The following delivery methods may be used to provide telemedicine within fee-for-service (FFS) Medicaid:
- Synchronous audio-only technology between the distant site provider and the client in another location
Synchronous audio-only, also called synchronous telephone (audio-only), technology – An interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act.
Conditions for reimbursement applicable to behavioral health services provided using a synchronous audio-only technology platform are those that meet the following conditions:
- Must be designated for reimbursement by HHSC.
- Provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral
- health service through a synchronous audio-only technology platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.
- Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
May not be denied solely because an in-person medical service between a provider and client did not occur.
- May not be limited by requiring the provider to use a particular synchronous audio-only technology platform to receive reimbursement for the service.
- Other conditions for reimbursement applicable to behavioral health services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on audio-only coverage conditions.
Conditions for reimbursement applicable to non-behavioral health services provided using a synchronous audio-only technology platform:
- Must be designated for reimbursement by HHSC.
- Clinically effective and cost-effective, as determined and published by HHSC.
- May not be denied solely because an in-person medical service between a provider and client did not occur.
- May not be limited by requiring the provider to use a particular synchronous audio-only technology platform to receive reimbursement for the service.
Note: Behavioral or non-behavioral health services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audio-only technology platform can be found in the appropriate TMPPM handbooks.
Procedure codes that are reimbursed to distant site providers when billed with the 93 modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the 93 modifier.
Behavioral health procedure codes that are reimbursed to distant site providers when billed with the FQ modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the FQ modifier.
See manual for codes MCOs must reimburse when delivered via telemedicine services.
Texas Medicaid MCOs may optionally provide reimbursement for telemedicine services that are provided through asynchronous audio-only technology, such as voice mail technology. Distant site providers should contact each MCO to determine whether an MCO provides reimbursement for a specified modality.
SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6-7, 8, & 12 (Dec. 2022). (Accessed Dec. 2022).
The following delivery methods may be used to provide telemedicine within fee-for-service (FFS) Medicaid:
- Synchronous audiovisual technology between the distant site provider and the client in another location
- Synchronous audio-only technology between the distant site provider and the client in another location
- Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
- Clinically relevant photographic or video images, including diagnostic images
- The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories
A Texas Medicaid Managed Care organization (MCO) is not required to provide reimbursement for telemedicine services that are provided through the following methods:
- A text-only email message
- A facsimile transmission
Texas Medicaid MCOs may optionally provide reimbursement for telemedicine services that are provided through asynchronous audio-only technology, such as voice mail technology. Distant site providers should contact each MCO to determine whether an MCO provides reimbursement for a specified modality.
SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 9 & 12-13 (Dec. 2022). (Accessed Dec. 2022).
Outpatient Mental Health Services
The following outpatient mental health services may be provided by synchronous telephone (audio-only) technology to persons with whom the treating provider has an existing clinical relationship and, if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as, the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology.
Outpatient mental health services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.
- Psychiatric diagnostic evaluation services with and without medical services
- Psychotherapy (individual, family, or group) services
- Pharmacological management services (most appropriate E/M code with modifier UD) for psychiatric care only
See manual for procedure codes
An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual outpatient mental health service from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual service prior to the initial synchronous telephone (audio-only) service may not be waived.
Mental Health Targeted Case Management (MHTCM) Services
Mental health targeted case management (MHTCM) services may be provided by synchronous telephone (audio-only) technology to persons with whom the treating provider has an existing clinical relationship and, if clinically appro- priate and safe, as determined by the provider, and agreed to by the person receiving services or LAR. In addition, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the plan of care of the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers of MHTCM services must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. MHTCM services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.
An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual MHTCM service from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual service prior to the initial synchronous telephone (audio-only) service may not be waived. See manual for additional information.
Mental Health Rehabilitative Services
The following MHR services may be provided by by synchronous telephone (audio-only) technology to persons with whom the treating provider has an existing clinical relationship and if clini- cally appropriate and safe, as determined by the provider, and agreed to by the person receiving services or LAR. In addition, except for crisis intervention services, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the plan of care of the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. MHR services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. See manual for procedure codes and additional requirements.
- Medication training and support
- Skills training and development
- Psychosocial rehabilitation services
- Crisis intervention services
Synchronous telephone (audio-only) technology may only be used for crisis intervention services as a back-up mode of delivery only, meaning if the person who is in crisis, not the treating provider, is unwilling or has limited technological capabilities that prevent them from using a synchronous audiovisual platform at the time the crisis intervention services are delivered. Also, the existing clinical relationship requirement is waived.
Peer Specialist Services
Peer specialist services may be provided by synchronous telephone (audio-only) technology to persons with whom the peer specialist has an existing clinical relationship and if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. In addition, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the person-centered recovery plan of the person receiving services.
Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. Peer specialist services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.
An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual peer specialist service from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual service prior to the initial synchronous telephone (audio-only) service may not be waived.
The provider is required to conduct at least one in-person or synchronous audiovisual peer specialist service every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits. The decision to waive the 12- month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:
- The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area.
- An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition.
See manual for additional information.
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
SBIRT services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. SBIRT services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. See manual for additional information.
Medication Assisted Treatment Services
The following SUD services may be provided by synchronous telephone (audio-only) technology to persons with whom the treating provider has an existing clinical relationship and if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. SUD services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.
- Comprehensive assessment (procedure code H0001) – Only during certain public health emergencies or natural disasters; to the extent allowed by federal law (assessments for withdrawal management services are excluded); and the existing clinical relationship requirement is waived.
- Individual and group counseling (procedure codes H0004 and H0005)
See manual for additional requirements.
SOURCE: TX Medicaid Behavioral Health and Case Management Services Handbook, pgs. 32, 50, 59, 73, 80-81, & 89, (Dec. 2022). (Accessed Dec. 2022).
A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms (ECGs) to a remote site is not a benefit of Texas Medicaid.
SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, pg. 65. (Dec. 2022). (Accessed Dec. 2022).
To the extent permitted by state and federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the executive commissioner by rule shall develop and implement a system that ensures behavioral health services may be provided using an audio-only platform consistent with Section 111.008, Occupations Code, to a Medicaid recipient, a child health plan program enrollee, or another individual receiving those services under another public benefits program administered by the commission or a health and human services agency.
If the executive commissioner determines that providing services other than behavioral health services is appropriate using an audio-only platform under a public benefits program administered by the commission or a health and human services agency, in accordance with applicable federal and state law, the executive commissioner may by rule authorize the provision of those services under the applicable program using the audio-only platform. In determining whether the use of an audio-only platform in a program is appropriate under this subsection, the executive commissioner shall consider whether using the platform would be cost-effective and clinically effective.
SOURCE: TX Government Code Title 4, Subtitle I, Chapter 531, Subchapter A, Sec. 531.02161. (Accessed Dec. 2022).
Telehealth Exclusions
Any PT, OT, ST, and SST services delivered through synchronous telephone (audio-only) technology is not a benefit.
During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.
See Children’s Services Handbook for a list of procedure codes that are in-person only and will not be reimbursed if provided through telehealth delivery.
Health and Behavior Assessment and Intervention
HBAI services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. HBAI services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. See manual for eligible services and additional requirements.
Medical Nutrition Counseling Services (CCP)
Procedure code S9470 may be authorized for delivery using synchronous telephone (audio-only) technologies during a Declaration of State of Disaster. Services delivered using audio-only technologies must be billed using modifier 93.
Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services.
Medical Checkups During a Declaration of State Disaster
During a Declaration of State Disaster, Health and Human Services Commission (HHSC) may issue direction to providers regarding the use of telemedicine or telehealth services to include the use of synchronous telephone (audio-only) platform to provide coverage of services outside of the allowances described herein. A Declaration of State of Disaster is when an executive order or proclamation by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.
The following limitations apply to all THSteps preventive medical checkups and exception-to-periodicity checkups during a Declaration of State Disaster when HHSC issues direction regarding the use of synchronous audiovisual and synchronous telephone (audio-only) technologies:
- Clients who are 2 years through 20 years of age may receive a THSteps medical checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
- Clients from birth through 2 years of age may not receive a THSteps checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
- Clients from birth through 24 months of age must receive in-person checkups.
A medical checkup provided using synchronous audiovisual or synchronous telephone (audio-only) technologies must be completed according to the age-specific checkup requirements listed on the THSteps Periodicity Schedule.
Synchronous audiovisual delivery for medical checkups is preferred over synchronous telephone (audio-only) delivery.
An in-person THSteps follow-up visit must be completed within six months of the synchronous audiovisual or synchronous telephone (audio-only) checkup in order for the checkup to be considered a complete THSteps checkup.
THSteps providers should use their clinical judgement regarding which checkup components may be appropriate for completion using synchronous audiovisual or synchronous telephone (audio-only) technologies.
See Children’s Services Handbook for additional information and a list of procedure codes.
SOURCE: TX Medicaid Children’s Services Handbook, pgs. 57, 66, 72 & 186-187, (Dec. 2022), (Accessed Dec. 2022).
Telehealth services may be provided using synchronous audiovisual technologies if clinically appro- priate and safe, as determined by the provider, and agreed to by the client receiving services.
Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telehealth services.
Providers must defer to the needs of the client receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the client in service’s choice and not provider convenience.
Services delivered by synchronous audiovisual technology will require participation of a parent or caregiver to assist with the treatment.
Therapy assistants may deliver services and receive supervision using synchronous audiovisual technology in accordance with each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline.
SOURCE: TX Medicaid Children’s Services Handbook, pgs. 56, (Dec. 2022), (Accessed Dec. 2022).
Some service delivery to children or youth and to the parents or caregivers may be delivered remotely. It is the LBA’s responsibility to ensure that remotely delivered telehealth services are within scope of practice, are not contraindicated for the child or youth, family, or particular situation, are clinically appropriate and effective, and are in compliance with Texas licensure and standards for telehealth and the Texas Health Steps-CCP and these Medicaid Autism Services requirements. ABA evaluation and treatment services may only be delivered via telehealth using synchronous audio-visual technology or a similar technology.
SOURCE: TX Medicaid Children’s Services Handbook, pgs. 39, (Dec. 2022), (Accessed Dec. 2022).
Synchronous audio-only, also called synchronous telephone (audio-only), technology – An interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act.
Procedure codes that are reimbursed to distant site providers when billed with the 93 modifier (audio- only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the 93 modifier.
Behavioral health procedure codes that are reimbursed to distant site providers when billed with the FQ modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the FQ modifier.
SOURCE: TX Medicaid Telecommunication Services Handbook, pgs. 6, 8 and 12 (Dec. 2022). (Accessed Dec. 2022).
Counseling and psychological telehealth services provided by LEAs during school hours through SHARS may also be delivered via synchronous telephone (audio-only) technologies.
Synchronous telephone (audio-only) technology is defined as an interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of HIPAA.
HHSC encourages the use of synchronous audiovisual technology over telephone (audio- only) delivery of telehealth services whenever possible. Therefore, if delivered by synchronous telephone (audio-only) technology, providers must document in the student’s medical record the reason(s) for why a synchronous audiovisual platform was not used.
The patient site must be a school, home, or community-based setting in order for the distant site provider to be eligible for reimbursement of these services.
Psychological telemedicine services provided by LEAs during school hours through SHARS may also be delivered via synchronous telephone (audio-only) technologies.
All telemedicine services provided by synchronous telephone (audio-only) technology must be billed using modifier 93. See manual for codes.
SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pgs. 28, 30, 32 & 33 (Dec. 2022). (Accessed Dec. 2022).
During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein. A Declaration of State of Disaster is when an executive order or proclamation by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.
SOURCE: TX Medicaid Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook pg. 10, (Dec. 2022). (Accessed Dec. 2022).
Healthy Texas Women Program
Certain telemedicine and telehealth services may be provided for HTW clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology.
HTW services are authorized for telemedicine delivery using synchronous telephone (audio-only) technologies.
For the diagnosis, evaluation and treatment of a mental health or substance use condition only, established patient services (procedure codes 99212, 99213, 99214 and 99215) may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Established patient service (procedure code 99211) should be used only during certain public health emergencies.
During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.
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