and digital communication used in the practice of teledentistry is secure to maintain confidentiality of the patient’s medical information as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and all other applicable laws and administrative regulations. Patients receiving services through teledentistry under this section are entitled to protection of their medical information no less stringent than the requirements that apply to patients receiving in-person services.

SOURCE: NC General Statutes Sec. 90-30.2. (Accessed Mar. 2024).

Involuntary Commitment

For an involuntary commitment, the respondent may either be in the physical face-to-face presence of the person conducting the screen or may be examined utilizing telehealth equipment and procedures. See statute for additional information.

SOURCE: NC General Statutes 122C-263 & 122C-266, (Accessed Mar. 2024).

Last updated 03/17/2024

Online Prescribing

Teledentistry

The indication, appropriateness, and safety considerations for each prescription for medication, laboratory services, or dental laboratory services provided through the use of teledentistry shall be evaluated by the licensed dentist in accordance with applicable law and current standards of care, including those for appropriate documentation. A licensed dentist’s use of teledentistry carries the same professional accountability as a prescription issued in connection with an in-person encounter. A licensed dentist who prescribes any type of analgesic or pain medication as part of the provision of teledentistry services shall comply with all applicable North Carolina Controlled Substance Reporting System requirements.”

SOURCE: NC Statute Sec. 90-30.2. (Accessed Mar. 2024).

Opioid treatment program medication unit. – A unit established as part of an opioid treatment program facility that meets all of the following criteria: …
  • Is a site where intake or initial psychosocial and appropriate medical assessments may be conducted with a full physical examination to be completed or provided within 14 days of admission and the site provides appropriate privacy and adequate space for quality patient care, where treatment with medication approved by the Food and Drug Administration may be initiated after an appropriate medical assessment has been performed, and where other opioid treatment program services, such as counseling, may be provided directly, or when permissible, through the use of telehealth services and the site provides appropriate privacy and adequate space for quality patient care.

SOURCE: NC Statute Sec. 122C-3, (Accessed Mar. 2024).

 

Last updated 03/17/2024

Professional Board Standards

Veterinary Medical Board

SOURCE: NC Admin Code, Title 21, Sec. 66 .0211 35:20, (Accessed Mar. 2024).

See statute for ‘practice of teledentistry’ requirements.

SOURCE: NC Statute Sec. 90-30.2. (Accessed Mar. 2024).

An audiology assistant may engage in the following direct patient services: … Providing services previously mentioned through telehealth to extend access to clinical care.

SOURCE: NC Admin Code, Title 21, Sec. 64.1104, (Accessed Mar. 2024).

Dietetics – Telepractice

SOURCE: NC Statute Sec. 90-365.5, (Accessed Mar. 2024).

Medical Nutrition Therapy

SOURCE: 21 NCAC 17 .0403, (Accessed Mar. 2024).

Last updated 03/17/2024

Definition of Visit

A core visit shall be a professional service that is rendered during a face-to-face encounter by a physician or other health professional listed in this policy. If the only services rendered during a visit are “incident to” services ordinarily performed by a nurse, technician, or office assistant (such as taking blood pressure and temperature, giving injections, or changing dressings), the visit does not constitute a core visit.

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. 6, Aug. 15, 2023. (Accessed Mar. 2024).

Last updated 03/17/2024

Eligible Distant Site

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).

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. 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.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, Jun. .2, 2023. (Accessed Mar. 2024).

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 of this policy.

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.

Please refer to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring for a list of other related clinical coverage policies that include telehealth, virtual patient communications and remote patient monitoring-eligible non-core visit services that may be delivered by eligible providers at an FQHC or RHC.

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

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 Mar. 2024).

See: NC Medicaid Live Video Eligible Providers

Last updated 03/17/2024

Eligible Originating Site

Hybrid Telehealth with Supporting Home Visit

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, Amended Jun. 1, 2023, (Accessed Mar. 2024).

Hybrid Telehealth with Supporting Home Visit: FQHCs and RHCs may bill their core service code (T1015, T1015-HI, or T1015-SC) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the patient’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, T1015-HI or T1015-SC) must be billed as a separate claim from the originating site facility fee code (Q3014).

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, p. 18, Aug. 15, 2023. (Accessed Mar. 2024).

Medicaid Telehealth manual indicates there are no restrictions on originating sites.

See: NC Medicaid Live Video Eligible Sites

Last updated 03/17/2024

Facility Fee

Hybrid Telehealth with Supporting Home Visit

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, Amended Jun. 1, 2023, (Accessed Mar. 2024).

Hybrid Telehealth with Supporting Home Visit: FQHCs and RHCs may bill their core service code (T1015, T1015-HI, or T1015-SC) and an originating site facility fee (Q3014) for hybrid model visits to reflect the additional cost of the delegated staff person attending the patient’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, T1015-HI or T1015-SC) must be billed as a separate claim from the originating site facility fee code (Q3014).

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, p. 18,  Aug. 15, 2023. (Accessed Mar. 2024).

See: NC Medicaid Live Video Facility/Transmission Fee

Last updated 03/17/2024

Home Eligible

FQHC and RHC core service providers may conduct telehealth visits with a supporting home visit by a delegated staff member (“hybrid model”) with new or established patients and bill using HCPCS code T1015 (or T1015-HI, T1015-SC), for a range of scenarios including (but not limited to) chronic disease management and perinatal visits.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pg. 19 Dec. 1, 2020. (Accessed Mar. 2024).

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: 1D-4, Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics, pg. 18 Aug. 15, 2023. (Accessed Mar. 2024).

Last updated 03/17/2024

Modalities Allowed

Live Video

Select services may be provided via telehealth, virtual patient communications, and remote patient monitoring. Services delivered via telehealth, virtual patient communications, and remote patient monitoring must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring.

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth if the service is: a. 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, b. Covered as a telehealth-eligible core visit service in Attachment A, Section C.1 of this policy.

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.

See: NC Medicaid Live Video


Store and Forward

As outlined in Section 5.7 and Attachment A, select services may be provided via telehealth, virtual patient communications, and remote patient monitoring. Services delivered via telehealth, virtual patient communications, and remote patient monitoring must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring.

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.

 See: NC Medicaid Store and Forward


Remote Patient Monitoring

As outlined in Section 5.7 and Attachment A, select services may be provided via telehealth, virtual patient communications, and remote patient monitoring. Services delivered via telehealth, virtual patient communications, and remote patient monitoring must follow the requirements and guidance set forth in Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications, and Remote Patient Monitoring.

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.

See: NC Medicaid Remote Patient Monitoring


Audio-Only

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.

Note: Virtual patient communications and remote patient monitoring services are always considered non-core visit services; please refer to Section 5.7 for more information on reimbursement for non-core visit services

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. 18, Aug. 15, 2023. (Accessed Mar. 2024).

See: NC Medicaid Audio-Only

Last updated 03/17/2024

Patient-Provider Relationship

No reference found.

Last updated 03/17/2024

PPS Rate

Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) core service providers may deliver core services via telehealth.

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.

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.

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 Mar. 2024).

Last updated 03/17/2024

Same Day Encounters

Core service encounters with more than one health professional, and multiple encounters with the same health professional, that take place on the same date of service and at a single location, constitute a single visit and are limited to one encounter per day, except when one of the following conditions exists:

  • After the first encounter, the beneficiary appears or presents with or suffers illness or injury requiring additional diagnosis or treatment; or
  • The beneficiary has a medical visit and an “other health” visit, such as a behavioral health visit. Core service visits for behavioral health are subject to the requirements and limitations specified in 42 CFR 405.2450 and 405.2452.

Note: Service is limited to a maximum of three encounters per day when the conditions of the above paragraphs are met. Written documentation shall be provided to justify more than three core visits billed on the same date of service.

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. 7, Aug. 15, 2023. (Accessed Mar. 2024).